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CAPE FEAR MEMORIAL BRIDGE: Updates, resources, and context

Federal agency again rates Novant NHRMC two out of five stars

Novant Health - New Hanover Regional Medical Center
Benjamin Schachtman
Novant Health - New Hanover Regional Medical Center

For the second consecutive year, New Hanover Regional Medical Center has received just two out of five stars on the federal government’s rating for hospital quality of care. Novant Health says the ratings, while important, don't paint a full picture of the hospital, especially more recent improvements.

The Centers for Medicare and Medicaid Services (CMS) works with hospitals nationwide to publicly report hospital quality performance information. The ratings, most recently updated on July 26, are publicly reported on a hospital care compare website. The Novant NHRMC page on that site is linked here.

CMS collects data on 47 quality measures from five areas: mortality, safety, readmission, patient experience and timely/efficient care. This year, 3,076 hospitals were rated. Another 1,578 hospitals did not submit enough metrics to be rated.

Overall, 22% of rated hospitals received two stars, 8% received one star. This means NHRMC scored in the bottom 30% of the nation’s rated hospitals, or behind 2,153 hospitals. The data for this survey is through July 2022, though some of it dates to July 2018, before the former New Hanover Regional Medical Center announced it was for sale.

Novant Health’s purchase of NHRMC became official on Feb. 1, 2021. The data ranges for each metric vary, but all of them include pre- and post-Novant Health acquisition data. NHRMC received the same two-star rating in the 2022 survey.

In four of the previous five years where data is available, the county-owned New Hanover Regional Medical Center received three stars. NHRMC did receive two stars in 2018, but recovered the next year. No data is available for 2020. CMS maintains data on its website for seven years, back to 2016.

In a statement, Novant said CMS ratings don’t paint a complete picture.

While publicly reported CMS measures are a necessary component of our quality assessment program, they do not provide a comprehensive view of the patient experience. Because they are based on historical data ranging from two to five years old, their usefulness in assessing our current performance is limited,” according to a Novant Health spokesman. "Over the last year, our care teams have driven significant improvements in hospital acquired infection rates and mortality metrics that are not reflected in the older data used by CMS to determine these ratings."

Novant said "patient experience" is its top priority, and that it continuously tracks patient outcomes and trends to provide a high quality of care.

Novant's quality issues

Novant Health’s issues with quality of care became very public last summer, when a patient death in the emergency department sparked a federal investigation that temporarily placed NHRMC’s license to operate in jeopardy and threatened its Medicaid and Medicare contracts.

The driving issue was staffing shortages, a problem shared by many hospitals in the state and nation. NHRMC addressed the situation and was removed from the “Immediate Jeopardy” list. Another complaint, again involving poor service and, ultimately, a patient death, was reported this week by Port City Daily. The report, based solely on anonymous sources, claims but doesn’t confirm the federal government is again investigating NHRMC.

Heather Davis, vice president of clinical affairs for Novant Health Coastal Region, issued a statement to WHQR regarding the article, effectively confirming the death but declining to comment on the details or allegations in the Port City Daily report.

“The loss of a loved one, at any age and under any circumstance, is devastating. We are investigating this particular issue but are unable to provide any specifics due to patient privacy laws. We value feedback, and our patient advocacy teams are singularly focused on giving families a voice. We are committed to providing the highest level of safety and quality and when any concern is raised about our care, it receives our full attention until it is resolved. Regulatory organizations routinely review our services as part of their oversight role. The care and safety of our patients are paramount to everything we do at Novant Health,” Davis said.

CMS also publishes a star rating based on patient satisfaction surveys over the prior 12 months. NHRMC received three stars on the just-released rating.

The rating system

Beyond Novant's critique, the hospital industry traditionally has criticized the star ratings system, often saying it unfairly penalizes hospitals that treat large numbers of sicker patients. With the latest release, the American Hospital Association credited CMS for many improvements, but said the system needs work to “level the playing field among hospitals offering differing levels of care.”

The AHA also encouraged CMS to “examine the influence of social drivers of health on star ratings, and consider approaches to ensure the ratings are not unintentionally biased against those hospitals caring for structurally marginalized communities."

The intent of the CMS star ratings is to allow patients and providers information to compare hospitals and guide healthcare choices. There are many third-party agencies rating American hospitals, some more respected than others. Leapfrog, which measures hospital safety, gives NHRMC a letter grade of B (while many other Novant hospitals earned A grades) and US News Reports, which ranks hospitals, lists NHRMC as the 11th best hospital in North Carolina.

CMS rankings for NHRMC

For most of the 47 metrics, NHRMC scored, in CMS’ language, “no worse (or better) than the national rate (or benchmark)."

However, there were a couple of concerning areas: infection and mortality rates.

The rankings include several measures of hospital acquired infections, or those that occur while the patient is receiving treatment for something else. With central line-associated bloodstream infections in intensive care units and other selected wards, the NHRMC rate was 1.613, versus a national benchmark of 1.0. Also with catheter-associated urinary tract infections in the same areas, the NHRMC rate was 1.623 versus a national benchmark of 1.0.

