By KATHRYN FLAGG
MIDDLEBURY — Based on scores on a recent statewide hospital “report card,” Middlebury’s Porter Medical Center might appear to have a bit of studying up to do.
Hospital officials say they’re taking the scores seriously, but when it comes to painting a complete picture of just how well Porter is doing, the June report card only goes so far.
According to the statute-required “Hospital Report Cards” study complied by the Vermont Department of Banking, Insurance, Securities & Health Care Administration (BISHCA), Porter’s scores fell below the state average in all four categories identified by the study. Those categories are heart attack care, heart failure care, pneumonia care and the hospital’s ability to prevent complications from surgery.
In all but one category — preventing complications — Porter also scored below national averages on the report card.
The BISHCA report shows that in Porter’s worst scoring category — heart failure care — only 59 percent of patients received all of the necessary procedures as defined by the report. On average, 82 percent of patients nationwide and 85 percent of patients in Vermont received all of these procedures.
But putting procedure aside, Porter officials say the hospital stacks up well by another metric — patient outcomes.
“If you step away from these charts a little bit that are so oriented in the process, and focus instead on the outcomes (of patients), you get a very different picture,” said Ron Hallman, the vice president for development and public relations at Porter. “When you do a relatively superficial treatment of a complex topic, you almost inevitably come up with an incomplete picture.”
The BISHCA report grades a hospital on how precisely it followed a list of prescribed procedures for each ailment, explained Porter Vice President for Patient Care Services Pat Jannene. In the case of heart attack care, for instance, the report considered steps such as administering aspirin to a patient on arrival and discharge, providing a beta blocker at discharge, providing smoking cessation counseling, and other medical procedures.
Hospitals needed to follow the list of procedures exactly for each patient, and document them in a patient’s chart, or else their BISHCA score suffered.
In some cases, Jannene said, doctors have differences of opinion about whether or not some of those criteria are appropriate.
Jannene also pointed out that in Porter’s case, some of the BISHCA scores represented a very small number of patients. Most heart attack patients, she said, are sent to Fletcher Allen Health Care. That means the treatment of those patients isn’t considered in Porter’s “report card.”
Pat Jones, the director of health care quality improvement at BISHCA, said officials at her agency agree that “process measures” like the report card are just one piece of a larger story about how hospitals are doing.
But she also said neither outcome measures, like mortality rates, nor process measures can stand alone. Outcome measures based on mortality rates tend to be fairly crude, she said, because of the large number of variables that go into mortality.
“It’s important to look at both (measures),” Jones said.
Hallman and Jannene were careful not to diminish the importance of the BISHCA report cards. These snapshots, Hallman said, provide an important update on a hospital’s performance to community members, patients, and legislators.
“We definitely don’t want to give the impression that we think these measurements aren’t important … but I think we do think that they only show a relatively small component of quality,” Hallman said.
When one sets aside the procedural ratings to look at patient outcomes, for example, Porter stacks up well compared to both state and national averages.
The mortality rate for heart attack victims is just under 15 percent within 30 days after treatment — lower than the 16.1 percent who die nationally and the 17.1 percent rate at Rutland Regional Medical Center, for example.
Similarly low is the number of patients who die within 30 days following treatment for heart failure at Porter — 11.4 percent, compared to the 13.8 percent at Fletcher Allen.
And the mortality rate in the month after treatment for pneumonia at Porter is 9.8 percent — the lowest in the state.
To Hallman’s mind, paying more attention to procedures than outcomes gets at one of the problems in the country’s approach to healthcare.
“As a nation, we seem to be recognizing that it’s outcomes that we need to be focusing on versus ‘doing things’ to people all the time,” Hallman said. “Right now, the way healthcare is delivered and paid for is that hospitals generally get paid for the more things we do to people: every test, every inoculation, every procedure, every day in the hospital, we get paid for doing those.
“Why don’t we pay for results, versus activities?” he went on. “If you judge Porter by the results … we must be doing something pretty well.”
Still, Jannene said that the hospital is continuously, and aggressively, working to improve the quality of its patient care.
Performance improvement teams have already made headway in some arenas of care. For instance, a group looking at heart attack care has developed a process for getting patients stabilized and to Burlington within 90 minutes.
Jannene also thinks that other developments on the hospital’s horizon, like the future investment in electronic medical records, will make executing and reporting patient procedures easier, which could boost Porter’s scores on future BISHCA report cards.
Another boost to heart failure and heart attack numbers could come after a full-time cardiologist joins the hospital staff this September, bumping the number of cardiologists on staff to one and a half full-time positions.
Though the BISHCA numbers only tell part of the story about Porter’s patient care, Jannene said, the hospital staff is motivated to see those numbers improve on future report cards. That means that in addition to concentrating on positive patient outcomes, the staff is motivated to work on “process-related” documentation.
“They want to be able to assure patients in the community that (patients are) getting the very best care they can get,” Jannene said.