Guest Opinion: What’s in a standard of care?


by Rachelle Schultz, EdD, president/CEO, Winona Health

Health care is one of the most highly regulated industries in the U.S. I believe the nuclear power industry is the only one that has more regulations than providing long-term care has; hospitals are a close second and demands on clinics are rising. As a result, Winona Health does a great deal of mandated quality reporting. This includes mandatory reporting requirements set out by the respective state and federal governmental agencies including the Centers for Medicare and Medicaid (CMS), Minnesota Department of Health (MDH), Minnesota Departments of Health and Human Services (DHS), and a variety of other agencies and departments. Additionally, insurance companies, with which we have contracts, also establish their own specific quality metrics, formulas, standards and reporting frequency. These may or may not be the same as the government-mandated metrics and we must report our outcomes accordingly.

A few examples of hospital metrics include infections, readmissions, pneumonia measures, c-section rates, and newborn screenings. There are other measures that do not apply to us, for example coronary artery bypass grafts as we do not do this at our hospital. Examples of outpatient service measures include screenings (depression, breast cancer, colorectal and more), at least five diabetes indicators, immunizations, asthma, hypertension, medication adherence and even dental visits, to name only a few. Given the variation in reporting requirements, a lot of time and resources are spent collecting data for these measures, reporting them to the respective parties, and attempting to reconcile them through our processes to lighten the burden on providers and staff. If you ever wondered why you are asked a lot of questions about your health status, now you know.

On top of these requirements is another layer of quality and performance standards related to certification and accreditation for specific programs and services offered at Winona Health. Examples include our Commission on Cancer accreditation with Silver Level Commendation, Breast Center of Excellence, Stroke Ready Hospital, Trauma Designation, National Committee for Quality Assurance for medical staff services, Clinical Laboratory Improvements Amendments (CLIA) and College of American Pathologists (CAP) accreditation for our laboratory, health care home certification, and multiple imaging certifications. Each of these has its own set of performance standards and requirements along with quality metric reporting. And all of this work is monitored, updated, improved, and reported on continuously through onsite surveys, audits, data submission and review. We are committed to providing high-quality care for our community at Winona Health. While we receive very good outcomes on these surveys, we are always interested in ways we can improve and ensure we are performing at a high level. The feedback we receive is highly valued. We own what we need to improve and proactively seek out areas to do so.

Minnesota has long led the way in patient quality and safety as evidenced by being the first state where the hospitals championed public reporting of adverse events. This has been in place since 2003. Minnesota Hospital Association committees, made up of people from hospitals across the state, have developed road maps for quality and safety issues. Winona Health is both a beneficiary and a participant in this work. For example, this past year we identified an issue with Clostridium difficile (C. diff) colitis, which is a common infection of the colon that is typically associated with the use of antibiotics. A team of our clinicians worked with experts from other hospitals around the state and the Minnesota Department of Health to understand the gaps, develop a plan to close them and then executed the plan. The work itself was not difficult, but it did depend on accurate data to understand the root causes to fix the issue. We excel at doing this at Winona Health, and this work also benefits other health care organizations and patients throughout Minnesota.

We have attempted to pull together all of the quality metrics we report on for the various parties just mentioned. While it is a bit of a moving target, the number is over 300, and this does not account for regulations. The processes and systems in place to manage the magnitude of reporting and updating of these external demands are robust and constantly evaluated. We are not perfect, but we pursue perfection because that is what we want for our patients and our community.

Last week, the Leapfrog Group posted its biannual grades for hospitals in the U.S. and we noted a significant drop in our grade, which caused a bit of panic internally. Upon investigation, we found that there had been a process error in which Leapfrog had not received our data (we assumed they had). This issue was corrected and they have our data, however, we were told that no change would be made to their report until next spring, when the process is done again. Not all hospitals report their data to this organization and, in fact, we have not consistently submitted our data given that much of it is duplicative of what is already publicly reported.

One of my issues within our industry is the constant reference to standards. When there are 10, 20, 50, or any number of standards for the same thing, there is NO standard. We continue to work with many of these agencies to try to align their definitions, formulas, and criteria. This is no small task, but it is important as the lack of alignment ultimately wastes resources and impedes progress across the industry.

Continuous improvement is part of our culture at Winona Health. Our entrepreneurial spirit of challenging standards of performance and reaching for higher targets is ingrained in our work. The care provided at Winona Health is top notch. We recently received a letter from CMS stating Winona Health is a four-star hospital, and we are proud of that achievement. Our excellent health care providers and staff care deeply about their patients and the care they provide to them. Rural community hospitals often deal with assumptions that the care they provide doesn’t measure up. The fact is, community hospitals have to be better than others just for this reason. And at Winona Health, we are.


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