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Report to the COMMUNITY A REVIEW OF 2017

Established in 1895, Huntsville Hospital is the second largest hospital in Alabama with 971 licensed beds. Huntsville Hospital is community-owned and 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 today includes hospitals in Madison, Athens, Decatur, Sheffield, Red Bay, and Moulton. 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


David Spillers Chief Executive Officer

Jeff Samz Chief Operating Officer

Philip Bentley, Jr. Chairman

THE HEALTH CARE AUTHORITY of the City of Huntsville

Goodman Arora


Smith Fehrenbach


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 3


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 CHEROKEE Hospital

Decatur Morgan Hospital

West Campus ETOWAH

Decatur General Campus MARION


Decatur Morgan Hospital Parkway Campus

ENTITIES AND RELATIONSHIPS Obligated Group Athens-Limestone Hospital Decatur Morgan Hospital Decatur Morgan Hospital Parkway Campus Decatur Morgan Hospital West Campus Digestive Disease Center Huntsville Hospital Huntsville Hospital for Women & Children Huntsville Hospital Accountable Care Organization Madison Hospital Heart Center Physicians Network Hospice Family Care Helen Keller Hospital Red Bay Hospital Spine & Neuro Center Huntsville Hospital Foundation 4 hhsys.org

Other Ownership Relationships The Surgery Center of Huntsville North Alabama Managed Care Inc. (NAMCI) CompOne First Community Health Group of Alabama (HGA) Occupational Health Group Best Start LHC Home Care (joint venture) Med South Medical Equipment (joint venture) Management Agreement Lawrence Medical Center

Affiliate Relationships Marshall Medical Centers Curae Health (Russellville, Haleyville & Winfield Hospitals) Joint Ventures Continuum RX (Home Infusion) Tennessee Valley Pain Consultants Alabama Community Care Alliance Cancer Care Contractual Agreement HealthSouth Rehabilitation Hospital (Encompass)

HUNTSVILLE HOSPITAL HIGHLIGHTS Our new 15-bed hospice inpatient facility opened on the campus of Redstone Village. The program is managed by Hospice Family Care, a member of our Health System. The Mazor X robotic technology was introduced for patients requiring spine surgery.

Tracy Doughty Senior Vice President of Operations for Huntsville Hospital

54 physicians joined the Medical Staff last year, bringing the total to 810 physicians serving our patients in Huntsville Hospital, Huntsville Hospital for Women & Children and Madison Hospital. The main Emergency Department expanded services to include an 8-bed admission unit for emergency patients waiting to be admitted. Physicians from the Heart Center performed the 100th TAVR (Transcatheter Aortic Valve Replacement) last year at Huntsville Hospital. (Incidentally, the 200th procedure was completed in April 2018). Plans were finalized for a new electronic medical record (EMR) system for Huntsville Hospital Health System. The new system will begin rolling out in 2018. Community donations to the Huntsville Hospital Foundation funded $2,550,430 for equipment and programs at the main campus last year, benefiting patients in the cardiac units, surgery, chemotherapy clinic, dialysis, hospice, and respiratory units. In addition, Foundation donors helped establish the SPEAK suicide prevention program. Thank you to our generous donors. Admissions* 62,190

Main ED Visits 79,392

Outpatients* 609,712

Employees* 8,730

Surgeries* 39,518

July 1, 2016 – June 30, 2017 | *Includes all Madison County campuses.


HUNTSVILLE HOSPITAL FOR WOMEN & CHILDREN HIGHLIGHTS A team of more than 40 nurses and physicians delivered the first set of sextuplets born in Alabama since 2011. Linnea Larson-Williams, MD, joined the Medical Staff. She is the only Pediatric Endocrinologist in North Alabama serving children with diabetes and other endocrine system problems. Paula Lucas Vice President of Operations

The Obstetrical Emergency Department expanded its scope to also care for women with gynecologic emergencies. Longtime Breast Center Nurse Navigator Sandy Cross was named as Prevention Magazine’s Most Amazing Nurse nominee. The Arts in Medicine program was launched, which includes a new Patient Art Gallery to showcase art created by patients. Community donations to the Huntsville Hospital Foundation funded $859,857 for equipment and programs at the Huntsville Hospital for Women & Children last year, benefiting the Breast Center, the Regional Neonatal ICU, maternity unit, Child Life and other programs. Special recognition goes to the Liz Hurley Ribbon Run and Swim for Melissa, two incredible annual events supporting patients in Huntsville Hospital for Women & Children. Thank you to our generous donors.

