Case Study High-Performing Health Care Organization • June 2010 Memorial Healthcare System: A Public System Focusing on Patient- and Family-Centered Care JENNIFER EDWARDS , DR.P.H. HEALT H MANAGE M ENT ASSOCIATES The mission of The Commonwealth Fund is to promote a high performance Location: Broward County, Fla., north of Miami-Dade County. health care system. The Fund carries Type: Public health care system. out this mandate by supporting Beds: 1,742 beds, including 301 at Memorial Hospital Pembroke, 1,014 at Memorial Regional independent research on health care Hospital and Memorial Regional Hospital South, 299 at Memorial Hospital West, and 128 at issues and making grants to improve Memorial Hospital Miramar. health care practice and policy. Distinction: Two Memorial Healthcare System hospitals scored in the top 1 percent of public and private U.S. hospitals on a composite of 23 process-of-care quality measures (Memorial Hospital Pembroke and Memorial Regional Hospital); two others scored in the top 5 percent of hospitals nationally (Memorial Hospital West and Memorial Hospital Miramar). More than 2,000 public and private hospitals were eligible for the analysis. Timeframe: July 2007 through June 2008. See Appendix for full methodology. This case study describes the strategies and factors that appear to contribute to high adherence to “core” quality measures at Memorial Healthcare System. It is based on information obtained from interviews with key hospital personnel, publicly available information, and materials provided by the For more information about this study, hospital in September and October 2009. please contact: Jennifer Edwards, Dr.P.H. Health Management Associates [email protected] SUMMARY Memorial Healthcare System (MHS) has provided public hospital care in South Broward County, Florida, for 56 years.1 Over time, the system has grown and diversified to include primary and long-term care, cancer care, and a dedicated pediatric hospital. Starting in 1993, MHS accepted responsibility for the county’s public clinics and continues to operate these programs in an effort to coordinate To download this publication and learn about others as they become available, visit us online at 1 www.commonwealthfund.org and For this case study series, public hospitals were defined as those that are government register to receive Fund e-Alerts. owned and/or members of the National Association of Public Hospitals. It was not Commonwealth Fund pub. 1410 possible to compare hospitals by their payer mix, since hospitals may define payer Vol. 46 categories in different ways. 2 TH E CO mm ONWEALT H FUND Exhibit 1. Staff Communication About the Recognition Program: Memoral Health System The award recognizes outstanding employees for their achievements and commitment to providing a healing environment that is safe, efficient, customer focused, and of superior quality. As we strive to become the safest healthcare system in the nation, we salute our employees for always putting patients and families' needs first. Nominations Eligibility All Memorial Healthcare System employees, with the exception of Department Leaders and Administrative Officers, can be nominated for the recognition program. Nominations can be made for individuals who exhibit extraordinary behavior, as outlined in the criteria below. Review Process To nominate fellow employees for this award, we ask that you please review the pillar-specific criteria below. Select the pillar that most closely illustrates the extraordinary behavior. We recognize that some behaviors will have characteristics that fall into more than one pillar category. All nominations received will be automatically routed to the respective hospital or healthcare system entity where the nominated employee works. Each facility will have a designated committee to review the nominations and select the award recipients. Pillar Criteria: Safety, Quality, Service Safety Criteria: • Individuals who go “above and beyond” for patient, family, or employee’s safety • Potential for harm is avoided • Patient safety is a focus • Identification of a situation that warrants immediate intervention • Employee speaks up and is persistent regardless of hierarchal position or resistance encountered • An Incident Report must be completed and filed with Risk Management, when appropriate Quality Criteria: • Challenges the “status quo” and attempts to promote change that benefits the organization • Suggests and/or implements an idea that improves quality of care and increases productivity/efficiency • Develops a new strategy for improvement • Develops improved techniques • Detects flaw/imperfection and brings to the attention of others Service Criteria: • Manager attestation • Recognized by customers as consistently