Joint Commission Publishes new Monograph about CLABSIs

On May 16th, the Joint Commission released a new Monograph reviewing the most recent evidence and thoughts surrounding Central Line-Associated Bloodstream Infections.

The free monograph can be downloaded here: http://www.jointcommission.org/assets/1/18/CLABSI_Monograph.pdf

Below is an excerpt from the press release announcing the free monograph (emphasis added in red):


New Monograph Aims to Decrease Central Line-Associated Bloodstream Infections (CLABSIs)

The Joint Commission, in collaboration with Joint Commission Resources (JCR) and Joint Commission International (JCI), developed a new monograph containing the most current information, evidence-based guidance and resources to help health care organizations reduce the current risks and resulting harm associated with CLABSI. JCR and JCI are not-for-profit affiliates of The Joint Commission. The monograph was produced in partnership with infection prevention leaders from the Society for Hospital Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the National Institutes of Health (NIH), the Infectious Diseases Society of America (IDSA), the Association for Vascular Access (AVA), and the International Nosocomial Infection Control Consortium (INICC). In addition, several other domestic and international infection prevention leaders from countries such as Argentina, Australia, Egypt, Switzerland, Thailand and Saudi Arabia have lent their expertise to the monograph.

“Recent patient safety initiatives have demonstrated how preventable CLABSIs can be when evidence-based guidelines are consistently put into practice at the bedside,” says Jerod M. Loeb, Ph.D., executive vice president, Division of Healthcare Quality Evaluation, The Joint Commission. “Our hope is that these resources will empower health care providers to implement practices that have been shown to not only improve patient safety, but also reduce costs.”

The project is supported by a research grant from Baxter Healthcare Corporation and focuses on the identification and broad dissemination of preferred practices and technological solutions to prevent CLABSI. 

At least 12 Indiana Hospitals Report Having No Central Line Infections

In early February 2012, CMS made hospital central line associated blood stream infection (CLABSI) data available on its HospitalCompare website.

Of the 125 Indiana hospitals listed in HospitalCompare, 88 were eligible for CLABSI reporting. For various reasons (small n, no ICU in hospital, etc...), no rating was provided for 65 hospitals. Of the remaining 22 hospitals, 12 reported no infections.

The 12 Indiana hospitals are:

Hospital	City
ELKHART GENERAL HOSPITAL	ELKHART
WILLIAM N WISHARD MEMORIAL HOSPITAL	INDIANAPOLIS
FRANCISCAN ST FRANCIS HEALTH - BEECH GROVE	BEECH GROVE
PORTER VALPARAISO HOSPITAL	VALPARAISO
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	NEW ALBANY
REID HOSPITAL & HEALTH CARE SERVICES	RICHMOND
COMMUNITY HOSPITAL EAST	INDIANAPOLIS
DEACONESS HOSPITAL INC	EVANSVILLE
INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL	MUNCIE
COMMUNITY HOSPITAL	MUNSTER
ST VINCENT HEART CENTER OF INDIANA LLC	INDIANAPOLIS

CMS published this data based on 1Q2011 only. This measure is based on the CDC's NHSN data collection protocol.

Release of 2010 Indiana Medical Errors Report Poorly Covered by Media

Although dated for 11/7/2011, the 2010 Indiana Medical Error Report was released to the public on 11/28/2011.

The link to the press release is here.
The link to the report itself is here.
The link to the data tables (containing facility specific numbers) is here.

In the month since the release of this report, coverage from the media has been disappointing. A brief google scan of Indiana news coverage shows the following:

