Page 1

2017 Quality Report

Quality Report 2017 1



94,018 admissions

72,874 surgeries 12,344


as of 5/2017


Obligated Group Athens-Limestone Hospital

Affiliate Relationships Marshall Medical Centers Curae Health (Russellville, Haleyville & Winfield Hospitals)

The Surgery Center of Huntsville North Alabama Managed Care Inc. (NAMCI) CompOne First Community

Decatur Morgan Hospital Decatur Morgan Hospital Parkway Campus Decatur Morgan Hospital West Campus Digestive Disease Center

Joint Ventures Continuum RX (Home Infusion) Tennessee Valley Pain Consultants North Alabama Community Care Alabama Community Care (probationary RCO) The Oncology Services of North Alabama

Health Group of Alabama (HGA)

Huntsville Hospital

Occupational Health Group Best Start program LHC Home Care (joint venture) Mid South Medical Equipment (joint venture)

Huntsville Hospital for Women & Children Madison Hospital Heart Center Physician Network Hospice Family Care

Contractual Agreement HealthSouth Rehabilitation Hospital

Management Agreement

Helen Keller Hospital

Lawrence Medical Center

Red Bay Hospital Spine & Neuro Center Huntsville Hospital Foundation


Madison Hospital

Helen Keller Hospital

FRANKLIN Huntsville Hospital GILES


Red Bay Hospital




Huntsville Hospital for Women JACKSON& Children MADISON DeKALB


Lawrence Medical Center




Decatur Morgan Hospital West Campus

Decatur Morgan Hospital


Decatur General Campus MARION


Decatur Morgan Hospital Parkway Campus

Quality Report 2017 3

Smith Goodman Arora


Fehrenbach Richardson

Phillips Kakani



Philip W. Bentley, Jr., Chairman

Amit Arora, MD

Macon Phillips, MD

Mike Goodman, Vice-Chairman

Kerry Fehrenbach

Beth Richardson

Frank Caprio, Secretary-Treasurer

Bhavani Kakani

David Smith

ABOUT THE HEALTH SYSTEM Established in 1895, Huntsville Hospital is the second largest hospital in Alabama with 971 beds. Serving as the regional referral center for north Alabama and southern Tennessee, Huntsville Hospital provides advanced trauma, emergency, cardiac, surgical, medical, maternity and pediatric care to approximately one million residents in the Tennessee Valley. Huntsville Hospital for Women & Children is one of only three dedicated pediatric hospitals in Alabama. Huntsville Hospital is community-owned and is governed by the Health Care Authority of the City of Huntsville. In recent years, the hospital has expanded its service in the region with the development of Huntsville Hospital Health System, which includes hospitals in Madison, Athens, Decatur, Sheffield, Red Bay, and Moulton. Huntsville Hospital Health System is the third largest publicly owned hospital system in the nation with more than 1,800 licensed beds and 12,344 employees. More than 1,200 physicians practice in Huntsville Hospital Health System facilities.

David Spillers Chief Executive Officer

Jeff Samz Chief Operating Officer

Philip Bentley, Jr. Chairman

IMPROVING LIVES Inherent in the mission of Huntsville Hospital Health System is our goal of improving the lives of the people that we serve. We believe that this goal is best accomplished when we work together and provide as much health care as possible at the local level. Huntsville Hospital Health System connects hospitals, physicians, outpatient services, and other health-related entities across the Tennessee Valley so that we can deliver quality care and service to patients in our respective communities. In this way, we cooperatively work to improve the lives of families like yours. In this report you will find data and other information that reflects the commitment and investment we have made in improving our services in the communities that we touch. As you are aware, health care is in the midst of an economic and political revolution. We know that we will be challenged going forward, and we pledge to you, our community, that we will do our very best to continue to improve the care and service we deliver across our region. It is our privilege to serve you.

