SD hospital hit with lowest quality rating: Inside the fight for improvement.

However, Monument's 2023 review by Leapfrog noted some of the same deficiencies as indicated in the CMS rating.

Monument was rated below the national average in several areas, including in sepsis infections after surgery, accidental cuts and tears, dangerous blood clots, surgical wounds splitting open, site infections after colon surgery, patient falls and injuries, and "deaths from serious treatable complications."

Monument Rapid City received a B grade from Leapfrog in 2022 but got a D grade in 2020.

Of the 10 South Dakota hospitals graded by Leapfrog in summer 2023, Monument's C grade was tied with six others for lowest in the state, with higher grades received only by the Brookings Health System (A grade) and Avera St. Luke's Hospital in Aberdeen (B grade).

Tice acknowledged that the Leapfrog ratings are based on data that are "not as robust" as the data used by CMS in its ratings.

Monument Health received other awards

Monument leaders provided News Watch with multiple examples of honors and awards received by the hospital.

Chief among them is that the hospital for at least the past seven years has been fully accredited and has implemented all national safety goals promoted by the Joint Commission, a national nonprofit that examines hospital safety and awards accreditation. Monument hospital received the commission's Gold Seal of Approval for its three-year accreditation.

The hospital's chest pain section has also received a platinum level achievement award for 12 straight years from the American College of Cardiology and upgraded its rating from the American Heart Association (AHA) regarding treatment of stroke patients.

The AHA also bestowed its Silver Award on the Monument Health Heart and Vascular Institute in its first year of operation.

Monument's orthopedic and specialty hospital and its urgent care facility on Jackson Boulevard in Rapid City received the Commission on Office Laboratory Accreditation for applying high standards of qualify and performance in 2022.

Tier system aimed at constant improvement

Monument in 2019 implemented a five-tier quality and safety reporting system in which any and all issues or problems are documented and directed to employees who can best make improvements.

It starts with a series of daily employee huddles regarding quality and safety within the hospital, with topics being prioritized based on importance or immediacy.

The more important the issue, the higher it rises up the tier system, starting with frontline employees at tier 1 and rising eventually up to the 5th tier of top leaders and executives.

"In the earliest hours of the morning, right when frontline caregivers start coming in, we have five tiers of huddles where we cover topics related to patient safety and quality. We talk about incidents that have happened, we talk about infections that have occurred, we talk about any breaks in practice or process that need follow up," Tice said. "And those things are then very easily escalated to the departments that we need to step in and help."

On a recent day, a huge white board in a conference room within the hospital administrative offices was nearly covered with notes on patient census, staffing needs, technology or equipment updates and other challenges facing hospital staff and leadership, with solutions offered on who can fix them and how. The notes are part of a process focused on constant improvement in hospital policies and procedures at Monument and common at other health systems.

For instance, a computer printer problem or slippery sidewalk can be solved at tier 1, whereas issues related to infections or other serious medical or procedural problems might rise up to the level where more systemic change may be needed, Tice said.

In regard to infections, which CMS and Leapfrog ratings have noted as areas of concern, Monument has made improvements that have prevented any "central line" catheter infections in more than two years and just two surgical site infections in the past 18 months, she said.

"Acquired infections is always something that we want to work towards elimination, not just decreasing the numbers, but eliminating them," Tice said. "We can demonstrate that we have started, we have moved towards elimination, which really puts us in line with those top performing hospitals across the nation."

The problem-solving process has had some notable success. When Monument staff recognized a high rate of surgical site infections after colon surgeries, a team approach led to a series of interventions that resulted in a 37% reduction in such infections in 2022.

Also, the infection control team at Monument noticed an increase in anti-microbial infections such as methicillin-resistant Staphylococcus aureus (MRSA) infection and central-line catheter infections, Monument employees devised a plan to improve patient safety and saw a resulting 92% reduction in central-line infections in 2022-23. Hospital-onset MRSA infections were also cut by 75% in the past nine months compared to the nine months prior.

Patients ranked Monument Health higher

On a separate CMS rating scale, based on patient surveys of their personal experiences, Monument hospital in Rapid City received a 3-star rating on a scale of 1 to 5 in 2023.

While the hospital scored well in several areas on the patient survey rating, it was behind comparable patient ratings for hospitals across the U.S. and South Dakota in regard to nurses and doctors always communicating well, rooms and bathrooms always being clean and patients who strongly agreed they understood the care they received.

Overall, the most recent survey showed that 62% of Monument patients surveyed would "definitely recommend" the hospital to others, compared to a similar recommendation level of 77% by patients at all South Dakota hospitals and a national positive recommendation average of 69%.

CMS ratings aimed at public education

CMS provides the public with several ways to evaluate and compare the performance of hospitals and other health care facilities in their communities and across the nation.

