An Important Message From Our CEO:Quality

An Important Message on Quality From Our CEO Gary Herbst

Kaweah Delta recently added “Excellence is our Focus” to our mission statement and we are all working hard to achieve our vision of becoming your world-class, healthcare choice for life. While we have more progress to make, we are working daily to achieve this vision. We are also committed to being open and transparent, so we are letting you know that the Centers for Medicare & Medicaid Services (CMS) has recently updated its overall hospital quality star ratings. The highest star rating that a hospital received within 100 miles of Visalia was three out of five stars; we received two stars. We are not satisfied with this rating and prior to the release of these scores, we began taking steps to improve.

The ratings are available on the Hospital Compare website and they reflect CMS’ assignment of star ratings to 4,586 hospitals nationwide based on their performance across seven quality performance areas: mortality, safety of care, readmission rates, patient experience, effectiveness of care, timeliness of care, and efficient use of medical imaging. Of the 25 hospitals within 100 miles of Visalia, 17 hospitals were given star ratings. Of those, six received three stars, six received two stars, and five received one star. The ratings are based on quality data as recent as October 2019, but some data is from 2015.

While many hospitals have been critical of the methodology that CMS uses for these ratings and CMS is changing its methodology, it published these scores using its unchanged methodology. This decision has frustrated many. In a statement, American Hospital Association (AHA) Executive Vice President Tom Nickels said, “AHA is disappointed that CMS continues to publish hospital star ratings that are plagued by longstanding concerns about accuracy and meaningfulness. While we appreciate that CMS is working on potential improvements to the star rating methodology for 2021, we strongly believe that today’s re-publication of the flawed and misleading ratings do not advance the goal of providing the public with accurate, purposeful information about quality of care. CMS should suspend the publishing of star ratings until needed improvements have been made to their methodology and have been vetted and are ready for implementation.”

We know that it is not always easy to make sense of the publically-released quality data, in part because they use different methodologies and look at different data. But the CMS star ratings are based on data we self-report, so they are not new to us. We have more than 70 committees of doctors, nurses and staff that are taking immediate action to improve quality in all areas of the hospital. One thing that impacted our star-rating in this release was our mortality rate, which was based on data from 2015-18. We are working to improve, but it’s important to keep in mind that we care for a very sick population. Our county ranks among the lowest in the state when it comes to access to clinical care, the number of physicians, overall health outcomes, patients’ health behaviors and people living in poverty. We do everything in our power to improve the health of every person who walks in our doors.

One of the opportunities we are working on is reducing hospital-acquired infections. We have seen some improvement, but we are not where we want to be yet. We recently completed a Kaizen event, a lean six sigma (quality improvement) approach founded by Toyota that has been adopted by other industries, including health care, to make changes for the better. We have another scheduled this week. Additionally, we have hired a Chief Quality Officer at Kaweah Delta, who will begin later this month. This senior executive will be focused on performance improvement and patient safety initiatives.

Again, excellence is our focus, and we will stop at nothing to improve in our care for this community. Our hope is that when the next report on quality is released, we will all see improvement.