Pediatric ED Visits 32,739

Well Baby Nursery Days 7,871

Births 4,220

Neonate Nursery Days 19,150

July 1, 2016 – June 30, 2017

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OB ED Visits 6,976

MADISON HOSPITAL HIGHLIGHTS Huntsville Hospital Health System earned permission from the state to add 30 new beds at Madison Hospital – eight for ICU patients, 22 for medical/surgical patients. A new Fast Track treatment area within the Emergency Department opened to assess, treat and discharge patients with non-life threatening illness and injuries. The Imaging Department added a second MRI, a nuclear medicine camera and EEG testing. Mary Lynne Wright President

Hospital Advisory Board Members 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

Madison Hospital became the first hospital in North Alabama and the fourth in the state to earn Baby-Friendly USA designation. The Baby-Friendly program recognizes hospitals and birthing centers that have demonstrated a commitment to the World Health Organization’s researchbased steps that support mother-infant bonding and baby centered feeding practices. This achievement reflects two years of work by medical and nursing staff to improve the quality of care offered to our families. Community donations to the Huntsville Hospital Foundation funded $279,003 for equipment and programs at Madison Hospital last year, benefiting medical units, cardiac monitoring and maternity patients. Thank you to our generous donors.

ED Visits 51,512

Surgeries 3,923

Births 954

Well Baby Nursery Days 2,711

Level II Nursery Days 536

July 1, 2016 – June 30, 2017


ATHENS-LIMESTONE HOSPITAL HIGHLIGHTS 16 new physicians joined the Medical Staff. Surgery Expansion is set to open in July 2018 at the Medical East Campus. Surgeon Paul Noel performed his 20,000th surgical case in 2017. Transition of Care and Chronic Care Management Programs began in Athens and served 358 patients. David Pryor President

Hospital Advisory Board Members John Morris Chairman Max Boone, MD Patrick Boyett, DO Kyle Bridgeforth John Curtis Camila Gaston Pat King Ben Ladner, MD Russ Mitchell Rick Mould Ray Neese Tom Norton Nauman Qureshi, MD

Dr. Sharon Bush-Coaxum joined Valley Women’s Center. The hospital remains a top performer for low infection rates in MedMined and adopted the Baldrige framework as an organization-wide improvement methodology. Community donations to Athens-Limestone Hospital Foundation, as well as proceeds from events, provided nearly $175,000 for the hospital’s surgery department expansion, mother baby unit, women’s health programs and other services. Employees also donated to the Foundation’s Helping Hands Fund, generating $21,799 in Helping Hands grants last year. Thank you to our generous donors.

Admissions 3,855

ED Visits 33,495

Surgeries 6,925

Births 456

Outpatients 103,716

Employees 816

July 1, 2016 – June 30, 2017

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DECATUR MORGAN HOSPITAL HIGHLIGHTS Four more pediatricians and an additional pediatric office were added to Decatur Morgan Pediatrics. Six other physicians joined the Medical Staff. Substantial construction progress was made at Decatur Morgan Hospital to modernize the facility including a new Emergency Department and increased inpatient bed capacity. Nat Richardson President

Hospital Advisory Board Members Mike Goodman Chairman Reginald Gladish, MD President of Medical Staff Judge David Breland David Burleson Melissa C. Craig Rodney Harney, MD Nicholas Roth Ken Schuppert Scott Sharp, MD C. Wallace Terry

Three new services were opened: Pulmonary Rehabilitation, Vein Center and Another Chance – Addiction Withdrawal Care. Decatur Morgan Hospital developed a Patient & Family Advisory Council (PFAC) to help provide input to the patient experience and care. Community donations to Decatur Morgan Hospital Foundation, as well as proceeds from events, provided $628,371 for the hospital, benefiting mammography services, pulmonary care, head injury care, a mobile medical unit, facility improvements, and Camp Bluebird adult cancer program. Thank you to our generous donors.

Admissions 10,824

ED Visits 64,765

Surgeries 5,735

Births 933

Outpatients 171,647

Employees 1,167

July 1, 2016 – June 30, 2017


HELEN KELLER & RED BAY HOSPITALS HIGHLIGHTS The combined Medical Staffs of Helen Keller Hospital and Red Bay Hospital added 45 new physicians during the year. A new cardiac catheterization lab was opened at Helen Keller Hospital, enhancing the care provided to our cardiac patients. A HUGS infant security system was installed at Helen Keller Hospital. Paul Storey President

Advisory Board Members Steve Hargrove Chairman Alford Boyd, Jr. Belinda Carmichael Larry Collum Ryan Conner, MD Michael Gosney, MD Larry Holcomb, MD Aaron Karr, MD Andy Mann Mark McIlwain, MD David Ruggles Keller Thompson Josh Vacik, MD

The hospital installed a new hemodynamic monitoring system for patient care. Hemodynamic monitoring helps determine how well the heart is working. Community donations to Helen Keller Hospital Foundation, as well as proceeds from events, provided $86,480 to help renovate the hospital’s Women Center. Thank you to our generous donors.

Admissions 10,035

ED Visits 48,061

Surgeries 9,726

Births 807

Outpatients 56,045


Statistics are from calendar year 2017

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LAWRENCE MEDICAL CENTER HIGHLIGHTS Lawrence Medical Center’s Urgent Care Center, located on Highway 157 in Moulton, expanded to seven days a week.

