QUALITY

at Maine Medical Center

SPRING 2016

2

At Maine Medical Center, we work diligently to improve Maine’s health and patient experience while providing our community members with the safest, highest-quality health care at an affordable cost. As a local and national leader in quality, we challenge ourselves every day to find the better way, improve the outcome, and make our community healthier. When it comes to delivering effective care, we stand behind our commitment to quality and safety for all patients.

3

Quality Reporting at MMC: Guiding Principles• We will present data on our website. Additional sources for Maine Medical Center quality data

include the Leapfrog Group, Hospital Compare, and the Maine Health Management Coalition

• We will not choose measures for public reporting based on our current or expected future performance. Specifically, we will publicly report on selected performance measures, even when there is a need to improve

• We will explain all reported measures in the simplest, most useful way possible

• We will describe the work being done to improve performance on publicly reported measures

• We will publish data on performance and outcomes for populations of patients treated for specific conditions at Maine Medical Center with meaningful local and national comparisons where available

• We will not publicly report physician-specific performance until we can adequately address the inherent inaccuracies in data with small sample sizes and inadequate risk adjustment

• We will engage members of our community in creating and choosing measures for public reporting

• We will protect patient privacy in developing processes for public reporting of performance measures

At Maine Medical Center, we aim to provide our patients with the safest, highest-quality care possible. We believe that public reporting of data supports our mission of delivering the most effective and safe care to our community. In an ever-changing health care environment, we must constantly measure our performance and look for areas of improvement. In these pages, you’ll find measures in three categories, each accompanied by a description of how the measure was taken, and why it’s important to patient safety and quality of care.

Many reporting agencies publish data using different time periods. Most of our Quality Data shared on the website is updated once a year.

Keeping Patients Safe Measures of MMC’s progress and initiatives to increase patient safety by proactively avoiding harmful risks to patients.

Providing Effective Care Reported outcomes of how well MMC follows the recommended guidelines of effective care for patients with chronic conditions and specific health care needs, such as heart attack, heart failure, pneumonia, stroke, and surgery.

Providing Patient-Centered Care Measures tracking patients’ experiences at MMC.

4

Keeping Patients SafePatient safety is at the forefront of health care initiatives nationwide – and our focus here at MMC is no different. Our clinicians and staff are proactive in identifying potential harmful risks to patients and collaborating to develop preventative measures to protect our patients and keep our hospital safe. We continuously study best practices and share knowledge with our peers in an effort to provide the safest care possible, including preventing infections, ensuring medication safety, communicating and coordinating care effectively, and accurately diagnosing patients’ conditions.

SPECIFIC CATEGORY MEASURE HOW ARE WE DOING?

HAI Measures MMC ‘15 National ‘15

Central Line Associated Bloodstream Infection (ICU + select Wards) 0.436 0.573

Central Line Associated Bloodstream Infection (ICU only) 0.863 0.513

Catheter Associated Urinary Tract Infections (ICU + select Wards) 0.981 0.577

Catheter Associated Urinary Tract Infections (ICU only) 1.030 0.752

SSI-Colon Surgery 1.600 1.030

SSI-Abdominal Hysterectomy 2.685 0.867

MRSA Bacteremia 0.217 0.932

Clostridium Difficile (C.Diff) 0.500 0.934

* Lower is better

What Are We Measuring and Why Is It Important For Patients and Families to Know?

MQF & HAI Measures

Infection Rate in Patients

We keep track of how many infections occur among patients.

Why is this important? Whenever the surface of the skin is broken, it makes infection (with bacteria or a fungus) possible. Infection rates are a measurement of how effectively hospitals prevent these types of infections. Tracking the number of patients who acquire an infection at MMC demonstrates how our rate of these infections compares to other hospitals and lets us know if we need to change our care processes to better prevent this type of problem.

5

Providing Effective CareBased on national research and outcomes, we know certain health conditions require specific treatment approaches and interventions. MMC embraces the national recommendations of care for patients with these conditions, and our clinicians ensure these patients are treated with the right care at the right time. These conditions include heart attack, heart failure, pneumonia, stroke, and surgery.

