Multihospital Health Systems Research Articles

Characteristics of High-Quality Multi-Hospital Health Systems Performing Major Cancer Surgery

Objective: To identify characteristics associated with high- and low-quality multi-hospital systems for major cancer surgery Background: Although multi-hospital health systems provide most inpatient healthcare in the US, our understanding of how these systems can optimize surgical quality among their hospitals remains limited. Identifying the structural characteristics (e.g., number of hospitals, procedural volume, geographic dispersion) that distinguish high- and low-quality systems may inform actionable strategies to improve surgical quality. Methods: We conducted a retrospective cross-sectional observational study of 270,491 Medicare beneficiaries (2016-2020) undergoing major cancer surgery at a multi-hospital health system. Systems were classified into quartiles of quality based on risk- and reliability-adjusted rates of 30-day mortality using a hierarchical multivariable logistical regression model to adjust for patient, procedural, and hospital factors. Results: The adjusted 30-day operative mortality rate in the highest- versus lowest-quality quartile of systems was 1.7% versus 3.1%,(P<0.001). High-quality systems had fewer hospitals per system (median [IQR], number of system hospitals, 5 [3-11] vs. 12 [8-30];P<0.001), with each performing more procedures per hospital (median [IQR] annual procedure volume, 104 [52-218] vs. 45 [22-90];P<0.001). High-quality systems were also more geographically concentrated (median [IQR] maximum distance between hospitals, 62 [19-194] vs. 321 [91-1125] miles;P<0.001). Furthermore, high-quality systems demonstrated less variation in quality between hospitals (mean [SD] within-system absolute variation in mortality, 0.8% [0.3%] vs. 2.6% [1.0%];P<0.001). Conclusions: The highest-quality multi-hospital systems had fewer, more geographically concentrated hospitals, with each performing more procedures per hospital. Among the highest-quality systems, diverse system phenotypes were represented, suggesting the potential to overcome structural limitations and achieve high quality.

A novel cardio-oncology service line model in optimizing care access, quality and equity for large, multi-hospital health systems

BackgroundDespite the rapid growth of cardio-oncology as a subspecialty, cancer patients are still underserved from a cardiovascular perspective. A new care model is needed to integrate comprehensive cardio-oncology care with community-based facilities to improve care access, quality, and equity. Here, we present a cardio-oncology service line model for large, multi-hospital health systems to address this need.MethodsAn academic cardio-oncology program was first established using a multidisciplinary approach. Five infrastructure elements for a service line model were created, including strategic accountability, standardized care, dedicated resources, patient experience/education, and branding/identity. We then utilized these elements across our healthcare system to establish a quality-controlled and centrally governed cardio-oncology service line structure. Protocols were created to standardize care and ensure consistency and quality, including referral workflow, imaging, cardiotoxicity surveillance, and clinical management. An IRB-approved cardio-oncology registry was established for outcome tracking.ResultsThe standardized cardio-oncology services were expanded to eight hospitals and ten outpatient care centers, including rural outreach offices, resulting in increased patient access and improved clinical quality measures. The service area expanded 17-fold, and an estimated rural population of 204,133 gained access to care. Cardio-oncology office visits increased by approximately 600% three years after implementation of the service line model.ConclusionsA cardio-oncology service line with standardized care is a feasible and effective care model to improve cardio-oncology care quality, patient access, and health equity in large, multi-hospital health systems. It can be used in conjunction with academic cardio-oncology programs to improve the overall cardio-oncology healthcare efficacy in the US.

Association of Commercial-to-Medicare Relative Prices With Health System Financial Performance

