Malcolm Baldrige National Quality Award
2013 Award Recipient, Health Care
Sutter Davis Hospital (SDH) is a nonprofit, 48-bed acute care hospital that offers care in four primary areas: medical-surgical and intensive care, birthing, emergency care and surgical services. Sutter Davis is the only acute care facility in Davis, Calif., and one of two in its county. It operates as part of a regional structure within the Sutter Health System. SDH's workforce consists of 385 employees and 394 medical staff members supported by 100 volunteers. The hospital operated in 2012 on nearly $95 million in revenues.
- SDH performance scores for specific patient groups such as acute myocardial infarction, congestive heart failure and pneumonia have ranked in the top 10 percent nationally for since 2010.
- SDH exceeds the top 10 percent benchmarks nationally for readmission rates and average length of stay for pneumonia, heart failure and acute myocardial infarction, as well as average length of stay for both Medicare and overall inpatient care.
- SDH demonstrates high standards for work and process efficiency. For example, the average door-to-doctor time in emergency has decreased from 45 minutes in 2008 to 22 minutes in 2012, well below the California benchmark of 58 minutes.
- An organizational focus on people is reflected in SDH’s employee satisfaction and engagement scores, which exceed the top 10 percent of marks in a national survey database.
Top-Level Care Maximizes Positive Outcomes
- Sutter Davis Hospital demonstrates sustained high levels of performance in many health care and patient-focused process results. For example, core measure scores reported to the Centers for Medicare and Medicaid Services (CMS) have ranked in the top 10 percent nationally since 2010. (Core measures are evidence-based performance metrics that set national standards for specific patient groups.) These include results for acute myocardial infarction, congestive heart failure and pneumonia. Sutter Davis' scores on performance measures defined by the Surgical Care Improvement Project, a national quality partnership dedicated to significantly reducing surgical complications, also have achieved top decile levels.
- MIDAS (Medical Information Data Analysis System), a health care software for tracking and trending quality-of-care data, shows Sutter Davis exceeds the top 10 percent benchmarks nationally for readmission rates and average length of stay for pneumonia, heart failure and acute myocardial infarction, as well as average length of stay for both Medicare and overall inpatient care.
- Sutter Davis Hospital's rate of hospital-acquired conditions outperforms benchmarks and is equal to or better than competitors' rates. Metrics for the Birthing Center, one of the hospital's focus areas, exceed benchmarks for C-section rates, elective deliveries at less than 39 weeks and rate of exclusive breast milk feeding.
- Sutter Davis performs in the top 10 percent nationally for post-operative orthopedic surgical infections rates, with no infections from 2008 through 2012. The hospital has experienced zero catheter-associated urinary tract infections since 2008 and zero central-line-associated blood stream infections events since 2010. No adverse events involving incompatible blood have occurred since 2008.
- The Birthing Center team, which delivers approximately 1,300 babies per year, has been nationally recognized as a highly collaborative model of care. Teams of physicians, certified midwives, anesthesiologists, pediatricians, doulas and nurses offer a comprehensive, family-centered approach to alternative birthing methods, as well as traditional birthing options. C-section rates are among the lowest in California and voluntary induction rates remain below the national benchmark.
- Sutter Davis Hospital's focus on compassion and caring has consistently ranked the hospital in the top 10 percent nationally for patient satisfaction and engagement as defined by the Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS). SDH also has a four-year record meeting CMS benchmarks for overall ratings of the hospital and measures of customers' willingness to recommend the hospital to others.
Fiscal Health Enables Quality Health Services
- Sutter Davis Hospital demonstrates financial excellence in its earnings before interest, taxes, depreciation and amortization margins, exceeding the 93rd percentile of California acute care hospitals from 2006 to 2009 (the last year for which data are available). SDH's margins topped 25 percent in 2011 and its net operating margin has grown steadily since 2008, significantly outperforming local competitors and the Truven Health Analytics "Top 100 Hospitals."
- The hospital's commitment to affordability is demonstrated by the measures of its cost per discharge (when adjusted by the mix of cases as weighted by Medicare). Sutter Davis' performance using this cost monitoring and control metric exceeds the top 25 percent of the hospitals in California and ranks the hospital's cost among the lowest in its system.
- Sutter Davis maintains overall market share against its larger competitors. Growth in two service lines—the emergency department and oncology—reflects the hospital's ability to meet community needs. Specifically, emergency visits reflect approximately 12 percent growth from 2008 through 2012, and oncology visits nearly doubled between 2007 and 2012. Additionally, the Birthing Center's total births are more than double the number of the local competitor.
Great Team + Great Environment = Successful Workforce
- Sutter Davis' Culture of Caring is reinforced through senior leaders' dedication to safe patient care, an engaged workforce and the community. Annual goals and action plans create accountability for the delivery of a consistently positive patient experience. This accounts for the hospital's solid clinical quality ratings and outcomes and its strong position as a preferred place to work and practice medicine.
- Sutter Davis Hospital demonstrates high standards for work and process efficiency. For example, the average door-to-doctor time in emergency has decreased from 45 minutes in 2008 to 22 minutes in 2012, well below the California benchmark of 58 minutes.
- An organizational focus on people is reflected in Sutter Davis' employee satisfaction and engagement scores, which exceed the top 10 percent of marks in a national survey database. Physician satisfaction shows sustained improvement over the past three years, increasing from 80 percent to 90 percent, and attaining Press Ganey top 10 percent performance in 2011 and 2012.
- Measures of workforce climate at Sutter Davis Hospital exceed Sutter Health's targeted goals. SDH employees have rated workforce health, safety and security at 100 percent from 2008 to 2012. Employee perceptions of safety exceed national top 10 percent benchmarks as measured in the hospital's annual Culture of Safety survey.
Good Citizens and Good Neighbors
- Sutter Davis Hospital demonstrates a commitment to its mission "to enhance the well-being of people in the communities we serve" via strong performance levels and trends on indicators of how the hospital has fulfilled its societal responsibilities and contributed to community health.
- From 2009 to 2012, Sutter Davis Hospital doubled the number of children retained by the Yolo Children's Alliance Health Initiative, a project dedicated to providing health insurance for all children in Yolo County, Calif.
- A Sutter Davis partnership with CommuniCare, Davis, Calif.'s Federally Qualified Health Center, ensures service to the medically indigent, reflecting a commitment to one standard of care for all patients.
- All Sutter Davis leaders exemplify ethical behavior, leading by example at all levels of the organization. All staff members are held responsible for meeting ethical expectations through ethics training and education, established standards of behavior, and a zero-tolerance policy for ethical breaches