Quality Report 2017 5

QUALITY MEASURES Huntsville Hospital Health System is committed to providing our patients with quality care and service. For several years we have published our Annual Quality Report, showing the data and describing the initiatives that we are taking to ensure that our patients receive quality care. We are investing in comprehensive internal improvement efforts, even as we face massive external pressures, including an uncertain economy, governmental regulation, and a rapidly-aging patient population. Although there is no single litmus test to accurately judge the quality of care provided by hospitals, there are many indicators which should be considered. As a consumer, you should ask many questions as you determine who and where to turn for your family’s health care services. Some of these questions might include: – Is the hospital Joint Commission accredited? – How does the hospital compare on the Centers for Medicare and Medicaid Services Core Measures? – Does the hospital have the experience necessary to be proficient in the procedure or service you require? – Is the hospital recommended by former patients? For this report we have provided the latest data from Core Measures that all hospitals must report. These measures are not all inclusive, but they reflect performance over time in delivering quality care to our patients. Scores may vary by facility due to small volumes.


Huntsville Hospital Decatur Morgan Hospital Athens-Limestone Hospital Helen Keller Hospital

77% Inpatient72% – Likelihood to Recommend 61% 72% July 2015 – June 2016 68% 72% 76% 72%

Inpatient – Likelihood to Recommend July 2015 – June 2016





Huntsville Hospital

Desired Direction

Decatur Morgan Hospital

Athens-Limestone Hospital

Helen Keller Hospital

National Performance 72%

Data source: Hospital Compare <>

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. The survey is conducted on behalf of CMS and the U.S. agency which oversees Medicare and Medicaid. The “Likelihood to Recommend” question measures the percentage of patients who answered “always.” Data source Hospital Compare *Huntsville Hospital data includes HH Main, Huntsville Hospital for Women and Children and Madison Hospital. *Decatur Morgan data includes Decatur and Parkway campuses. *Helen Keller data includes Helen Keller Hospital and Red Bay Hospital.

Quality Report 2017 7

Huntsville Hospital Decatur Morgan Hospital Athens-Limestone Hospital Helen Keller Hospital

0.74 0.90 1.15 0.90 0.87 0.90 0.98 Patient 0.90 Safety Composite Index July 2013 â&#x20AC;&#x201C; June 2015

Patient Safety Composite Index July 2013 â&#x20AC;&#x201C; June 2015

1.15 0.87 0.74

Huntsville Hospital

Decatur Morgan Hospital

Athens-Limestone Hospital

0.98 Desired Direction

Helen Keller Hospital

National Performance 0.90

Data source: Hospital Compare <>

Patient Safety Indicators (PSIs) are a set of measures that provide information on potential hospital complications and adverse events following procedures. The measure shown above include the following PSIs: decubitus ulcer, Iatrogenic pneumothorax, central venous catheter related blood stream infection, postoperative hip fracture, perioperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, postoperative wound dehiscence and accidental puncture or laceration. This index value is a ratio of observed to expected events. A score of less than 1.0 is considered good. Data source: Hospital Compare


untsville Hospital ecatur Morgan Hospital hens-Limestone Hospital elen Keller Hospital

13.1% 14.5%

11.7% 18.7% 12.4% 19.2% 12.4% 18.8% 30–day Mortality Rates (30 days from admission) 15.6% 12.9% 19.1% Inpatient Medicare only July 2012 – June 2015

30-day Mortality Rates (30 days from admission) Inpatient Medicare only July 2012 – June 2015

18.7% 13.1% 11.7%



18.8% 15.6%

14.5% 12.4%



Athens-Limestone Hospital

Helen Keller Hospital

Desired Direction

N/A Huntsville Hospital

Decatur Morgan Hospital

AMI - Acute Myocardial Infarction (heart attack)