Various studies have documented the rise in commercial insurance prices during the past 2 decades; however, estimates on the association of rising costs with health systems' financial health are lacking. This study calculated 2 measures from standardized Audited Financial Statements (AFSs)-operating margins and days of unrestricted cash on hand-to explore the associations. To estimate the association between health systems' financial condition and the ratio of commercial to Medicare relative prices. This cross-sectional analysis combined standardized 2018 AFSs from a large sample of US health systems with publicly available relative price data to assess the association between their financial outcomes and commercial-to-Medicare relative inpatient prices. The 2018 AFSs were collected and standardized from a convenience sample of multihospital health systems and single hospitals that were included in round 4 of the RAND Hospital Price Transparency Study. Cross-sectional, multivariate regression models were estimated, controlling for payer mix and other system characteristics, and models were weighted by health systems' 2018 adjusted admissions. The analyses were conducted July 2021 through November 2022. The commercial-to-Medicare relative price for inpatient services (2018-2020 pooled average), which represents the average amount paid by commercial plans as a percentage of what Medicare would have paid to the same health system for the same services. Operating margins and days cash on hand, which capture complementary aspects of financial performance (profitability and liquidity). The study sample included 156 health systems in the US, representing diverse geography, size, and ownership type. Mean (SD) days cash on hand were 180.1 (113.3) and operating margins were 3.3% (3.6%) in 2018. Overall, a 1-unit increase in the commercial-to-Medicare relative price ratio was associated with a 21.3% (95% CI, 21.3% to 21.4%; P < .001) increase in days cash on hand and a 2.7 (95% CI, 2.7 to 2.7; P < .001) percentage point increase in average operating margins. Higher Medicaid payer mix share was associated with fewer days cash on hand (-3.3%; 95% CI, -3.3% to -3.3%; P < .001) and lower operating margins (-0.081; 95% CI, -0.082 to -0.081; P < .001). This cross-sectional study of health system financial data found that higher commercial-to-Medicare relative prices and a lower Medicaid payer share were associated with higher profits and more days cash on hand. These findings provide evidence against the claim that relatively higher commercial prices are primarily used to offset losses from public payers rather than to increase profits and liquidity.

Longitudinal Trends in 30-Day Mortality Between Multi-Site and Single-Site Surgeons.

Quality leaders are concerned that creation of multi-hospital health systems may lead to surgeons traveling to and from distant hospitals and thus to more fragmented surgical care and worse outcomes for their patients. Despite this concern, little empirical data exist on outcomes of multi-site versus single-site surgeons. Using national Medicare data, we assessed trends in the number of multi-site vs. single-site surgeons from 2011 to 2016. We performed a multivariable regression analysis to compare overall 30-day mortality differences, stratified by system and rural status, and examined trends over time. The number of multi-site surgeons and the percentage of multi-site surgeons per hospital decreased over time (24.2%-19.0%; 44.3%-41.8%). Overall, multi-site surgeons had lower 30-day mortality than single-site surgeons (2.24% vs 2.50%, P < 0.01). When stratified by system status, multi-site surgeons performed better in-system (2.47% vs 2.58%, P < 0.01); by rural status, multi-site surgeons had lower mortality in non-rural hospitals (2.42% vs 2.51%, P < 0.01). The statistically significant but small mortality advantage of multi-site versus single-site surgeons decreased over time, such that by 2016 there was no difference in outcomes between multi-site and single-site surgeons. For the majority of study years, multi-site surgeons had lower 30-day mortality than single-site surgeons, but this trend narrowed until outcomes were equivalent by 2016. Surgeons operating at multiple hospitals can provide surgical care to patients without any evidence of increased mortality.

ASHP Pharmacy Executive Leadership Alliance kicks off with discussion with AHA CEO Richard Pollack.

ASHP’s Pharmacy Executive Leadership Alliance (PELA™) held its inaugural event virtually Oct. 29 to celebrate the creation of the new ASHP member engagement opportunity, share experiences, and brainstorm about innovations that will drive financial and organizational recovery from the effects of the COVID-19 pandemic. PELA™ was created by ASHP for chief pharmacy officers and multihospital system pharmacy executive leaders who face distinct challenges working within highly complex vertically and horizontally integrated networks and multihospital health systems. The inaugural session of what is just the start of a series of events included more than 160 pharmacy executives representing chief pharmacy officers and directors of pharmacy from more than 100 multihospital health systems and 80 major hospitals and academic medical centers. “The idea for PELA™ has been at the forefront of ASHP leadership discussions for some time,” said ASHP Chief Executive Officer (CEO) Paul W. Abramowitz. “We understand that there is a...

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014\u20132016

BackgroundComputerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics.MethodsWe analyzed longitudinal data (2014–2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use.We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016.ResultsBetween 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics.ConclusionsSmall practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

Pharmacy informatics in multihospital health systems: Opportunities and challenges.

Challenges and opportunities in managing pharmacy-related technology in a multihospital health system are reviewed. With electronic medical record (EMR) implementations, pharmacy technology deployments, and increased numbers of hospitals merging into single health systems, opportunities and challenges for pharmacy informatics (PI) teams have grown. Pharmacy leaders must consider the implications of using technology in a multihospital health-system environment, as well as the impact of the health system's organizational structures on technology implementations and dedicated support teams. Common challenges in achieving EMR and other technology implementation and standardization initiatives in multihospital health systems include harmonization of practices across hospitals of various sizes and types and issues of platform compatibility and interoperability. PI teams must collaborate with information technology teams at the system level to identify practical strategies for making the best use of available resources to implement pharmacy automation and software to help pharmacists continue to provide safe and effective patient care. The organizational structures that affect informatics teams, pharmacy integration and standardization initiatives, formulary management practices, data management and analytics, and clinical decision support systems all must be areas of focus. An integrated pharmacy enterprise can be well positioned to leverage operational efficiencies gained from appropriate use of technology to enhance patient care. Careful attention must be paid to the manner in which these systems are designed, implemented, and managed in order to make the best use of the technological resources used by the health system.