Dean Griffin CEO

Lawrence County Health Care Authority Board Members Gary Terry Chairman Hillman Locklayer Vice Chairman Bobby Dover Secretary/Treasurer Greg Dutton Patrick Mason Sam Spruell Benny Williams Faye Wilson, MD

All of the hospital’s primary care clinics – Complete Family Care, Moulton Pediatrics, Moulton Primary Care, Urgent Care Center, and Courtland Clinic – completed successful surveys by the Alabama Department of Public Health and are qualified Rural Health Clinics pursuant to CMS guidelines. Lawrence Medical Center offers transitional care for patients requiring post-acute services. Transitional care services provide rehabilitation services outside of the nursing home setting. All transitional care patients have the benefit of a private room. Transitional care is the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.

Admissions 645

ED Visits 10,557

Outpatients 40,585

Employees 200

Surgeries 53

July 1, 2016 – June 30, 2017


QUALITY MEASURES Huntsville Hospital Health System is committed to providing quality care and service to our patients. Each year we publish our quality data so that you can see how we are doing compared to national benchmarks. Although there is no single indicator of quality care, there are many measurements and questions which can help you determine where to turn for your health care. Several of those indicators are provided in the following section.

Patient Safety Indicators (PSIs) are a set of measures that provide information on potential hospital complications and adverse events following procedures. The measure shown to the right include the following PSIs: decubitus ulcer, iatrogenic pneumothorax, postoperative hip fracture, perioperative hemorrhage or hematoma, postoperative acute kidney injury, postoperative respiratory failure rate, 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. The goal is remain below a score of 1.0.

Patient Safety Composite Index July 2014 – September 2015 1.11 1.02 0.95 0.87





National Average 1.0

Data source: Hospital Compare www.medicare.gov/ hospitalcompare

CHART KEY HH - Huntsville Hospital DMH - Decatur Morgan Hospital

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ALH - Athens-Limestone Hospital HKH - Helen Keller Hospital

*Huntsville Hospital data includes Huntsville Hospital Main, Huntsville Hospital for Women and Children and Madison Hospital. Decatur Morgan data includes Decatur and Parkway campuses. Helen Keller data does not include Red Bay Hospital.

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, which oversees Medicare and Medicaid. The “Likelihood to Recommend” question measures the percentage of patients who answered “always.”

Inpatient Likelihood to Recommend July 2016 – June 2017









Data source: Hospital Compare www.medicare.gov/ hospitalcompare

National Average 72%

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 the patients’ severity of illness upon admission.

30–day Mortality Rates (30 days from admission) Inpatient Medicare only | July 2013 – June 2016 18.7



17.8 14.8

13.1 11.6

14.6 12.3


Data source: Hospital Compare www.medicare.gov/ hospitalcompare







Acute Myocardial Infarction (Heart Attack) National Average 13.6% Heart Failure National Average 11.9% Pneumonia National Average 15.9%


30–day Readmission Rates (to any acute facility) Inpatient Medicare only July 2013 – June 2016 (Heart Failure) July 2015 – June 2016 (Hospital-wide)

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 readmissions to the hospital that were potentially avoidable. The rates are “risk-adjusted,” meaning that the calculations take into consideration the patients’ severity of illness upon admission.






14.9 22.3


Data source: Hospital Compare www.medicare.gov/ hospitalcompare

15.4 22.4



Heart Failure National Average 21.6% Hospital Wide National Average 15.3%

Health Care-Associated Infections Ratio July 2016 – June 2017

Health care-associated infections (HAIs) are infections people get while they are receiving health care for another condition. HAIs can happen in any health care facility, including hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities. HAIs can be caused by bacteria, fungi, viruses, or other, less common pathogens.


1.9 1.7


1.0 0.5

0.7 0.8 0.2




0.5 0.0

0.5 N/A


0.3 N/A

Data source: Hospital Compare www.medicare.gov/ hospitalcompare


CLABSI (Central Line-Associated Bloodstream Infection) National Average 0.85 CAUTI (Catheter-Associated Urinary Tract Infection) National Average 0.90 MRSA (Methicillin-Resistant Staphylococcus Aureus) National Average 0.90 C. Diff (Clostridium difficile) National Average 0.86 Ratio of the actual observed rate to the predicted rate.

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


Charity care Non-reimbursed cost to hospital

System Statistics 2017 Health

101,144 admissions




Uncollected accounts Cost to hospital


Medicaid Non-reimbursed cost of care for Medicaid patients


Medical education Non-reimbursed cost of educating medical residents and interns


7,652 Cardiac

Catheterizations 60,273 surgeries 13,000

Community Health Initiative grants


Support of schools


Community classes, screenings and support for health events


$89,205,700 15

101 Sivley Road · Huntsville, AL 35801 (256) 265-1000 | hhsys.org

Profile for Huntsville Hospital Health System

Report to the Community 2017  

Report to the Community 2017  

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