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2020 QUALITY REPORT Resilience: A Commitment to 20 Patient Safety Fuels Quality Initiatives During 20 a Pandemic TABLE OF CONTENTS Message from WHA President and CEO Eric Borgerding Wisconsin Hospital Association Quality Team ..............................................................................................................1 About This Report ....................................................................................................................................................... 2 Wisconsin Hospital Performance with Federal Medicare Measures ..............................................................................3 Hospital Value-Based Purchasing ..................................................................................................................................... 3 Hospital-Acquired Conditions ......................................................................................................................................... 4 Hospital Readmissions Reduction .................................................................................................................................... 5 CMS Star Ratings .............................................................................................................................................................. 5 Wisconsin Quality Initiatives .......................................................................................................................................6 Readmissions ................................................................................................................................................................... 7 Falls ................................................................................................................................................................................. 8 Pressure Injuries .............................................................................................................................................................. 8 Health Care-Associated Infections ................................................................................................................................... 9 Methicillin-Resistant Staphylococcus Aureus .......................................................................................................... 9 Clostridioides Difficile ............................................................................................................................................. 10 Central Line-Associated Blood Stream Infection and Catheter-Associated Urinary Tract Infection ........................ 10 Sepsis ...................................................................................................................................................................... 10 Surgical Site Infections ............................................................................................................................................ 11 Looking Forward ........................................................................................................................................................... 11 Collaboration Opportunities and Resources ............................................................................................................... 12 Superior Health Quality Alliance .................................................................................................................................... 12 Quality Residency .......................................................................................................................................................... 14 Physician-Led Quality Improvement ............................................................................................................................. 15 Hospital COVID Response Stories ............................................................................................................................... 17 Wisconsin Hospital Association ..................................................................................................................................... 17 Children’s Wisconsin, Milwaukee .................................................................................................................................. 19 Children’s Wisconsin, Milwaukee ................................................................................................................................... 19 Fort HealthCare, Fort Atkinson ...................................................................................................................................... 20 Marshfield Medical Center-Park Falls ............................................................................................................................ 21 Gundersen Health System, La Crosse . ........................................................................................................................... 22 Marshfield Clinic Health System .................................................................................................................................... 22 Sauk Prairie Healthcare, Prairie du Sac .......................................................................................................................... 23 Tomah Health ................................................................................................................................................................. 24 Hospital Quality Improvement Showcase .................................................................................................................. 25 Children’s Wisconsin, Milwaukee .................................................................................................................................. 25 Marshfield Medical Center-Park Falls ............................................................................................................................ 26 Froedtert & the Medical College of Wisconsin, Milwaukee . ......................................................................................... 26 Marshfield Clinic Health System .................................................................................................................................... 27 Marshfield Clinic Health System .................................................................................................................................... 27 Marshfield Clinic Health System .................................................................................................................................... 28 Marshfield Medical Center – Marshfield ....................................................................................................................... 28 Marshfield Clinic Health System .................................................................................................................................... 29 Sauk Prairie Healthcare, Prairie du Sac ......................................................................................................................... 30 SSM Health St. Mary’s Hospital, Madison ...................................................................................................................... 31 UW Health, Madison ...................................................................................................................................................... 32 Wisconsin Hospital Association Member Hospitals .................................................................................................... 33 2020: A YEAR OF RESILIENCE A Message From Eric Borgerding, WHA President and CEO The period covered in this Wisconsin Hospitals Caring for their Communities 2020 Wisconsin Hospital Association (WHA) annual Quality Report 1.5 million was one in which hospitals and 5 million Outpatient visits Emergency the people working in them Department Visits: were tested like never before. Deservedly so, health care Provided care for 400,000 admitted patients, accounting for 2.2 million days of inpatient care. providers here and around the world have drawn praise and 60,000 gratitude for their resilience in Provied $2 billion in charity care babies the face of COVID-19. Undoubtedly, the commitment and community benefits (2019) delivered of Wisconsin’s hospitals and health systems to their patients and their communities over the past year Across the Centers for Medicare & Medicaid saved countless lives and prevented even greater Services’ (CMS’s) various health care quality virus spread throughout the state. programs, Wisconsin hospitals demonstrate leadership. 2020 saw a continued trend of increasing Wisconsin’s hospitals served as both the front line numbers of hospitals in the state qualifying for and the last line of defense in fighting the COVID-19 the higher-level payment bonuses for the agency’s pandemic, adapting their operations quickly to Hospital Value-Based Purchasing Program. Wisconsin maximize the safety of their patients, staff and the hospitals also register fewer unplanned readmissions community while adding workers where needed than the national average, according to CMS data. and appropriating available space and resources to attend to increasing numbers of infected patients. Wisconsin hospitals and health systems have been Health care providers throughout the state also pioneers in quality measurement and have long stepped up to perform hundreds of thousands shared safety and quality data with the public. of COVID tests