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Avera Health Quality Report

Hospital Acquired Conditions

Hospital Acquired Conditions

The Patient Protection and Affordable Care Act (ACA) established the Hospital Acquired Condition Reduction Program to encourage hospitals to reduce HACs. HACs are a group of reasonably preventable conditions that patients did not have upon admission to a hospital, but which developed during the hospital stay. Hospital performance under the HAC Reduction Program is determined based on a hospital’s Total HAC Score, which can range from 1 to 10.

The higher a hospital’s Total HAC Score, the worse the hospital performed under the HAC Reduction Program. Hospitals are given an opportunity to review their data and request a recalculation of their scores if they believe an error in the score calculation has occurred. Effective beginning FY 2015, the law requires the Secretary of the Department of Health and Human Services to reduce payments to hospitals that rank in the quartile of hospitals with the highest Total HAC Scores by 1 percent.

Avera’s HAC scores have successfully kept all regional hospitals out of the range for receiving the 1% HAC penalty issued to the top 25% of hospitals whose scores result in a 1% payment reduction.

Facility

Total HAC Score 2015

Total HAC Score 2016

Payment Reduction

Avera St. Luke’s

1.98

2.250

No

Avera Heart Hospital

3.33

3.625

No

Avera Sacred Heart

2.30

4.250

No 

Avera Queen of Peace

3.10

5.375

No

 

Avera McKennan

3.30

5.500

No

 

Avera St. Mary’s

3.00

6.750

No 

 

Readmissions

Readmission Reduction Program

Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.

FY 2015 Readmission Reduction Program Summary Program Details:

  • FY 2015 FY 2016 Readmission Reduction Program includes the following 30-day Risk Standardized Readmission measures:
    • Acute Myocardial Infarction, (AMI) readmission
    • Heart Failure, (HF) readmission
    • Pneumonia, (PN) readmission
    • Chronic Obstructive Pulmonary Disease, (COPD) readmission
    • Total hip and/or knee arthroplasty, (THA/TKA) readmission
  • If a hospital performs better than an average hospital that admitted similar patients the ratio will be less than 1.0000.
  • If a hospital performs worse than average, the ratio will be greater than 1.0000.
  • The facilities below with a ratio greater than 1.0000 and will receive a payment reduction. Calculations for FY 2015 are complete; reduction calculations for FY 2016 are pending.

FY 2015

AMI Excess Readmission Ratio

COPD Excess Readmission Ratio

HF Excess Readmission Ratio

PN Excess Readmission Ratio

THA/TKA Excess Readmission Ratio

Penalty

AQOP

0.9842

0.9658

0.9646

0.8236

1.1117

$67,323

ASHH

0.9618 

1.0064

1.0547

0.9426

0.9335

$18,506

AMCK

0.9496

0.9031

0.8667

0.8381

0.8951

NA

ASM

0.9881                    (not enough cases)

0.9686 

1.0093

0.9666

0.9372

$758

ASL

 0.8880

0.8897

0.8333

0.8384

0.8426

NA

AHHSD

0.8216

1.0007                       (not enough cases)

0.8465

0.9617

NA

NA

FY 2016

AMI Excess Readmission Ratio

COPD Excess Readmission Ratio

HF Excess Readmission Ratio

PN Excess Readmission Ratio

THA/TKA Excess Readmission Ratio

Penalty

AQOP

0.9984

0.9696

0.9248

0.7903

1.0816

Yes

ASHH

0.9745 

0.9801

0.9853

0.8966

1.0755

Yes

AMCK

1.0074

0.9115

0.9815

0.8632

0.8448

No

ASM

0.9768

0.9453

0.9699

0.9327

0.9082

No

ASL

0.8870

0.9266

0.8919

0.8672

0.8926

No

AHHSD

0.8005

0.9950

0.7328

0.97857

NA

No

Value Based Purchasing

Value Based Purchasing

Hospital Value-Based Purchasing (VBP) is part of the Centers for Medicare & Medicaid Services’ (CMS’) long-standing effort to link Medicare’s payment system to a value-based system to improve healthcare quality, including the quality of care provided in the inpatient hospital setting.

The program attaches value-based purchasing to the payment system that accounts for the largest share of Medicare spending, affecting payment for inpatient stays in over 3,500 hospitals across the country.

