Star Ratings Fight Call-Button Blues

Aug 5, 2015

When multiple sclerosis patient Meesha Cook suffers a seizure, she doesn’t get to decide where she’ll go for treatment.

If the Brevard County resident is at her job, as a cashier at Lowe’s Home Improvement in Rockledge, paramedics take her down the road to Wuesthoff Medical Center.

If she’s at home in Viera, the next town south, they take her to the hospital there.

Cook would much rather go to Viera Hospital, she says, not only because it is new and Wuesthoff is decades older. The nurses at Viera are nicer, and quicker to respond, said Cook, 42.

Meesha Cook
Credit Courtesy of Meesha Cook

“I just think that Viera’s more professional,” said Cook. “I mean, when I had my seizures at Wuesthoff, it seems like I had to wait and wait and wait.  The people there, they seem like they treat you like a number, more than like somebody that’s alive, that has a beating heart and has feelings.”

Cook is not alone. In April’s release of federal patient-opinion surveys of hospitals, Viera joined Mayo Clinic in Jacksonville, Sacred Heart Hospital on the Gulf in Port St. Joe, and Mariners Hospital in Tavernier as just four of 165 Florida hospitals in the state earning the highest rating possible -- five stars. 

Meanwhile, Wuesthoff in Rockledge was at the bottom of the list, one of 11 Florida hospitals accorded just one star.

An updated star-rating report came out in late July. In that report, six Florida hospitals earned five-star ratings, and 18 received just one star. The new five star hospitals are Jay Hospital in Jay, and Sacred Heart on the Emerald Coast in Miramar. The interactive map below shows that most recent information.

Wuesthoff and Viera hospitals are just eight miles apart along I-95, north of Melbourne and south of Cape Canaveral. Taken together, the hospitals’ scores made Brevard County the only one in the state that had both a one-star and a five-star hospital. 

The patient survey results are just the latest in a rollout of five-star ratings from the Centers for Medicare and Medicaid Services that began in 2008 with nursing homes. Since then, the agency has added the five-star ratings symbols to indicate quality on Medicare Advantage plans, prescription drug plans, hospitals and home-health agencies.

The hope is that patients will learn to use the government-sponsored websites (Hospital Compare, Nursing Home Compare, etc.)   the same way shoppers refer to Consumer Reports when buying an appliance or car.

The data are compiled from mail and phone surveys to a representative sample of adult patients after their discharge from a hospital. They are asked about cleanliness, speed of response to a call button, pain control and how well the nurses and doctors kept them informed.  The hospital gets credit only if the answer is "always"; "usually" doesn't count.

Donald Davidson of Satellite Beach, who was recently in Viera Hospital for heart tests, said he chose that hospital when he moved to the area four years ago because it was new. Davidson, 69, said  he gave Viera high ratings on surveys following his two previous stays for knee operations. 

The food is good, Davidson said, adding, “I’ve always been treated well here. I think they’re well-trained.”

The star ratings are derived from percentages in the survey results, and are graded on a curve. In percentage terms, Viera was above average and Wuesthoff was below average on all 11 questions on the survey. The national and state averages were midway between the two.

On the survey results released in April, 90 percent of patients from Viera strongly agreed that they “would definitely recommend the hospital to others,” compared with just 53 percent of patients from Wuesthoff.

Wuesthoff Health System declined a request to be interviewed for this story. Communications Director Diana Vandemark issued a written statement that noted there has been a changed of management since the period in which the survey data were gathered.

Wuesthoff’s new owner, Tennessee-based Community Health Systems (CHS), brought “new resources to support our work to provide quality care and a positive patient experience through training and education on best practices,” she wrote.

The hospital already has embarked on a number of new initiatives, Vandemark said, including  more frequent rounds to see patients, bedside shift reports and follow-up calls to discharged patients.

“These initiatives are already showing a positive impact on communication, responsiveness and overall satisfaction,” Vandemark wrote. “We are committed to our patients and their families and remain focused on meeting their expectations for quality, service and environment of care.”

Ratings? What Ratings?

Since the hospital star-rating system was announced in April, there has been little attention paid to it. The directors of both the local health planning agency and a health foundation said they hadn’t heard about Brevard’s unique status with a five-star and a one-star hospital.

But the ratings matter have an impact on hospital finances – increasingly so. Viera’s five-star rating will bring it $100,000 in Medicare bonuses this year, officials there said, and an equally high rating for next year would bring in even more.

Viera Hospital patient advocate Geraldine Stubbert speaks with Monica Burchfield, the daughter of a patient, who brought her Yorkie named Demi to see her father Max Driver.
Credit Carol Gentry / Health First

Wuesthoff’s one-star rating could mean a pay cut, but both CMS and Wuesthoff said they were unable to provide that information.

Steven G. Ullmann, director of programs in the Center for Health Sector Management and Policy at the University of Miami, said the survey draws responses from two groups: those who are really angry and those who are really happy.

Usually less than half return them, said Ullman, an economist and bioethics expert.

“Most response rates are in the 20-to-30% range,” Ullmann said. “So therefore you have to take any of these rankings with a grain of salt … Having said that, they can provide a facility insight on where it may be experiencing issues.”

Brevard County resident Meesha Cook said she was first admitted to Wuesthoff in December 2011, right after doctors confirmed her diagnosis of MS. She stayed just over a week in the mental health unit being treated for depression.