SPECIFIC CATEGORY MEASURE HOW ARE WE DOING?

Heart Failure MMC ‘15 National ‘15

Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function 100% 99%

Mortality Rates MMC 12’ - 15’ National 12’ - 15’

Mortality Heart Attack 12.8% 14.1%

Mortality Heart Failure 13.4% 12.1%

Mortality Pneumonia 17.1% 16.3%

Pneumonia MMC ‘15 National ‘15

Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s) for Immunocompetent Patient 100% 95%

Readmission Rates MMC 12’ - 15’ National 12’ - 15’

Readmission Heart Attack 14.6% 16.8%

Readmission Heart Failure 19.2% 21.9%

Readmission Pneumonia 15.5% 17.1%

Stroke MMC ‘15 National ‘15

Plan for Rehabilitation Was Considered for Stroke Patients 99% 98%

Stroke Education Was Provided for Stroke Patients 89% 94%

Stroke Patients Discharged on Anti-Thrombotic Medication 98% 99%

Stroke Patients Given Anti-Thrombotic Medication Within 48 Hours of Hospitalization 98% 98%

Stroke Patients Prescribed Cholesterol-Lowering Medication at Discharge 96% 97%

Surgery Patients MMC ‘15 National ‘15

Patients Who Received Treatment at the Right Time (Within 24 Hours Before or After Their Surgery) to Help Prevent Blood Clots After Certain Types of Surgery

100% 100%

Surgery Patients Who Were Given An Antibiotic at the Right Time (Within One Hour Before Surgery) to Prevent Infection

99% 99%

Surgery Patients Whose Preventive Antibiotics Were Stopped at the Right Time (Within 24 Hours After Surgery)

98% 98%

6

What Are We Measuring and Why Is It Important For Patients and Families to Know?

Heart Failure

Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function

We keep a record of how many eligible heart failure patients at MMC are evaluated for how effectively the left side of their heart is pumping blood.

Why is this important? The left ventricle is the chamber of the heart that pumps blood to the rest of the body, including other vital organs. In patients with suspected heart failure, an assessment of left ventricular function – the heart’s ability to pump blood effectively – is a key diagnostic test that is essential for planning treatment. The most common test to assess LVS function is an echocardiogram, or “echo.”

Mortality Rates

Mortality Heart Attack

The Centers for Medicare & Medicaid Services (CMS) track the number of Medicare patients who die within 30 days of being discharged from a hospital after treatment for heart attack, and MMC tracks and reports data according to CMS requirements. This mortality (death) rate has been risk-adjusted, which means that it takes into account how sick heart attack patients were before they were admitted to the hospital.

Why is this important? One way to evaluate if a hospital is delivering good heart attack care is to look at whether patients admitted for treatment have 30-day mortality rates that are lower, about the same as, or higher than the national rate, given how sick they were when admitted to the hospital. CMS chose a 30-day mortality as the benchmark of performance so it can include deaths that hospitals might not notice because the patients died after they were discharged. This information enables you to make an objective comparison of MMC’s heart attack mortality rate compared to the U.S. national rate as well as to the mortality rates of other hospitals.

Mortality Heart Failure

The Centers for Medicare & Medicaid Services (CMS) track the number of Medicare patients who die within 30 days of being discharged from a hospital after treatment for heart failure, and MMC tracks and reports data according to CMS requirements. This mortality (death) rate has been risk-adjusted, which means that it takes into account how sick heart failure patients were before they were admitted to the hospital.

Why is this important? One way to evaluate if a hospital is delivering good heart failure care is to look at whether patients admitted for treatment have 30-day mortality rates that are lower, about the same as, or higher than the national rate, given how sick they were when admitted to the hospital. CMS chose a 30-day mortality as the benchmark of performance so it can include deaths that hospitals might not notice because

7

the patients died after they were discharged. This information enables you to make an objective comparison of MMC’s heart failure mortality rate compared to the U.S. national rate as well as to the mortality rates of other hospitals.