• The Indy Star and WTHR carried the same small piece on 11/29/2011 highlighting that bed sores were the most commonly reported error and foreign objects left inside patients after surgery was the second. To it's credit, the report did not single out any hospital with high raw numbers.
• However, on the day that the report was released, WTHR posted a separate story on its website highlighting that medical errors had reached a new high. Unfortunately, it reported raw numbers of events at various central Indiana facilities without any type of responsible interpretation. This story did attempt to offer readers advice on how to stay safe, however, the reporter clearly confused prevention concepts (surgery site marking, patient turning) with error reporting ("...what can you do if you suspect an error?).
• On 12/2/2011, the Palladium-Item from Richmond, IN, carried a story highlighting the performance of its local hospital (Reid). It focused on the two patients that Reid reported fell in 2010 causing serious disability or death. It appears that the reporter (Pam Tharp) did interview hospital officials (a vice president, the director of patient safety and quality, and a spokesman) and provided quotes to balance the reported numbers. The story then proceeded to report the 5-Year reporting high, but noted possible explanations (changes in operational definitions) for this.
• The Herald-Bulletin (Anderson), ran a story on 12/8/2011 describing the performance of the two area hospitals. The CEO of Community hospital provided detail of the hospitals process to minimize missing sponges and that it seeks to learn from its errors. The President of Saint John's Hospital and its CNO both provided similar detail as to how it prevents bed sores. Healthcare quality professionals will be happy to see that this article also noted that "Medical errors generally are not the sole result of people’s actions but rather the failure of the systems and processes used in providing health care... The requirement to report events identifies persistent problems, encourages increased awareness of patient safety issues and assists in the development of evidence-based initiatives to improve patient safety."

Of the above referenced coverage, it would appear that the reporter from the Herald-Bulletin (Abbey Dole) provided the most responsible reporting of the annual Medical Error report. With a story that could easily be irresponsibly covered to incite and inflame the public, this reporter educated the public on how the medical error reporting system helps healthcare in Indiana become safer.

Study Shows Baldrige Hospitals Perform Better than Non-Baldrige Hospitals

Thomson Reuters recently released a research paper investigating the performance of Baldrige hospitals vs. non-Baldrige hospitals in key outcome measures. In this study, Baldrige hospitals were defined as hospitals that have won the Baldrige award or have publicly disclosed that they have received a site visit. Non-Baldrige hospitals were the remaining hospitals in the 100 Top Hospitals data set.

Of interest to healthcare quality professionals:

• Baldrige hospitals were significantly more likley than their peers to display faster five-year performance improvement.
• Baldrige hospitals performed better than their peers in the CMS core measures by 4.90 percantage points.

Although not statistically significant, the study also showed that Baldrige hospitals performed better on the following measures than their peers:

• risk-adjusted mortality
• patient safety index
• severity-adjusted length of stay.
• adjusted operating profit margin

The research paper can be downloaded from NIST here or from Thompson Reuters here.

The NIST press release associated with this research paper can be found here. For your convenience, excerpts from this press release have been copied and pasted below. Sections of interest to healthcare quality professionals are in red with some emphasis added.

New Study Finds that Baldrige Award Recipient Hospitals Significantly Outperform their Peers

A new report has found that healthcare organizations that have won Baldrige National Quality Awards for performance excellence or been considered for a Baldrige Award site visit outperform other hospitals in nearly every metric used to determine the 100 Top Hospitals, a national recognition given by Thomson Reuters.

Commissioned by the Foundation for the Malcolm Baldrige National Quality Award, a private organization, and conducted by Thomson Reuters, the report found that Baldrige hospitals were six times more likely to be counted among the 100 Top Hospitals, which represent the top 3 percent of hospitals in the United States, and that they statistically outperform the 100 Top Hospitals on core measures established by the U.S. Centers for Medicare & Medicaid Services.

Health care organizations have accounted for more than 50 percent of Baldrige award applicants since 2005.
Baldrige hospitals also were far more likely than their peers to be cited for marked improvement over a span of five years. According to the report, "[m]ore than 27 percent of Baldrige winner hospitals also won a 100 Top Hospitals: Performance Improvement Leaders award, while only 3 percent of their non-Baldrige peers won the award."

"The results of the Thomson Reuters study confirm what we've known for years: using the Baldrige Criteria and the earnest pursuit of the Baldrige evaluation will improve your organization by nearly every measure of success, be it in outcomes, safety, customer and employee satisfaction, or profitability," says Baldrige Performance Excellence Program Director Harry Hertz.

The study, Comparison of Baldrige Award Applicants and Recipients with Peer Hospitals on a National Balanced Scorecard, is available at www.nist.gov/baldrige/upload/baldrige-hospital-research-paper.pdf.