Development and innovation of system resources to optimize patient care.

Various incremental and disruptive healthcare innovations that are occurring or may occur are discussed, with insights on how multihospital health systems can prepare for the future and optimize the continuity of patient care provided. Innovation in patient care is occurring at an ever-increasing rate, and this is especially true relative to the transition of patients through the care continuum. Health systems must leverage their ability to standardize and develop electronic health record (EHR) systems and other infrastructure necessary to support patient care and optimize outcomes; examples include 3D printing of patient-specific medication dosage forms to enhance precision medicine, the use of drones for medication delivery, and the expansion of telehealth capabilities to improve patient access to the services of pharmacists and other healthcare team members. Disruptive innovations in pharmacy services and delivery will alter how medications are prescribed and delivered to patients now and in the future. Further, technology may also fundamentally alter how and where pharmacists and pharmacy technicians care for patients. This article explores the various innovations that are occurring and that will likely occur in the future, particularly as they apply to multihospital health systems and patient continuity of care. Pharmacy departments that anticipate and are prepared to adapt to incremental and disruptive innovations can demonstrate value in the multihospital health system through strategies such as optimizing the EHR, identifying telehealth opportunities, supporting infrastructure, and integrating services.

Multihospital health systems: Seize the opportunity.

Healthcare today is a challenging business. The costs of maintaining market competitiveness are extreme due to the complexity of modern treatments and the expense of implementing technological advances.[1][1],[2][2] Healthcare organizations are responding to these challenges in many ways, including

Creating a learning organization to help meet the needs of multihospital health systems.

The considerations that leaders of multihospital health systems must take into account in developing and implementing initiatives to build and maintain an exceptional pharmacy workforce are described. Significant changes that require constant individual and organizational learning are occurring throughout healthcare and within the profession of pharmacy. These considerations include understanding why it is important to have a succession plan and determining what types of education and training are important to support that plan. Other considerations include strategies for leveraging learners, dealing with a large geographic footprint, adjusting training opportunities to accommodate the ever-evolving demands on pharmacy staffs in terms of skill mix, and determining ways to either budget for or internally develop content for staff development. All of these methods are critically important to ensuring an optimized workforce. Especially for large health systems operating multiple sites across large distances, the use of technology-enabled solutions to provide effective delivery of programming to multiple sites is critical. Commonly used tools include live webinars, live "telepresence" programs, prerecorded programming that is available through an on-demand repository, and computer-based training modules. A learning management system is helpful to assign and document completion of educational requirements, especially those related to regulatory requirements (e.g., controlled substances management, sterile and nonsterile compounding, competency assessment). Creating and sustaining an environment where all pharmacy caregivers feel invested in and connected to ongoing learning is a powerful motivator for performance, engagement, and retention.

Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach.

Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results. We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods. Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts. Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Creating a Pediatric Joint Council to Promote Patient Safety and Quality, Governance, and Accountability Across Johns Hopkins Medicine

Large multihospital health systems with multiple children's hospitals are relatively few in number. With a paucity of national pediatric measures for quality and patient safety, there are unique challenges to ensuring consistent levels of care across diverse health care delivery settings. At Johns Hopkins Medicine, a Pediatric Joint Council was created to help ensure high-quality and safe care across a health system encompassing two full-service children's hospitals and two community hospitals with significant pediatric volumes across two states. Across the health system, a governance, leadership, and management structure was developed to coordinate the quality and safety of patient care throughout the academic health system. Within the pediatric service line, the multidisciplinary Pediatric Joint Council included representation from each pediatric entity and was supported by project managers, quality improvement (QI) team leaders, QI leads from each entity, infection control, and clinical analysts. The Pediatric Joint Council was responsible for setting standards and improvement goals, as well as monitoring and improving performance of pediatric services across the health system and identifying training gaps and research opportunities. The Pediatric Joint Council model, as implemented, provides a focused structure for coordinated efforts across disparate pediatric entities, ensuring horizontal peer learning and entity-specific improvements, as well as vertical lines of accountability and central oversight with shared governance. This model has served to help identify areas in need of pediatric expertise and has facilitated the use of resources from across the entire health system focused on improving pediatric care.

Cost-Efficiency Analysis of a Multi-Pavilion Hospital in Cluj County.