Mortality Pneumonia

The Centers for Medicare & Medicaid Services (CMS) track the number of Medicare patients who die within 30 days of being discharged from a hospital after treatment for pneumonia, and MMC tracks and reports data according to CMS requirements. This mortality (death) rate has been risk-adjusted, which means that it takes into account how sick pneumonia patients were before they were admitted to the hospital.

Why is this important? One way to evaluate if a hospital is delivering good pneumonia care is to look at whether patients admitted for treatment have 30-day mortality rates that are lower, about the same as, or higher than the national rate, given how sick they were when admitted to the hospital. CMS chose a 30-day mortality as the benchmark of performance so it can include deaths that hospitals might not notice because the patients died after they were discharged. This information enables you to make an objective comparison of MMC’s pneumonia mortality rate compared to the U.S. national rate as well as to the mortality rates of other hospitals.

Readmission Rates

Heart Attack Patients Readmitted Within 30 Days

Readmission refers to when patients who have been hospitalized return to a hospital again. We keep track of the number of Medicare patients who are readmitted to the hospital within 30 days of being discharged from MMC after treatment for heart attack. These patients may have been readmitted to MMC or to a different hospital or acute-care facility. They may have been readmitted for the same condition as their recent hospital stay (heart attack) or for a different reason. This readmission rate has been risk-adjusted, which means that it takes into account how sick heart attack patients were before they were first admitted to the hospital.

Why is this important? One way to evaluate if a hospital is delivering good heart attack care is to look at whether patients admitted for treatment have 30-day readmission rates that are lower, about the same as, or higher than the national rate, given how sick they were when first admitted to the hospital. This information enables you to make the objective comparison of MMC’s heart attack readmission rate compared to the U.S. national rate as well as to the readmission rates of other hospitals.

Heart Failure Patients Readmitted Within 30 Days

Readmission refers to when patients who have been hospitalized return to a hospital again. We keep track of the number of Medicare patients who are readmitted to the hospital within 30 days of being discharged from MMC after treatment for heart failure. These patients may have been readmitted to MMC or to a different hospital or acute-care facility. They may have been readmitted for the same condition as their recent hospital stay (heart failure) or for a different reason. This readmission rate has been risk-adjusted, which means that it takes into account how sick heart failure patients were before they were first admitted to the hospital.

8

Why is this important? One way to evaluate if a hospital is delivering good heart failure care is to look at whether patients admitted for treatment have 30-day readmission rates that are lower, about the same as, or higher than the national rate, given how sick they were when first admitted to the hospital. This information enables you to make an objective comparison of MMC’s heart failure readmission rate compared to the U.S. national rate as well as to the readmission rates of other hospitals.

Pneumonia Patients Readmitted Within 30 Days

Readmission refers to when patients who have been hospitalized return to a hospital again. We keep track of the number of Medicare patients who are readmitted to the hospital within 30 days of being discharged from MMC after treatment for pneumonia. These patients may have been readmitted to MMC or to a different hospital or acute-care facility. They may have been readmitted for the same condition as their recent hospital stay (pneumonia) or for a different reason. This readmission rate has been risk-adjusted, which means that it takes into account how sick pneumonia patients were before they were first admitted to the hospital.

Why is this important? One way to evaluate if a hospital is delivering good pneumonia care is to look at whether patients admitted for treatment have 30-day readmission rates that are lower, about the same as, or higher than the national rate, given how sick they were when first admitted to the hospital. This information enables you to make an objective comparison of MMC’s pneumonia readmission rate compared to the U.S. national rate as well as to the readmission rates of other hospitals.

Stroke Measures

Plan for Rehabilitation Was Considered for Stroke Patients

We track the number of eligible stroke patients for whom rehabilitation is considered as part of their care plan.

Why is this important? Patients who have a stroke may have damage to the brain that makes it difficult for them to resume their normal daily activities. Rehabilitation after a stroke – which can include physical, occupational, and speech therapy, in addition to therapies to address difficulty swallowing, psychological issues, and cognitive deficits – can help patients adapt to any remaining effects of a stroke. It can also help a patient’s brain to recover more fully. At MMC, our goal is to ensure that a rehabilitation plan is considered for all eligible stroke patients to ensure that they are able to live as actively and independently as possible.