Registry for Nursing Sensitive Patient Care - Is Everyone Doing It?

Hospitals participating in the Hospital Inpatient Quality Reporting Program (IQR) for FY2012 are required (among other structural measures) to report their participation status in a "Systematic Clinical Database Registry for Nursing Sensitive Care". Hospitals are not required to participate in a registry, but to qualify for the annual payment update, they must report if they participate in one or not.

The most recent data released by CMS in October 2011 show that 51 Indiana hospitals reported "yes", 43 reported "no", and 24 were listed as "Not Available". Of these 24, only one was not a critical access hospital.

The following is the list of all Indiana hospitals that responded "Yes" to participating in a registry of nursing sensitive care:


BALL MEMORIAL HOSPITAL INC
COLUMBUS REGIONAL HOSPITAL
COMMUNITY HOSPITAL
COMMUNITY HOSPITAL EAST
COMMUNITY HOSPITAL NORTH
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY
COMMUNITY HOSPITAL SOUTH
DEACONESS HOSPITAL INC
DEKALB HEALTH
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES
FRANCISCAN ST ANTHONY HEALTH - CROWN POINT
FRANCISCAN ST ANTHONY HEALTH - MICHIGAN CITY
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE CENTRAL
FRANCISCAN ST ELIZABETH HEALTH - LAFAYETTE EAST
FRANCISCAN ST FRANCIS HEALTH - BEECH GROVE
FRANCISCAN ST FRANCIS HEALTH - INDIANAPOLIS
FRANCISCAN ST FRANCIS HEALTH - MOORESVILLE
GOOD SAMARITAN HOSPITAL
HANCOCK REGIONAL HOSPITAL
HENDRICKS REGIONAL HEALTH
HOWARD REGIONAL HEALTH SYSTEM
INDIANA UNIVERSITY HEALTH
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL
INDIANA UNIVERSITY HEALTH BLOOMINGTON HOSPITAL
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL
INDIANA UNIVERSITY HEALTH WEST HOSPITAL
IU HEALTH GOSHEN HOSPITAL
KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICESTHE
LAPORTE HOSPITAL AND HEALTH SERVICES
LUTHERAN HOSPITAL OF INDIANA
MAJOR HOSPITAL
MARION GENERAL HOSPITAL
MEMORIAL HOSPITAL
MEMORIAL HOSPITAL AND HEALTH CARE CENTER
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC
PARKVIEW HOSPITAL
PARKVIEW HUNTINGTON HOSPITAL
PARKVIEW LAGRANGE HOSPITAL
PARKVIEW NOBLE HOSPITAL
PARKVIEW WHITLEY HOSPITAL
REID HOSPITAL & HEALTH CARE SERVICES
SAINT JOSEPH REGIONAL MEDICAL CENTER
SAINT JOSEPH'S REGIONAL MEDICAL CENTER - PLYMOUTH
SCHNECK MEDICAL CENTER
ST CATHERINE HOSPITAL INC
ST MARY MEDICAL CENTER INC
ST MARY'S MEDICAL CENTER OF EVANSVILLE INC
ST VINCENT HOSPITAL & HEALTH SERVICES
TIPTON HOSPITAL
UNION HOSPITAL INC
WILLIAM N WISHARD MEMORIAL HOSPITAL

CMS Announces final details of Value Based Purchasing for Inpatient Acute Care

On April 29th, CMS announced the final rules of its upcoming Value Based Purchasing program for Inpatient Acute Care. This long anticipated program transitions the inpatient care provided to Medicare beneficaries from "pay for reporting" to "pay for performance".

The HHS press release itself is of little value to the healthcare quality professional. You can view it here: http://www.hhs.gov/news/press/2011pres/04/20110429a.html. However, it links to a CMS press release that contained more details. You can view it here: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=3947.

Although these rules become effective with fiscal year 2013, CMS also released the list of measures for 2014 as well.

The following are excerpts from the CMS press release:


PERFORMANCE SCORING:

Performance Period: CMS has established a performance period that runs from July 1, 2011 through March 31, 2012, for the FY 2013 Hospital VBP payment determination. CMS anticipates that in future program years, if it becomes feasible, it may propose to use a full year as the performance period.

