Zero readmission penalties & a 5-star rating: What's behind EvergreenHealth Medical Center's success?

Under the Hospital Readmissions Reduction Program, CMS has cut funding to hospitals with higher-than-expected rates of readmissions for the last five years. EvergreenHealth Medical Center in Kirkland, Wash., is one of just 318 hospitals in the nation never penalized under the program.

On top of that, EvergreenHealth Medical Center is one of just two hospitals in Washington with five stars from CMS in the agency's Overall Hospital Quality Star Rating Program.

Jeff Tomlin, MD, EvergreenHealth's senior vice president and CMO, says the hospital has achieved success doing the "usual things," like focusing on reducing infections and improving the patient experience, as well as having a great nursing staff committed to safety. However, he also attributes the hospital's success to two less traditional aspects: its historic focus specifically on readmissions and a team dedicated to proper clinical documentation.

According to Dr. Tomlin and Ettore Palazzo, MD, the hospital's medical director of readmission reduction, EvergreenHealth Medical Center has a longstanding commitment to reducing readmissions.

In fact, Dr. Palazzo has been leading the readmission reduction charge since 2004, when hospital officials recognized room for improvement in that area. "We had no idea why these patients were coming back," he says, and he got to the bottom of it.

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He started with chart analysis, looking into every readmission and identifying the diagnosis and service lines linked to that readmission. Then he shared the information: Department heads received department-level data, and providers knew their readmission rates compared to their peers.

This process of analysis and explanation led to a significant reduction in seven-day readmissions (which CMS focused on until 2009) between 2004 and 2007.

When CMS shifted focus to 30-day unplanned readmissions and started fining for excessive readmissions, EvergreenHealth Medical Center was ready and continues to record lower-than-expected readmission rates today.


While EvergreenHealth Medical Center saw absolute readmissions decrease, CMS uses observed versus expected readmission ratios in its readmission reduction program, which is where airtight clinical documentation comes into play.

EvergreenHealth Medical Center has had a clinical documentation review process in place for the last six years. A team of clinical documentation nurses, overseen by Scott Stuart, MD, EvergreenHealth's medical director for utilization management, review every patient chart, except those for Medicaid patients, making sure physicians have appropriately and accurately recorded each patient's risk.

For instance, a physician may document a patient as having pneumonia, but that patient had a 10-day hospital stay. "Why not document more appropriately and specifically and say this patient had a complex pneumonia, related to atypical bacteria, and was septic," says Dr. Stuart. "It paints a more accurate picture."

Dr. Tomlin says putting a physician in charge of the clinical documentation program was the "secret sauce" that led to its success, because physicians are usually more receptive to listening to a physician colleague. Dr. Stuart can "much more effectively go to physicians about what they document and why," as opposed to nurses, Dr. Tomlin says.

Communication is of upmost importance. "We make sure medical staff understand why nurses are querying them on diagnoses," Dr. Stuart says. "It's not meant to threaten their autonomy or judge them."

The main message to physicians about documentation is that "it's in everyone's best interest if you document better," Dr. Tomlin says.

Not only has proper clinical documentation helped EvergreenHealth Medical Center avoid cuts to its Medicare reimbursement, it has also aided with denials management. "We're prepared to defend our work," Dr. Stuart says.

While analysis and proper clinical documentation have far-reaching effects, patient safety is the real reason for the time and effort, Dr. Tomlin says. "It's way beyond the grades…anything to improve patient safety and quality is at the forefront of all of this."

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