Stroke Education Was Provided for Stroke Patients

We track the number of stroke patients for whom we provide education and information about stroke prevention and the resources available to patients following hospitalization.

Why is this important? Information is power, and education following a stroke can help prevent a future stroke. At MMC, our goal is to provide all stroke patients with accurate, easily understandable information about what they can do to help reduce the risk of having another stroke. We also aim to make patients aware of the various educational and support resources available to them after they are discharged from the hospital.

9

Stroke Patients Discharged on Anti-Thrombotic Medication

We measure the number of eligible stroke patients who are discharged from MMC on anti-thrombotic (also called anti-platelet) medication.

Why is this important? Patients who experience an ischemic stroke (a stroke caused by a blood clot that blocks blood flow to the brain) are at risk of having another stroke. Anti-platelet medication, such as aspirin (the most commonly prescribed medication of this kind), helps to prevent blood clots from forming or helps to dissolve blood clots that have formed. Anti-platelet therapy has been shown to reduce the risk of a recurrent stroke by more than 20 percent. At MMC, our goal is to ensure that all eligible stroke patients are taking anti-platelet medication when they are discharged.

Stroke Patients Given Anti-Thrombotic Medication Within 48 Hours of Hospitalization

We keep track of the number of eligible stroke patients who are given anti-thrombotic medication (medication that helps keep blood platelets from sticking together) within 48 hours of arriving at the hospital.

Why is this important? The most common type of stroke (called an ischemic stroke) occurs when a blood clot blocks blood flow to the brain, depriving it of oxygen. Anti-thrombotic therapy involves administering medication that helps prevent blood clots from forming or helps to dissolve blood clots that have formed. Aspirin is the most commonly used medication for this purpose. At MMC, our goal is to ensure that all eligible stroke patients receive anti-thrombotic medication within 48 hours of being hospitalized.

Stroke Patients Prescribed Cholesterol-Lowering Medication at Discharge

We track the number of ischemic stroke patients:

• with an LDL (the “bad” cholesterol) level greater than 100.

• with an LDL that has not been measured.

• who were taking cholesterol-lowering medication before they were hospitalized and who were discharged from MMC on cholesterol-lowering drugs.

Why is this important? A high LDL level is a risk factor for developing fatty deposits in the arteries, which can contribute to heart or vascular disease and increase the risk of stroke and heart attack. Studies show that reducing LDL with cholesterol-lowering medications can significantly lower the chances of future strokes and heart attacks. Our goal at MMC is to ensure that all eligible stroke patients receive a lipid profile (a blood test that measures the level of fats in the blood, including cholesterol and triglycerides) and, if their LDL is greater than 100, to prescribe a cholesterol-lowering medication when they are discharged from the hospital.

10

Surgery Measures

Patients Who Received Treatment at the Right Time (Within 24 Hours Before or After Their Surgery) to Help Prevent Blood Clots After Certain Types of Surgery

At MMC, we keep track of the number of eligible surgery patients who receive treatment to prevent blood clots within 24 hours before or after their operation.

Why is this important? Sometimes, patients can develop blood clots after they undergo surgery. This is because when patients remain in bed for a long time after certain types of surgery, the risk of developing a blood clot in the veins of the legs or pelvis is increased. This can limit blood flow and even cause a potentially fatal lung condition called pulmonary embolism.

To help prevent blood clots from forming after surgery, certain treatments can be started just before or after a patient undergoes surgery. These include blood-thinning medications, elastic support stockings, or mechanical compression stockings that help promote circulation in the legs. To be effective, these treatments must be started at the right time, which typically is during the period that begins 24 hours before surgery and ends 24 hours after surgery. Our goal at MMC is to ensure that all eligible surgery patients receive an appropriate preventive treatment within this time frame.

Surgery Patients Who Were Given an Antibiotic at the Right Time (Within One Hour Before Surgery) to Prevent Infection

We keep track of the number of eligible surgery patients who are given antibiotic(s) one hour before the start of surgery to help prevent infection.