Scoring Methods: CMS will score each hospital based on achievement and improvement ranges for each applicable measure. A hospital’s score on each measure will be the higher of an achievement score in the performance period or an improvement score, which is determined by comparing the hospital’s score in the performance period with its score during a baseline period.

For scoring on achievement, hospitals will be measured based on how much their current performance differs from all other hospitals’ baseline period performance. Points will then be awarded based on the hospital’s performance compared to the threshold and benchmark scores for all hospitals. Points will only be awarded for achievement if the hospital’s performance during the performance period exceeds a minimum rate called the “threshold,” which is defined by CMS as the 50th percentile of hospital scores during the baseline period.

For scoring on improvement, hospitals will be assessed based on how much their current performance changes from their own baseline period performance. Points will then be awarded based on how much distance they cover between that baseline and the benchmark score. Points will only be awarded for improvement if the hospital’s performance improved from their performance during the baseline period.

Finally, CMS will calculate a Total Performance Score (TPS) for each hospital by combining the greater of its achievement or improvement points on each measure to determine a score for each domain, multiplying each domain score by the proposed domain weight and adding the weighted scores together. In FY 2013, the clinical process of care domain will be weighted at 70 percent and the patient experience of care domain will be weighted at 30 percent.

Incentive Payment Calculations: CMS will utilize a linear exchange function to calculate the percentage of value-based incentive payment earned by each hospital. Those hospitals that receive higher Total Performance Scores will receive higher incentive payments than those that receive lower Total Performance Scores. CMS will notify each hospital of the estimated amount of its value-based incentive payment for FY 2013 through its QualityNet account at least 60 days prior to Oct. 1, 2012. CMS will notify each hospital of the exact amount of its value-based incentive payment on Nov. 1, 2012.

FISCAL YEAR 2013 MEASURES

Clinical Process of Care Measures
AMI-7a - Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8a - Primary PCI Received Within 90 Minutes of Hospital Arrival
HF-1 - Discharge Instructions
PN-3b - Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital
PN-6 - Initial Antibiotic Selection for CAP in Immunocompetent Patient
SCIP-Inf-1 - Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2 - Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3 - Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time
SCIP-Inf-4 - Cardiac Surgery Patients with Controlled 6AM Postoperative Serum Glucose
SCIP-Card-2 - Surgery Patients on a Beta Blocker Prior to Arrival That Received a Beta Blocker During the Perioperative Period
SCIP-VTE-1 - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-VTE-2 - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience of Care Measures (HCAHPS)
· Communication with Nurses
· Communication with Doctors
· Responsiveness of Hospital Staff
· Pain Management
· Communication About Medicines
· Cleanliness and Quietness of Hospital Environment
· Discharge Information
· Overall Rating of Hospital

ADDITIONAL MEASURES FINALIZED FOR FY2014

Mortality Measures:
· Mortality-30-AMI: Acute Myocardial Infarction (AMI) 30-day Mortality Rate
· Mortality-30-HF: Heart Failure (HF) 30-day Mortality Rate
· Mortality-30-PN: Pneumonia (PN) 30-Day Mortality Rate

Hospital Acquired Condition Measures:
· Foreign Object Retained After Surgery
· Air Embolism
· Blood Incompatibility
· Pressure Ulcer Stages III & IV
· Falls and Trauma: (Includes: Fracture, Dislocation, Intracranial Injury, Crushing Injury, Burn, Electric Shock)
· Vascular Catheter-Associated Infections
· Catheter-Associated Urinary Tract Infection (UTI)
· Manifestations of Poor Glycemic Control

AHRQ Patient Safety Indicators (PSIs), Inpatient Quality Indicators (IQIs), and Composite Measures:
· Complication/patient safety for selected indicators (composite)
· Mortality for selected medical conditions (composite)

Unadjusted "Fall and Trauma" Rates for Hospitals in Indiana

On April 6, 2011, CMS released a spreadsheet linked to its Hospital Compare website showing the frequency of the eight (8) Hospital Acquired Conditions (HAC) in hospitals participating in the Medicare Program. This data set is of Medicare beneficiaries only, is not risk adjusted for the severity of the patients, and is based on administrative data only for patients discharged between Oct 1, 2008 to June 30, 2010.