HF - Heart Failure

PN - Pneumonia

National rates: AMI 14.1% | HF 12.1% | PN 16.3%

ata source: Hospital Compare <>

The 30-day mortality rates are the percent of patients who expire after 30 days of being hospitalized. Mortality rates are considered an “outcome of care” measure and show what happened after patients with certain conditions receive care. The rates are “risk-adjusted,” meaning that the calculations take into consideration how sick patients were when they were hospitalized. Data source: Hospital Compare

Quality Report 2017 9

Huntsville Hospital Decatur Morgan Hospital Athens-Limestone Hospital Helen Keller Hospital

HF - Heart FHospital-wide 21.5% 15.2% 21.7% 14.6% 22.9% Readmission 16.0% Rates (to any acute facility) 30–day Inpatient 22.4% 15.9% Medicare only July 2012 – June 2015 (Heart Failure) July 2014 – June 2015 (Hospital-wide)

30-day Readmission Rates (to any acute facility) Inpatient Medicare only July 2012 – June 2015 (Heart Failure) July 2014 – June 2015 (Hospital-wide) 22.9%


21.5% 15.2%

Huntsville Hospital


Decatur Morgan Hospital

22.4% 16.0%

Athens-Limestone Hospital

HF - Heart Failure


Desired Direction

Helen Keller Hospital


National rates: HF 21.9% | Hospital-wide 15.6%

Data source: Hospital Compare <>

The 30-day readmission rates are the percent of hospitalized patients who return to the hospital within 30 days of discharge. While some readmissions are appropriate, the measure is intended to highlight admissions to the hospital that were potentially avoidable. The goal is to assure that a patient spends no more time in the hospital than is medically necessary for their condition and health status. The rates are “risk-adjusted”, meaning that the calculations take into consideration how sick patients were when they were hospitalized. Data source Hospital Compare


CLABSI CAUTI MRSA C. Diff CLABSI-n CLABSI 0.6 CAUTI 0.6 MRSA 1.1 C. Diff 0.5 CLABSI-n 0.97 Hospital-Acquired Infections 0.6 0.6 1.1 0.5 0.97 0.0 20160.5 0.82016 (CLABSI, 0.4 0.97 January – December CAUTI) 0.0 0.5 0.8 0.4 0.97 0.0 0.6 July 2015 – June 2016 (MRSA, C. Diff) 0.97 0.0 0.6 0.97 0.0 0.3 0.2 0.97 0.0 0.3 0.2 0.97

Huntsville Huntsville Decatur Morgan Decatur Morgan Athens-Limestone Athens-Limestone Helen Keller Helen Keller

Desired Desired Direction Direction

Hospital-Acquired Infections Hospital-Acquired Infections January 2016 – December 2016 (CLABSI, CAUTI) 1.1 1.1

January (CLABSI, CAUTI) July2016 2015––December June 20162016 (MRSA, C. Diff) July 2015 – June 2016 (MRSA, C. Diff) 0.8 0.8

0.6 0.6 0.6 0.6

0.5 0.5 0.3 0.3

Huntsville Huntsville

0.0 0.0

Decatur Morgan Decatur Morgan

N/A N/A N/A 0.0 N/A 0.0

Athens-Limestone Athens-Limestone

CLABSI - Central Line-Associated Blood System Infection CLABSI - Central Line-Associated Blood System Infection CAUTI - Catheter-Associated Urinary Tract Infection CAUTI - Catheter-Associated Urinary Tract Infection MRSA - Methicillin-resistant Staphylococcus aureus MRSA - Methicillin-resistant Staphylococcus aureus C. Diff - Clostridium difficile C. Diff - Clostridium difficile

0.0 0.0


Helen Keller Helen Keller

CLABSI National Performance CLABSI National Performance CAUTI National Performance CAUTI National Performance MRSA National Performance MRSA National Performance C. Diff National Performance C. Diff National Performance

Data sources: Data sources: CLABSI, CAUTI: National Healthcare Safety Network surveillance System 2016 Report CLABSI, NationalCompare Healthcare Safety Network surveillance System 2016 Report MRSA,Data C.CAUTI: Diff: Hospital <> sources: MRSA,CLABSI, C. Diff: Hospital Compare <> CAUTI: National Healthcare Safety Network surveillance System 2016 Report MRSA, C. Diff: Hospital Compare

