16-150 chi mem 2015 year in review (3)

CHI Memorial’s 2015 Year in Review

Photo © by Michael Peck

16-150 CHI MEM 2015 Year in Review.indd 1 1/6/16 5:15 PM

Healthcare is constantly evolving, and CHI

Memorial is positioned to lead rather than

follow the trends. We are focused on what’s

important – better patient outcomes, better

patient experiences and better healthcare

value. This Year In Review provides a high level

overview of the progress and accomplishments

we’ve made as well as a look into the future of

medical care at CHI Memorial.

CHI Memorial’s 2015 Year in Review


Matthew H. Kodsi, M.D.,Vice-Chief of Staff

David B. Dodson, M.D.,Immediate Past Chief

Christopher St. Charles, M.D.,Chief of Staff

W. McKinney Young, Jr., M.D.Secretary

Fiscal 2015 Financial Highlights $606 million | Total Income for the Health System $579 million net revenue from patient services 24,442 admissions (2.3% increase) 81,115 ER visits (5.5% increase) 22,161 surgeries 483,327 office visits

Physician Statistics 672 medical staff458 clinical privileges214 affiliate memberships

CHI Memorial Medical Group124 physicians (14 new in 2015)39 advanced practice clinicians (28 new in 2015)


Quality Metrics

Quality Composite Score: Defined by Premier Quality Advisor or National Healthcare Safety NetworkSeven standardized and risk-adjusted indicators: death due to pneumonia, death due to heart attack, catheter associated urinary tract infection, central line associated blood stream infections, surgical site infections following colon surgery, and surgical site infections following abdominal hysterectomy Baseline performance: 39th percentileCurrent performance: 53rd percentile

Patient Safety Composite Score: Defined by the Agency for Healthcare Research and Quality (AHRQ)Eight risk adjusted, weighted component PSI measures combined into a single composite score: accidental puncture or laceration, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, latrogenic pneumothorax, central line-associated blood stream infection, pressure ulcer, postoperative wound dehiscence, and post operative hip fracture. Baseline performance: 85th percentileCurrent performance: 95th percentile


Patient Experience | Overall Rating of HospitalGoal performance: 75th percentile Current performance: 84th percentile

Medicare’s Hospital Compare Star Rating | Summary Star Rating: 4 Cleanliness: 3 Nurse communication: 4Doctor communication: 4Staff responsiveness: 4Pain management: 4Communication about medication: 4 Discharge information: 4Care transition: 4Overall hospital rating: 5Quietness: 4Recommend hospital: 5

Quality Metrics


Quality Metrics (continued)

Overall Inpatient Experience (HCAHPS)Large: 250 or More BedsMemorial Hospital (CHI) Top Box: 84.3% Percentile Rank: 93rd

CG CAHPS – OverallCHI Memorial Robotics and Urological Cancer Care (CHI)Top Box: 97.5% Percentile Rank: 99th

CG CAHPS - Clinic-UrologyCHI Memorial Robotics and Urological Cancer Care (CHI) (Lee Jackson)Top Box: 97.5% Percentile Rank: 97th


Cancer ServicesThe Rees Skillern Cancer Institute provides the overarching structure for CHI Memorial’s first class cancer care program. Our extraordinarily comprehensive patient care experience is provided through care navigation, support for survivorship, and genetic risk assessments and counseling. Radiation oncology services is experiencing unprecedented patient volumes due in part to a great team of physicians and staff, department renovations and new capabilities in brachytherapy and stereotactic radiotherapy.


CHI Memorial is currently developing a multidisciplinary valvular disease center at the Guerry Heart and Vascular Center. In 2015, CHI Memorial achieved Primary Stroke Center Accreditation through the Joint Commission, which acts as a springboard for additional opportunities in neurologic care. The multidisciplinary Transcatheter Aortic Valve Replacement (TAVR) team performed its 100th procedure and is expanding into Transcatheter Mitral Valve Replacements, a first for this market. STEMI door to balloon times were maintained well below 60 minutes, and the CHF management program has led to substantial reductions in patient mortality and readmission rates that are half the national average.1,324 percutaneous coronary interventions3,723 diagnostic procedures667 open-heart surgeries

The Chattanooga Heart Institute23 cardiologists10 advanced practice clinicians

Cardiac Care


CHI Memorial is proud of the investments it has made to improve population health in our region. Mission Health Care Network (MHCN), CHI Memorial’s clinically integrated network, involves 526 physicians and 272 advanced practice clinicians for a network of 798 providers. MHCN actively manages nearly 35,000 individuals through our employee health plan and participation in the Medicare Shared Savings Program. The physician-led Board of Managers continues to do a remarkable job of guiding this effort that is quickly gaining the attention of additional payors and employers. Other innovative models of care include participation in Bundled Payments for Care Improvement (BPCI) initiatives in total joint replacement and congestive heart failure. Patient Centered Medical Home (PCMH) journeys are active in a number of CHI Memorial physician practices.

Clinically Integrated Care


Infrastructure ImprovementsPlans for 2016 include opening of the Lehman Center for Cardiac Rehabilitation and Employee Fitness Center and increased parking for the Hixson campus with access to Northgate’s Ring Road. Improvements to physician parking will include re-striping and signing existing north campus options to complement the existing south campus lot. Expansion of services throughout North Georgia will include increased presence in the region by adding cardiology clinics and imaging to the Ooltewah campus. Additional services are planned for the Cleveland and Sequatchie Valley areas.

Surgical Services CHI Memorial is the first to offer three da Vinci Robotic Systems with the addition of the da Vinci Xi Surgical System. The O-arm Imaging and Navigation system for spine surgery has led to dramatic improvements in spine surgical care. Because of our experience with this technology, CHI Memorial is a host site for educational programs for visiting surgeons using cadavers. Same-day discharge joint replacement surgeries for appropriately selected patients are now performed at CHI Memorial Hixson. Mission


Surgery Center transitioned to a Hospital Outpatient Surgery Center to maintain the center as a convenient option for ambulatory procedures.

Technology TransformationsIn 2016, CHI Memorial is pursuing plans to resolve or improve several communication functions designed to offer the connectivity needed for efficient and effective patient care. Thanks to the Clinical Informatics team and Chattanooga Emergency Medicine providers, CHI Memorial will likely attest for Meaningful Use Stage One on Meditech 5.66. Future plans are to consider CHI One Care and other platforms for documentation before moving toward the later stages of Meaningful Use and Computerized Provider Order Entry for our entire medical staff.Ongoing Practitioner Performance Evaluations (OPPE) and overall quality improvement will be enhanced by the installation of the Physician Focus software suite by Premier. Streamlined processes reduce the turnaround time from application to appointment to the medical staff. A new Physician Leadership Development program is being designed with planned implementation in 2016. Hospital telephone system repairs will include an upgrade of the “brains” of the system to provide increased stability for more complex communications. A secure messaging solution for mobile devices will allow HIPPA compliant exchanges of text information, documents, and images so providers can better communicate and improve patient care.


2525 deSales AvenueChattanooga, TN 37404 memorial.org Follow us on Twitter@CHI_MemorialFollow us on Facebook@CHIMemorial Watch us on YouTube/MemorialChattanooga


16-150 chi mem 2015 year in review (3)

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