The Care Compare website tool enables users to examine the quality of a particular medical facility and to compare up to three medical providers at the same time based on dozens of quality metrics. On a simpler level, CMS created the Overall Hospital Quality Star Rating system to enable the public to obtain a snapshot of a facility's quality based on 46 quality measures grouped into five major categories.

The five general areas of review include patient mortality, safety of care, readmission rates, patient experience and timely and effective care, the agency said.

"Patients and families can use the star rating, along with other information on Care Compare, to learn about the quality of hospitals and the services they offer," a CMS spokesman wrote to News Watch in an email. "Overall star ratings are meant to capture a hospital's performance as a snapshot in time."

CMS added that the star ratings are subject to change over time and can serve as motivation for medical facilities to make changes and improvements in procedures and outcomes to boost future star ratings.

To provide a level playing field for facility analysis, the star ratings are also based on comparisons with all other hospitals in the nation, creating a stronger baseline for overall comparisons, CMS said.

East River hospitals fare better on CMS scale

In the region around Rapid City, Monument Health hospital in Spearfish received a 4-star CMS rating in 2023, as did the Veterans Affairs Black Hills Health Care System in Sturgis. The closest 5-star rated hospital to Rapid City was Sheridan Memorial Hospital in Sheridan, Wyoming.

Not all South Dakota hospitals provided enough data to be rated by CMS, but hospitals in eastern South Dakota that were rated by the government agency generally fared well in 2023.

The Avera Gregory Hospital in Gregory and Avera St. Mary's Hospital in Pierre both received 3-star ratings. Avera McKennan Hospital in Sioux Falls and Sanford Medical Center in Aberdeen received 4-star ratings.

The 5-star ratings were awarded to Avera hospitals in Yankton and Aberdeen and the Avera Heart Hospital in Sioux Falls, the Brookings Health System, Prairie Lakes Health Care System in Watertown and the Sanford USD Medical Center and VA Medical Center in Sioux Falls.

Two hospitals within a 200-mile radius of Sioux Falls received 1-star ratings in 2023, including MercyOne Siouxland Medical Center in Sioux City, Iowa, and Montgomery County Memorial Hospital in Red Oak, Iowa.

According to CMS data, fewer than 1 in 10 of all U.S. hospitals rated in 2023 received a 1-star rating. CMS reported that 250 of 3,076 U.S. hospitals rated by the agency in 2023 had a 1-star rating, about 8% of the total.

Meanwhile, 668 hospitals (22%) had a 2-star rating, 872 (28%) had a 3-star rating, 803 (26%) had a 4-star rating and 483 (16%) had a 5-star rating.

The CMS ratings are an important tool to allow patients to quickly gain insight into the recent performance of a hospital and its staff, a process that otherwise would be complicated and unwieldy, said Shelly Ten Napel, CEO of the Community HealthCare Association of the Dakotas in Sioux Falls.

"It's hard for consumers to really understand if they are getting good health care or if a lot of money just being put into fancy buildings and high-cost specialty care," said Ten Napel, who previously served in health care innovation in Washington and began her career as a health care analyst for former U.S. Sen. Tom Daschle.

"I do think they're worth looking at for consumers to better understand, 'Are we paying for high volume or are we paying by outcomes,' and is there any transparency for consumers into what are truly high-quality services?"

Ten Napel did not want to comment on the specific CMS ratings for Monument Health and acknowledged that the concept of creating a quality rating for a medical facility can depend on a lot of factors, such as which data is requested and how it is then used by the rating agency.

But she said the CMS star ratings and other ranking services can help medical providers maintain quality or improve areas of deficiency by putting pressure on them to meet a range of quality metrics.

"From a primary care perspective, it can sometimes be the only way to know if you're doing well," Ten Napel said. "We really believe in the importance of measuring and pay a lot of attention to how we perform to metrics."

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Monument strives to obtain excellence

Tice told News Watch that based on current data, Monument leadership - which includes public relations manager Stephany Chalberg, who also serves on the South Dakota News Watch board of directors - expects to see improvement in both the CMS star rating and the grade from the Leapfrog Group when new rankings are released later this year.

"Can we get to a 5 in this next (CMS rating) release? No. Can we get there someday? Absolutely we can, and we will," she said. "We think, unfortunately, the 1-star rating is not what who we are today, that the star rating doesn't tell the story of who we are today, and what our performance looks like today or even last year. So do I feel safe coming and getting care here? Absolutely."

This story was produced by South Dakota News Watch, an independent, nonprofit news organization. Read more in-depth stories at sdnewswatch.org and sign up for an email every few days to get stories as soon as they're published. Contact Bart Pfankuch at bart.pfankuch@sdnewswatch.org.