Quality Report 2017 11

Tracy Doughty, Senior Vice President of Operations for Huntsville Hospital

HUNTSVILLE HOSPITAL 2016 Stats Admissions 50,993

Laboratory tests 4,938,457

ER Visits 74,799

Outpatient Registrations 597,255

Surgeries 34,544

Number of employees 7,787*

Imaging 429,025

Licensed Beds 881

*Includes all Madison County operations

Recent Accomplishments In December 2016 the Joint Commission completed a five day review of Huntsville Hospital’s operations in Madison County, including the Women & Children’s Hospital, Madison Hospital, and other ambulatory facilities. The Joint Commission’s visit occurs every three years and is the most comprehensive evaluation of a hospital’s standards and practices in delivering quality health care. In awarding our facilities a full three-year accreditation, the surveyors gave high praise to our clinical team for the excellent care that is delivered to our patients.



Paula Lucas, Vice President of Operations

2016 Stats Births 4,315

Well baby nursery days 8,267

Pediatric ER Visits 34,599

Neonate nursery days 18,754

Recent Accomplishments Alabamaâ&#x20AC;&#x2122;s first dedicated Obstetrical Emergency Department opened at Huntsville Hospital for Women & Children in August 2016. Even more recently, the hospital opened a new Post Anesthesia Care Unit in Labor & Delivery. Among the celebrations at the hospital was the 10th Anniversary of the St. Jude Hospital Outpatient Affiliate Clinic which is located on campus. This special clinic is one of eight located across the United States.

Quality Report 2017 13

Mary Lynne Wright, President


Hospital Advisory Board Members

2016 Stats

Mike Goodman, Chairman Beth Richardson Ashley Burchfield, MD Bobby DeNeefe Gerald Dupree Paul Finley Matthew Hunt, MD Carole Jones Krishna Srikakolapu Taron Thorpe Clarence Tidwell Carmeleita Winburn

Admissions 5,588

Well baby nursery days 2,267

ER Visits 49,925

Employees 529

Surgeries 3,600

Licensed Beds 90

Births 881

Recent Accomplishments Madison Hospital was approved by the State of Alabama to add 30 beds to its 60-bed facility. The hospital opened in 2012 with the infrastructure in place to add patient rooms more easily as the need required. The hospitalâ&#x20AC;&#x2122;s maternity program was recognized for earning Baby-Friendly status and the Emergency Department continued to grow in serving the needs of western Madison County.



David Pryor, President

2016 Stats

Hospital Advisory Board Members

Admissions 4,067

Laboratory tests 547,982

ER Visits 36,147

Outpatient Registrations 99,036

Surgeries 6,576

Employees 802

Births 513

Licensed Beds 71

Imaging 70,338

Recent Accomplishments

Steve Smith John Curtis John Morris Camilla Gaston Rick Mould Ray Neese Russ Mitchell Pat King Kyle Bridgeforth Nauman Qureshi, MD Ben Ladner, MD William Woodall, MD Patrick Boyett, DO

Athens-Limestone Hospital earned a full accreditation from its review by the Joint Commission in 2016. More recently, the hospital broke ground on an expansion of outpatient surgery department at new MOB on the Medical East campus.

Quality Report 2017 15

Nat Richardson, President


Hospital Advisory Board Members

2016 Stats

Judge David Breland Melissa C. Craig David Burleson Nicholas Roth Pat Woller James E Boyle, MD Wallace Terry Mike Goodman Rodney Harney, MD Ken Schuppert Scott Sharp, MD

Admissions 10,467

Laboratory tests 682,156

ER Visits 65,757

Outpatient Registrations 171,366

Surgeries 5,903

Employees 1,374

Births 942

Licensed Beds 457

Imaging 97,636

Recent Accomplishments Hard hats are the rule in Morgan County as facility upgrades are occurring all over the campuses and within the walls of Decatur Morgan Hospital. Specifically, 29 distinct projects, including new spaces and demolition of old spaces, are underway at the Decatur General facility, Parkway and Decatur West.