“It was very dirty, the floors, you wouldn’t want to walk on the floor even to go to the bathroom,” she said. “As soon as I got out of bed I grabbed my socks and put them on because I was afraid I was going to get some strange disease…

“I had to ask for a pair of socks twice a day, because I would pull my socks off and they would be black. It was disgusting.”

As a full-time employee at Lowe's, Cook had health insurance to cover that stay. But in 2012, as she grew weaker, she had to cut her hours, which meant she lost her insurance coverage. Two stays at Wuesthoff following seizures resulted in bills totaling $19,000 that she couldn’t pay.

Court records show Wuesthoff filed suit against her for non-payment. A letter in the file Cook wrote to Wuesthoff explained her MS and lack of insurance and begged for a break.  She didn't get it.

“I just can’t (pay), I don’t have the money,” said Cook, who estimates her annual income at less than $11,000. “They don’t care. They just want their money – no ifs, ands or buts.”

Cooks says things were quite different after she suffered a seizure at home and was taken to Viera Hospital in 2013.

“Viera Hospital told me about charity care,” something Wuesthoff had never mentioned, she said.

Showing its age

The differences between the hospitals start with their age: Wuesthoff in Rockledge is 74 years old. It was named for Eugene Wuesthoff, a winter visitor whose heirs provided $12,500 in start-up funds. 

Wuesthoff Hospital in Rockledge
Credit WuesthoffHospital.com

For most of those years, Wuestoff was an independent not-for-profit, but four years ago a Naples corporation bought it. That company, Health Management Associates, was purchased two years ago by CHS, the current owner.

On the outside, Wuesthoff has a bright new paint job. Inside, though, it looks dated and drab, with dim fluorescent lights and two patients to a room.  It sits on a hill, flanked by small houses of considerable age and fronted by shabby shops.

By contrast, 4-year-old Viera sits on a 50-acre campus that includes a fitness center and medical office building in a prosperous suburb surrounded by golf courses and lakes.

Credit Health First

Health First, a non-profit health network based in Melbourne, equipped the hospital with the latest technology, all-private rooms, high ceilings and a flood of natural light.

Viera Hospital has just 100 beds, about one-third the number at Wuesthoff. And it offers a helipad for quick transport to Holmes Regional Medical Center in Melbourne, among the state’s most sophisticated trauma centers.

Acing the test

Viera’s Chief Operating Officer Deborah Angerami says the hospital didn't always come out on top in patient surveys.  Last year, when she saw how Viera compared with other hospitals, she became concerned.

“At the time, our scores en masse were the 24th percentile, so we were performing worse than 76 percent of the hospitals in the country,” she said.

Viera Hospital Chief Operating Officer Deborah Angerami
Credit Health First

Angerami and others drilled down into the results for each question and found a big problem: doctors’ comparatively poor communication skills. Patients said the medical staff didn't keep them informed or treat them with respect, she discovered.

Doctors on the hospital’s medical executive committee took on the challenge of making the staff aware of what wasn’t working and how to change. Two of the incentives: they threatened to cut off new-patient referrals to low-scorers. And they posted survey scores in the doctors’ lounge. While they were listed by ID numbers, it didn’t take doctors long to match the numbers with names. That got results, said Angerami.

“Most folks just didn’t realize there were small behaviors that really meant a lot to the patient,” she said. “Do you sit down when you talk to them? Do you ask them before you leave the room: ‘Is there anything else I can answer for you?’ ”

Viera Surgeon Kenneth Tieu said he earned 98 percent approval by staying cheerful, getting test results back to patients quickly, and visiting patients far more often than he has to.   

“I’m in between (surgical) cases right now,” he said recently when approached during a break on a patient floor. “I do surgery all day, but I come up here two to three times a day.”

Dr. George Walker, medical director at Viera Hospital’s Emergency Department, says it’s especially important for physicians to speak soothingly to patients there because they are terrified.

Viera Hospital Dr. Kenneth Tieu
Credit Carol Gentry / Health News Florida

“A simple thing like going into a patient’s room and sitting down, even if it’s for five seconds,” he said, “makes a huge impact on the way the patient perceives you.”

The survey results are one of three measures that go into CMS’ Hospital Value-based Purchasing Program, which grew out of a quality initiative that began in 2001 and was beefed up by the Affordable Care Act in 2011.

It adjusts Medicare payments to hospitals up or down depending on how they score on a mix of the three. The other measures are less subjective: cost-efficiency and quality-of-care comparisons, including the percentage of patients readmitted within 90 days.

The five-star system that CMS uses for its patient opinion surveys will eventually be broadened to include the cost-efficiency and quality-of-care measures, the agency says.

Some criticize tying patient-opinion surveys to payments since most patients don't have enough medical knowledge to rate their quality of care.

But Dr. Donald Berwick, founder of the Institute for Healthcare Improvement, said he insisted on including patient-opinion surveys in the new hospital payment system when serving as President Barack Obama’s CMS administrator in 2010 and 2011.

“The patient is the boss; we are the servants,” he said. “They, not others, should direct their own care, and the doctors, nurses and hospitals should know and honor what the patient wants.”

Special Correspondent Carol Gentry is a reporter for WUSF in Tampa. WUSF is a part of Health News Florida, which receives support from the Corporation for Public Broadcasting.