Why is this important? Sometimes patients can develop infections at their incision sites after they undergo surgery. It’s been shown that patients who take a preventive antibiotic within one hour before their operation are less likely to develop this type of infection. The timing of administering the antibiotic is important because it’s also been shown that taking an antibiotic earlier, or after surgery begins, is not as effective in preventing infections. Our goal at MMC is to make sure that all eligible surgery patients are given preventive antibiotics within one hour prior to the start of their surgery.

Surgery Patients Whose Preventive Antibiotics Were Stopped at the Right Time (Within 24 Hours After Surgery)

At MMC, we track the number of surgery patients whose preventive antibiotics are stopped within 24 hours after surgery.

Why is this important? With few exceptions, it isn’t necessary to continue giving patients preventive antibiotics more than 24 hours after surgery since their incision is closed and the risk of infection is greatly reduced. In addition, overuse of antibiotics when there is no infection can cause side effects and contribute to bacterial resistance (certain strains of bacteria develop a tolerance to antibiotics to which they once were susceptible). Our aim at MMC is to ensure that all appropriate surgery patients who are given preventive antibiotics prior to surgery have these antibiotics stopped within 24 hours after surgery.

11

Providing Patient-Centered CareWhile standards of care across conditions often apply to all patients, we know every patient is different. We believe all patients deserve the personalized care and attention they need to heal, and we are passionate about partnering with patients and their families to ensure their experiences are of the highest quality – both clinically and emotionally. Like many of our national peers, we employ a survey called the Hospital Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) to measure our patients’ experiences. We use this patient-reported data to drive our improvement initiatives around the patient experience, including communication with clinicians, satisfaction with hospital environment, and communication about medication and discharge.

SPECIFIC CATEGORY MEASURE HOW ARE WE DOING?

Patient Experience Measures MMC ‘15 National ‘15

Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest) 74% 71%

Patients at each hospital who reported that YES, they were given information about what to do during their recovery at home

89% 86%

Patients who reported that staff ALWAYS explained about medicines before giving it to them

64% 65%

Patients who reported that their doctors ALWAYS communicated well 81% 82%

Patients who reported that their nurses ALWAYS communicated well 78% 80%

Patients who reported that their pain was ALWAYS well controlled 69% 71%

Patients who reported that they ALWAYS received help as soon as they wanted 63% 68%

Patients who reported YES, they would definitely recommend the hospital 78% 71%

What Are We Measuring and Why Is It Important For Patients and Families to Know?

Patient Experience HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

Patients Who Gave Their Hospital a Rating of 9 or 10 on a Scale from 0 (Lowest) to 10 (Highest)

Patients who are hospitalized at MMC are asked to give an overall rating of the hospital on a scale from 0 to 10, where “0” means “worst hospital possible” and “10” means “best hospital possible.” Here, we are reporting those incidences where patients gave MMC a rating of 9 or 10.

12

Why is this important? We want to ensure that patients receive high-quality medical care and that their experience while in the hospital is a positive one. An important indicator of how MMC is doing in this regard comes from feedback about how high they rate the hospital. By asking questions about the patients’ overall ratings, we can assess where there’s room for improvement – with the aim of improving patients’ overall hospital experience.

Patients at Each Hospital Who Reported That YES, They Were Given Information About What to Do During Their Recovery at Home

Patients who are hospitalized at MMC are asked if hospital staff talked with them about whether they would have the help needed during their recovery at home, and whether they were given written information about what symptoms or health problems to look out for after they left the hospital (these questions are part of a survey sent to a random sample of adult patients within six weeks after discharge from MMC). We keep track of how many patients report that yes, they were given information about what to do during their recovery at home.

Why is this important? We want to ensure that patients receive high-quality medical care and that their experience while in the hospital is a positive one. An important indicator of how MMC is doing comes from feedback about how well prepared and informed patients feel about recovering at home. By asking questions about the instructions patients receive, we can assess how informed they feel and identify where there’s room for improvement – with the aim of improving patients’ overall hospital experience.