Paul Storey, President

2016 Stats

Advisory Board Members

Admissions 6,977

Laboratory tests 450,045

ER Visits 47,653

Outpatient Registrations 61,371

Surgeries 6,135

Employees 1,103

Births 806

Licensed Beds 210

Imaging 77,392

Recent Accomplishments

Josh Vacik, MD Ryan Conner, MD Keller Thompson Steve Hargrove, Chairman Aaron Karr, MD Alford Boyd David Ruggles Mark McIlwain, MD Larry Collum Belinda Carmichael Larry Holcomb, MD Jack McLendon, MD Chief of Staff â&#x20AC;&#x201C; Ex-officio member

Helen Keller Hospital achieved status as Level II Stroke Center and Level 3 Trauma Center this past year while its affiliate Red Bay Hospital enjoyed a deficiency free survey from the Alabama Department of Public Health. Red Bay also celebrated its 50th year of service recently.

Quality Report 2017 17

Dean Griffin, CEO


Lawrence County Health Care Authority Board Members

2016 Stats

Gary Terry, Chairman Hillman Locklayer, Vice Chairman Bobby Dover, Secretary/Treasurer Patrick Mason Greg Dutton Benny Williams Sam Spruell Robert Hall, MD

Admissions 639

Laboratory tests 176,851

ER Visits 10,926

Outpatient Registrations 42,649

Surgeries 429

Employees 202

Imaging 122,972

Licensed Beds 66

Recent Accomplishments Lawrence Medical Center opened a rural health clinic last year while also seeing a dramatic increase in visits to its urgent care clinic. LMC is owned by the Lawrence County Health Care Authority and managed by Huntsville Hospital Health System.


A fixture in the community’s outreach to the underserved, Huntsville Hospital’s Mobile Medical Unit provided care to more than 7,500 people at 230 screening events in 2016. In addition, the MMU along with Dr. Shane O’Neill established a twice-a-month primary care clinic for the homeless population at the Downtown Rescue Mission. More than 1,200 patient encounters were registered.

The physicians of the Spine & Neuro Center represent the largest and most experienced group of neurosurgeons between Birmingham and Nashville.

Reaching out to the community The community benefit of a hospital can be measured by the number of people served and in the services that are provided free or below actual cost. These numbers reflect only the operations in Madison County.

Charity care ....................................... $13,683,366 non-reimbursed cost to hospital

Uncollected accounts ...................... $52,911,502

The community’s first inpatient hospice unit is nearing completion on the campus of Redstone Village. The 15-bed unit is a joint project of Huntsville Hospital, Hospice Family Care and Redstone Village. Community donations to the Huntsville Hospital Foundation are helping build this special facility.

cost to hospital

Medicaid .............................................. $5,206,063 non-reimbursed cost of care Medicaid patients

Medical education .............................. $4,784,429 non-reimbursed cost of educating residents & interns

Community Health Initiative grants ..... $500,000 Support of schools ............................. $1,250,000 Community classes, screenings and support for health events ..................... $250,000 COMMUNITY BENEFIT.......................$78,585,360

Huntsville Hospital’s nationally recognized cardiac program went “red” to bring more awareness and education to the issue of heart disease among women. Quality Report 2017 19


in a small house

FALL 2016

Our Mission Provide high quality care and services that will improve the health of those we serve. Our Vision To be one of the best health systems in America and consistently strive to provide clinical and service excellence. Our Values Integrity, Excellence, Innovation, Accountability, Compassion and Safety

101 Sivley Road ¡ Huntsville, AL 35801 (256) 265-1000 |

Quality Report 2017  
Quality Report 2017