Background and aimMulti-hospital health systems have become the most popular administrative structure in healthcare, leading to both opportunities and challenges for hospital administrators. In government-funded healthcare systems, there is a balance between costs and the provision of health services.The aim of the present study is to assess the efficiency in terms of costs of a multi-pavilion hospital from Cluj County, Romania.MethodsThe institution analyzed in this article is the Adults’ Clinical Hospital in Cluj-Napoca. A descriptive retrospective study collected data from January 2004 to December 2010. A set of indicators were compiled, divided into three main categories: personnel, statistics, and financial.ResultsTwenty-one financial indicators were investigated. Heterogeneity between different years was observed for the continuous hospitalization indicator and the wage budget indicator. The highest variability was observed between the budget and expenses indicators, while a smaller variability was observed at the average costs per patient. The costs per patient have increased at all pavilions in the studied time frame, the higher costs being at the Internal Medicine and Surgery pavilions: 10,203 RON in 2010 (1 euro ~ 4.4 RON)ConclusionThe pavilions included in the Adults’ Clinical Hospital Cluj-Napoca have different expenses patterns, as each pavilion is focused on different specialties. Each pavilion serves different target groups, requiring different procedures. This in turn results in different expense patterns across each pavilion.

Hospital Consolidation: “Safety in Numbers” Strategy Prevails in Preparation for a Value-Based Marketplace

One of the most significant unintended consequences of the passage of the Affordable Care Act (ACA) in March 2010 has been the ignition of another wave of consolidation activity among U.S. healthcare providers. Similar to the industry's response to the threat of managed in the mid-1990s, merger and acquisition (M&A) activity between multihospital health systems, stand-alone hospitals, large multispecialty medical groups, small independent physician group practices, and other provider organizations has accelerated dramatically in response to the ACA. According to Irving Levin Associates, the number of hospital mergers more than doubled between 2009 and 2012 (Creswell & Abelson, 2013). Tracking physician consolidation nationally is less precise, but Medical Group Management Association survey data suggest that the percentage of physicians working in practices owned by a hospital or an integrated delivery system increased from 24% in 2004 to 54% in 2012 (MGMA, 2013).At the end of the last wave of consolidation, by 2000, the overall percentage of hospitals in systems had increased from 38% to 52%. And since the Great Recession and passage of the ACA, nearly another 400 hospitals (10% of U.S. community hospitals) had joined multihospital systems and the percentage of hospitals in systems had increased to 62% by the end of 2013 (AHA, 2014). Additionally, these figures do not include the substantial number of announced that ultimately were never consummated. For a variety of factors (cultural, political, legal, and regulatory), transactions between nontaxable entities are significantly more time consuming, unpredictable, and difficult to close than are mergers between taxable entities. In spite of the challenges of successfully executing merger strategies, it seems that nearly all hospitals and health systems, from organizations worth $ 100 million to those worth more than $ 1 billion, are asking, Are we big enough to not merely survive, but to thrive, in the emerging postreform environment?Intended to reduce the fragmentation of delivery (thereby improving quality and reducing cost), the ACA has triggered market forces that are working to essentially flip the provider-side business model from fee-for-service (FFS) to value-/risk-based reimbursement models (e.g accountable care/shared savings, bundled payments, partial or full capitation arrangements). This shift is akin to auto insurers telling auto body shops that over the next few years the shops will increasingly be paid to prevent auto accidents rather than earn fee-for-service revenues to repair damaged vehicles. Traffic safety is no more a core competency for auto body shops than wellness, prevention, and coordination are for most community hospitals. Hospitals seeking to go it alone face a daunting level of investment in both financial and human resources to build the infrastructure and capabilities required to shift from an acute event-driven sick care system to a proactive prevention and coordination mind-set.Although the respective financial strength of both parties is certainly a key consideration in any business combination, pursuit of a merger to simply create a fortress balance sheet is not sufficient to position an organization for success in the valuebased marketplace. One of the lessons of the Great Recession is that even the most unassailable community hospital balance sheets can be compromised in a shockingly short period. In addition to shoring up the balance sheet, many hospital transactions have been justified in the pursuit of economies of scale. The literature suggests, however, that many, if not most, M&A transactions do not achieve the desired results. In fart, the most recent data released by the Synthesis Project, an ongoing national study by the Robert Wood Johnson Foundation, suggest that consolidation (absent true integration) does not lead to cost reductions or clinical improvement and may lead to enhanced market power for providers (Gaynor & Town, 2012). …

Pharmacy initiatives in multihospital health systems

Pharmacy initiatives in multihospital health systems