With sepsis, a complication that occurs when the body has an extreme response to an infection and is often life-threatening, the percentage of NHRMC patients who received appropriate care for severe sepsis or septic shock was 47%, compared to a state average of 56% and national average of 58%.

It's worth noting that the C.diff. intestinal infection rate of 0.828 was deemed “better than” the national benchmark of 1.0.

With the most-recent Leapfrog survey, infections were also an issue. Leapfrog noted “worse than average” issues with bloodstream, urinary tract, C.diff. and MRSA infections.

With the CMS mortality metrics, the death rate for heart failure patients of 14.4% was “worse than” the national rate of 11.8%, and the COPD death rate 12.1% was “worse than” the national rate of 9.2%. NHRMC scored 'no worse than the national rate' for heart attack, stroke, and pneumonia patients.

There were a number of CMS ratings where NHRMC distinguished itself. In an Emergency Department with a “very high” volume, per CMS standards, the average time a patient spent in the ED was 169 minutes, compared to 180 minutes, or three hours, at other North Carolina “very high” volume hospitals, and 191 minutes at similar hospitals in the nation.

However, the data range for this metric cuts off at July 2022, in the midst of the worst of the ED issues that led to the patient death and Immediate Jeopardy issues. Novant officials, notably John Gizdic, the former NHRMC CEO and now a Novant Vice President, said the patient experience in the ED last summer was “not what it should have been.”

Related:Novant touts NHRMC sale benefits but admits current situation is 'unsustainable'

Another positive note was the rate of hospital readmissions, typically measured within 30 days. The 13.2 % rate at NHRMC was “better than the national rate” of 14.6 %.

Cost of care, a flashpoint of criticism from those who opposed New Hanover County selling the hospital in 2020-21, scored well in the CMS survey. The ratio of Medicare spending per beneficiary of 0.97 was less than the national average of 0.99, but exceeded the state rate of 0.95.

Payment for hip/knee replacement at NHRMC was $18,788, or about $3,500 less than the national average, and payment for pneumonia was $19,374, about $1,000 less than the national average. However, these metrics may say more about NHRMC’s inability to negotiate favorable rates with third-party payors, notably Blue Cross Blue Shield, than a commitment to lower costs.

During a press conference in September 2022, WHQR asked Gizdic whether Novant had better leverage with Blue Cross Blue Shield than NHRMC did as a standalone county-owned hospital. Gizdic skirted the question, claiming the “days of arm wrestling over rates is about over” without actually saying if Novant was getting a better deal or not.

Patient surveys

Under Novant, NHRMC received three stars out of five in the patient satisfaction portion of the report, based on surveys from 1,330 recently discharged patients. Though most responses were again close to national averages, some sour notes did emerge.

When asked if they received help as soon as they wanted, patients responded “always” in just 51% of surveys, compared to a state average of 63% and the national average of 65%. On the question of whether the room and bathroom were clean, 56% said “always,” compared to a state average of 68 %and the national average of 72%. Both responses may suggest issues with adequate staffing.

On overall rating and referral to others, NHRMC scored poorly. Just 58% said they would give NHRMC a rating of 9 or 10, compared to 68% of patients at North Carolina hospitals and 70% nationally. And the 59% who said they would definitely recommend NHRMC compares to a state average of 66% and national average of 69%.

Versus peer hospitals

Most of the state’s larger hospitals — NHRMC’s peers — earned more CMS quality stars and more, or at least as many, stars for patient experience. This includes the onetime suitors that competed with Novant Health to buy NHRMC.

Duke Hospital — which was one of the serious contenders in the NHRMC sale process back in 2019 — was among the 10% of the nation’s hospitals in the survey that received a perfect five stars. Duke also received four stars for patient experience and earned an “A” grade in its latest Leapfrog survey. In the CMS survey, 83% of patients said they would recommend the hospital to others.

Another top suitor, Charlotte-based Atrium Health, scored three quality stars but just two for patient experience.

Other five-star hospitals in the state include UNC Hospital and Moses Cone Memorial Hospital in Greensboro. WakeMed in Raleigh and FirstHealth Moore Regional Hospital in Pinehurst scored four stars each on quality and patient experience. Mission Hospital in Asheville, recently acquired by the for-profit healthcare company HCA, scored four stars on quality but two on patient experience.

Alongside NHRMC with two quality stars were N.C. Baptist Hospital and ECU Health Center in Greenville. Cape Fear Valley Hospital in Fayetteville had one quality star and a “C” grade from Leapfrog.

Novant’s other two larger hospitals, Presbyterian Medical Center in Charlotte and Forsyth Medical Center in Winston-Salem, each scored three starts on quality and patient experience. Novant Brunswick in Supply, a significantly smaller hospital, scored four stars on quality.

Ben Schachtman is a journalist and editor with a focus on local government accountability. He began reporting for Port City Daily in the Wilmington area in 2016 and took over as managing editor there in 2018. He’s a graduate of Rutgers College and later received his MA from NYU and his PhD from SUNY-Stony Brook, both in English Literature. He loves spending time with his wife and playing rock'n'roll very loudly. You can reach him at BSchachtman@whqr.org and find him on Twitter @Ben_Schachtman.