Participating hospitals are paid for inpatient acute care services based on the quality of care, not just quantity of the services they provide. Congress authorized Inpatient Hospital VBP in Section 3001(a) of the Affordable Care Act. The program uses the hospital quality data reporting infrastructure developed for the Hospital Inpatient Quality Reporting (IQR) Program, which was authorized by Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003

Federal Fiscal Year

2013

10/01/12

09/30/13

2014

10/01/13

09/30/14

2015

10/01/14

09/30/15

Avera McKennan

$77,000

-$5,732

$69,510

Avera Queen of Peace

$31,900

$39,230

$74,224

Avera Sacred Heart

$28,000

$21,503

$57,613

Avera St. Luke's

-$2,700

-$1,803

$95,291

Avera St. Mary's

-$16,200

-$17,151

$33,892

Avera Heart Hospital

$105,500

$84,780

$221,389

Estimated Impact

$223,700

$120,827

$551,919

QUEST

QUEST

Today health systems are navigating through a variety of strategies and tactics to respond to current unprecedented financial pressures. Alternative models for care delivery are surfacing more frequently, yet the impact of value-based purchasing (VBP) and associated payment penalties will still be felt by most for years to come.

Reform has tied payment to quality and health systems must improve their performance if they wish to succeed under VBP. Premier’s QUEST collaborative provides an ongoing opportunity for health systems to review data from peer organizations and work with fellow executives to drive quality improvement in seven domains: evidence-based care (EBC), cost and efficiency, mortality, safety, patient and family engagement, appropriate hospital use and community health. Avera regional hospitals located in Pierre, Sioux Falls, Mitchell, Yankton and Aberdeen participate in the Premier QUEST initiatives.

Avera Health performs in the top threshold for the program in Evidence Based Care, Mortality, Appropriate Hospital Use and Cost and Efficiency.   

Outcomes for Avera System after 1 year of participation in Quest 3.0

Dollars Saved

$14,679,040

Deaths Avoided

139

Harm Events Avoided

18

Readmissions prevented

No change

Patients receiving Evidence Based Care

53

Evidence Based Care Inpatient

Evidence Based Care Outpatient

Safety Chart 2014

Patient & Family Engagement

Mortality Chart 2014

Appropriate Hospital Use Chart

Cost and Efficiency Chart 2014

Satisfaction

Avera Patient Experience Report

“I would like to mention all of the staff … where I had my biopsy done. There was not a person there who wasn't kind and concerned and helpful. It was just another experience at Avera. It was absolutely, it's the best facility I've ever had the privilege of going to, and I thank you very, very much for the hospital and clinic and all of the people there because you make it easy to go through an experience like this. Just, thank you very much.”

Comments such as this one are received at every Avera facility and indicate the compassionate care provided throughout Avera. This caring environment reflects “The Avera Way” – Guided by Christian values, we commit to consistently deliver an excellent experience to every person at every encounter.

Based on the Mission and Values of Avera, teams of leaders representing facilities across Avera seek to standardize evidence based practices to ensure that care is delivered in a consistent manner throughout Avera. During fiscal year 2015, standardized practices implemented by facilities included:

  • AIDET – a verbal communication structure to ensure effective communication
  • Hourly Rounding – a care practice that anticipates and addresses patient needs
  • Nurse Leader Rounding – a leader practice to connect with patients and families to ensure quality care is provided
  • Patient Communication Boards – a practice that provides enhanced communication to patients and families

The public now is able to compare hospital facilities online by the 5 Star methodologies – similar to other service industries. Avera St. Anthony’s Hospital and Avera Holy Family Hospital were among the elite 5 Star recipients in the first publication of data by CMS in 2015!

Patient experience results, indicated in the graphs, continue to impact inpatient reimbursement by CMS through Value Based Purchasing and are an increasing focus for third party payers. CMS is moving forward to mandate the publication of results and/or reimbursement adjustments for additional services such as In-center Hemodialysis, Home Health/Hospice, Emergency Departments and Clinic Groupings. As a result, it is critical to provide excellent experience to our patients, residents and families across the entire continuum of services provided by Avera. To provide actionable information, patient experience surveys are conducted in the following areas:

  • Inpatient
  • Outpatient
  • Ambulatory Surgery
  • Emergency Department
  • Home Health/Hospice
  • Long Term Care
  • In Center Hemodialysis
  • Clinic - Pilot Project

Standardizing practices across the continuum of care to create a consistently excellence experience for every person at every encounter is our commitment to “The Avera Way”.

Avera Facility Overall Inpatient

Avera CAH Facility Overall Inpatient Percent Rank

Live Better. Live Balanced. Avera.

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