exceeding Memorial Healthcare System’s Standards of Behavior • Promotes optimism, teamwork, and collaboration on a consistent basis • Recognizes others for their efforts in meeting or exceeding department/organization goals • Respectfully welcomes open-minded and diverse opinions which creates a fertile environment for learning and collaboration • Identified as a great mentor and/or wise counsel • Excels at interdisciplinary collaboration Source: MHS, 2010. ME M ORIAL HEALT H CARE SYSTE M : A PUBLIC SYSTE M PUTS PATIENTS FIRST 3 the use of outpatient and inpatient care and provide Memorial Healthcare System is governed by a seven- savings for taxpayers who help fund bad debt and member board appointed by the governor. While gov- charity care at MHS. ernors have replaced board members at staggered On average, public hospitals do not perform as intervals of four to eight years, the president and CEO, well as private hospitals on the process-of-care, or Frank Sacco, FACHE, has been leading the organiza- “core,” measures reported by hospitals to the Centers tion for more than 22 years. for Medicare and Medicaid Services (CMS). The core MHS has experienced steady growth over the measures, developed by the Hospital Quality Alliance last few years as patients from across South Florida (HQA), relate to achievement of recommended treat- seek care from its hospitals and clinics, and as new ment in four clinical areas: heart attack, heart failure, hospitals have been acquired within a fairly small area pneumonia, and surgical care. The differences in core (the farthest hospitals are 15 miles apart). Inpatient measure performance between public and private hos- and outpatient volume are on the rise, with admissions pitals are not well understood, but may relate to public growing by 17 percent between 2005 and 2009 and hospitals having more complex patients, tighter bud- outpatient visits growing by 18 percent during the gets, or older infrastructure. MHS hospitals, however, same period. scored very well on process-of-care measures, not only County tax revenue helps to support the cost of compared with other publicly owned hospitals but uncompensated care at MHS, which reached $725 mil- compared with all hospitals. All four Memorial hospi- lion in FY2009; that year, bad debt and charity care tals were in the top 5 percent of hospitals on a com- rose by 19 percent over FY2008 levels. Despite the posite measure, and two were in the top 1 percent increased demand for indigent care, the system’s (among more than 2,000 hospitals in the analysis cov- FY2009 financial performance was the strongest in its ering the year ending June 2008). history, according to hospital leaders. Effective finan- MHS leaders have developed a multifaceted cial management has allowed the board to lower taxes quality and safety strategy that relies on storytelling to in each of the past three years. County tax-generated convey to staff and patients the type of care they wish revenue is less than 4 percent of the system’s total to provide. Monitoring and reporting of performance revenue. data, combined with careful design of care processes, MHS is implementing components of an elec- help the hospital achieve its goals. Staff also receive tronic health record system. In some parts of its hospi- training and coaching on ways to enhance the quality tals, physicians use the system to order treatments, of care. In addition, hospital leaders’ desire to appeal tests, and consultations. An automated pharmacy sys- to privately insured patients, and to keep people tem alerts clinicians about allergies, duplications, and healthy before and after hospitalizations, appears to risks. Bar-coding technology enables clinicians to drive improvement. For further information about the compare a medication’s bar code with a patient’s iden- public hospital selection process and cross-cutting les- tification bracelet to help prevent medication adminis- sons about their improvement efforts, please see our tration errors. The move from paper to electronic med- introduction to the public hospital case study series. ical record documentation is under way. In many patient care areas, clinical staff can access electronic Organization nursing notes, progress notes, vital signs, and other MHS is the nation’s fifth-largest public health care clinical information, but physician notes are not yet system. It operates five hospitals (in six sites), two part of the system. cancer institutes, a nursing home, an adult day care program, and numerous community and school-based clinics. Legally the South Broward Hospital District, 4 TH E CO mm ONWEALT H FUND System-Level Quality Activities (Exhibit 1). Honorees are recognized in their own MHS has a cohesive, centralized approach to