The data can be downloaded from CMS here.

The table below shows the performance of the listed Indiana hospitals for the "Fall and Trauma" measure sorted from high to low.

Hospital name	Rate (per 1,000 discharges)	Number of eligible discharges (Denominator)	Number of HACs (Numerator)	National HAC rate (per 1,000 discharges)
UNITY MEDICAL AND SURGICAL HOSPITAL	7.634	131	1	0.564
RIVERVIEW HOSPITAL	2.428	3707	9	0.564
THE HEART HOSPITAL AT DEACONESS GATEWAY LLC	1.878	1065	2	0.564
SAINT CATHERINE REGIONAL HOSPITAL	1.641	1219	2	0.564
FAYETTE REGIONAL HEALTH SYSTEM	1.553	1932	3	0.564
REID HOSPITAL & HEALTH CARE SERVICES	1.257	9549	12	0.564
FRANCISCAN PHYSICIANS HOSPITAL LLC	1.233	811	1	0.564
MEMORIAL HOSPITAL OF SOUTH BEND	1.205	9955	12	0.564
ST. CLARE MEDICAL CENTER	1.179	1697	2	0.564
WITHAM HEALTH SERVICES	1.174	1704	2	0.564
KOSCIUSKO COMMUNITY HOSPITAL	1.084	2767	3	0.564
PARKVIEW HUNTINGTON HOSPITAL	1.065	939	1	0.564
INDIANA UNIVERSITY HEALTH ARNETT HOSPITAL	1.02	4904	5	0.564
MARION GENERAL HOSPITAL	0.962	4158	4	0.564
HENRY COUNTY MEMORIAL HOSPITAL	0.957	3134	3	0.564
BLUFFTON REGIONAL MEDICAL CENTER	0.944	2118	2	0.564
CLARK MEMORIAL HOSPITAL	0.932	8581	8	0.564
INDIANA UNIVERSITY HEALTH NORTH HOSPITAL	0.906	3313	3	0.564
COMMUNITY HOSPITAL NORTH	0.9	6664	6	0.564
ST. FRANCIS HOSPITAL - BEECH GROVE	0.853	9377	8	0.564
THE ORTHOPAEDIC HOSPITAL	0.788	1269	1	0.564
ST. VINCENT CARMEL HOSPITAL, INC.	0.767	2609	2	0.564
ST. MARGARET MERCY - DYER	0.725	5515	4	0.564
WESTVIEW HOSPITAL	0.7	1429	1	0.564
INDIANA UNIVERSITY HEALTH WEST HOSPITAL	0.689	4352	3	0.564
ELKHART GENERAL HOSPITAL	0.676	8879	6	0.564
GOOD SAMARITAN HOSPITAL	0.641	6241	4	0.564
DEARBORN COUNTY HOSPITAL	0.617	3239	2	0.564
DUPONT HOSPITAL LLC	0.603	1658	1	0.564
BALL MEMORIAL HOSPITAL INC	0.591	11840	7	0.564
METHODIST HOSPITALS, INC	0.588	13602	8	0.564
ST. CATHERINE HOSPITAL, INC	0.576	5211	3	0.564
INDIANA ORTHOPAEDIC HOSPITAL LLC	0.565	1770	1	0.564
COMMUNITY HOSPITAL	0.557	16165	9	0.564
COMMUNITY HOSPITAL SOUTH, INC.	0.549	5468	3	0.564
SAINT ANTHONY MEDICAL CENTER	0.545	9179	5	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - SOUTH BEND	0.541	11100	6	0.564
LUTHERAN HOSPITAL OF INDIANA	0.535	13088	7	0.564
INDIANA HEART HOSPITAL, THE	0.528	3791	2	0.564
ST. MARY'S MEDICAL CENTER OF EVANSVILLE INC	0.514	11672	6	0.564