Communications About Medications

Patients hospitalized at MMC are asked how often hospital staff explained what a new medicine was for before giving it to them, and how often the staff described the possible side effects in a way the patient could understand (these questions are part of a survey sent to a random sample of adult patients within six weeks after discharge from MMC). We keep track of how many patients report that staff always explained a medication before giving it to them.

Why is this important? We want to ensure that patients receive high-quality medical care and that their experience while in the hospital is a positive one. An important indicator of how well MMC is doing in this regard comes from patient feedback about how informed they feel about the medications they are taking while in the hospital. By asking questions about how well hospital staff explained medications, we can assess how effectively our staff communicates and identify where there’s room for improvement – with the aim of improving patients’ overall hospital experience.

Communications With Doctors

Patients who are hospitalized at MMC are asked how often their doctors treated them with courtesy and respect, listened carefully to them, and explained things in a way they could understand (these questions are part of a survey sent to a random sample of adult patients within six weeks after discharge from MMC). We keep track of how many patients report that their doctors always communicated well.

Why is this important? We want to ensure that patients receive high-quality medical care and that their hospital experience is a positive one. An important indicator of how well MMC is doing comes from patient

13

feedback about our doctors’ communication skills. By asking patients about interaction with our doctors, we can identify areas in which doctors’ communication skills could be improved – with the aim of improving our patients’ overall hospital experience.

Communications With Nurses

Patients who are hospitalized at MMC are asked how often their nurses treated them with courtesy and respect, listened carefully to them, and explained things in a way they could understand (these questions are part of a survey sent to a random sample of adult patients within six weeks after discharge from MMC). We keep track of how many patients report that their nurses always communicated well.

Why is this important? We want to ensure that patients receive high-quality medical care and that their experience while in the hospital is a positive one. An important indicator of how well MMC is doing in this regard comes from patient feedback about our nurses’ communication skills. By asking patients about their interaction with our nurses, we can identify areas in which the nurses’ communication skills could be improved – with the aim of improving our patients’ overall hospital experience.

Patients Who Reported That Their Pain Was ALWAYS Well Controlled

Patients who are hospitalized at MMC are asked how often during their hospital stay their pain was well controlled, and how often the hospital staff did everything they could to help manage their pain (these questions are part of a survey sent to a random sample of adult patients within six weeks after discharge from MMC). We keep track of how many patients report that their pain was always well controlled.

Why is this important? We want to ensure that they receive high-quality medical care and that their experience while in the hospital is a positive one. An important indicator of how well MMC is doing comes from patient feedback about pain management. By asking patients questions about how well their pain is managed while in the hospital, we can assess how effective our pain management efforts are and identify where there’s room for improvement – with the aim of improving patients’ overall hospital experience.

Patients Who Reported That They ALWAYS Received Help As Soon As They Wanted

Patients who are hospitalized at MMC are asked how often after pressing the call button they received help, and how often they received help in getting to the bathroom or in using a bedpan as soon as they wanted (these questions are part of a survey sent to a random sample of adult patients within six weeks after they are discharged from MMC). We keep track of how many patients report that they always received help as soon as they wanted it.

Why is this important? We want to ensure that patients receive high-quality medical care and that their experience while in the hospital is a positive one. An important indicator of how well MMC is doing in this regard comes from patient feedback about how responsive our staff is to patients’ needs. By asking questions about how frequently staff responded to patients’ requests for help in a timely fashion, we can assess how attentive our staff is and identify where there’s room for improvement – with the aim of improving our patients’ overall hospital experience.

14

Patients Who Reported YES, They Would Definitely Recommend the Hospital

Patients who are hospitalized at MMC are asked if they would recommend our hospital to their family and friends (this question is part of a survey sent to a random sample of adult patients within six weeks after discharge from MMC). We report the number of patients who report yes, they would definitely recommend MMC.

Why is this important? We want to ensure that patients receive high-quality medical care and that their experience at MMC is a positive one. Asking patients if they would recommend us to their family and friends gives us important feedback about how patients perceive their experience while hospitalized at MMC, and if we need to look more closely at ways in which we can improve our service.