GOSHEN GENERAL HOSPITAL	0.489	4088	2	0.564
PORTER HOSPITAL, LLC, VALPARAISO HOSP CAMPUS	0.481	10389	5	0.564
PARKVIEW HOSPITAL	0.465	10748	5	0.564
MAJOR HOSPITAL	0.457	2189	1	0.564
BLOOMINGTON HOSPITAL	0.445	8981	4	0.564
ST. FRANCIS HOSPITAL - MOORESVILLE	0.435	2299	1	0.564
DEACONESS HOSPITAL INC	0.422	18959	8	0.564
SCHNECK MEDICAL CENTER	0.421	2378	1	0.564
JOHNSON MEMORIAL HOSPITAL	0.421	2378	1	0.564
TERRE HAUTE REGIONAL HOSPITAL	0.411	4861	2	0.564
MEMORIAL HOSPITAL AND HEALTH CARE CENTER	0.385	5190	2	0.564
UNION HOSPITAL INC	0.383	13057	5	0.564
ST. JOSEPH HOSPITAL	0.381	2626	1	0.564
FLOYD MEMORIAL HOSPITAL AND HEALTH SERVICES	0.375	10678	4	0.564
WILLIAM N WISHARD MEMORIAL HOSPITAL	0.368	5431	2	0.564
ST. VINCENT HOSPITALS AND HEALTH SERVICES	0.358	19569	7	0.564
CLARIAN HEALTH PARTNERS, INCORPORATED	0.321	28027	9	0.564
ST. FRANCIS HOSPITAL - INDIANAPOLIS	0.313	6388	2	0.564
COLUMBUS REGIONAL HOSPITAL	0.296	6766	2	0.564
THE KING'S DAUGHTERS' HOSPITAL AND HEALTH SERVICES	0.28	3574	1	0.564
ST. ELIZABETH EAST	0.244	4090	1	0.564
COMMUNITY HOSPITAL EAST	0.244	8195	2	0.564
LA PORTE HOSPITAL AND HEALTH SERVICES	0.235	4263	1	0.564
ST. MARGARET MERCY HEALTHCARE CENTERS - HAMMOND	0.228	8754	2	0.564
ST. MARY MEDICAL CENTER, INC.	0.224	8912	2	0.564
ST. ELIZABETH CENTRAL	0.219	4558	1	0.564
COMMUNITY HOSPITAL OF ANDERSON AND MADISON COUNTY	0.179	5601	1	0.564
SAINT JOHN'S HEALTH SYSTEM	0.169	5918	1	0.564
SAINT ANTHONY MEMORIAL HEALTH CENTER	0	5335	0	0.564
KENTUCKIANA MEDICAL CENTER LLC	0	619	0	0.564
MEMORIAL HOSPITAL	0	1480	0	0.564
HENDRICKS REGIONAL HEALTH	0	3423	0	0.564
DAVIESS COMMUNITY HOSPITAL	0	1727	0	0.564
HOWARD REGIONAL HEALTH SYSTEM	0	4148	0	0.564
PHYSICIANS' MEDICAL CENTER LLC	0	180	0	0.564
SURGICAL HOSPITAL OF MUNSTER	0	31	0	0.564
ST. JOSEPH HOSPITAL & HEALTH CENTER, INC	0	3856	0	0.564
PINNACLE HOSPITAL	0	542	0	0.564
HANCOCK REGIONAL HOSPITAL	0	2989	0	0.564
MONROE HOSPITAL	0	1335	0	0.564
ST. VINCENT HEART CENTER OF INDIANA, LLC	0	5756	0	0.564
WOMEN'S HOSPITAL, THE	0	114	0	0.564
PARKVIEW WHITLEY HOSPITAL	0	807	0	0.564
STARKE MEMORIAL HOSPITAL	0	785	0	0.564
PARKVIEW NOBLE HOSPITAL	0	1175	0	0.564
SAINT JOSEPH REGIONAL MEDICAL CENTER - PLYMOUTH	0	1773	0	0.564
DEKALB MEMORIAL HOSPITAL INC	0	1100	0	0.564
MORGAN HOSPITAL AND MEDICAL CENTER	0	1472	0	0.564
ORTHOPAEDIC HOSPITAL AT PARKVIEW NORTH LLC	0	1039	0	0.564