From ‘F’ to ‘A’: How one hospital turned around its Leapfrog grade

In just under two years, an independent safety-net hospital on Chicago’s South Side changed its Leapfrog Group safety grade from an ‘F’ to an ‘A.’

How St. Bernard Hospital transformed patient safety outcomes could be a guide for health systems looking to deliver better care and score higher on external quality measures.

For the 174-bed facility, the work fell into three buckets: staffing, technology and culture.

The hospital, located in Chicago’s Englewood neighborhood, serves a nearly all Black patient population with the majority covered by Medicare and Medicaid. Neighboring hospitals, including UChicago Medicine, University of Illinois Hospital and South Shore Hospital, are less than a 15-minute drive away.

The facility still struggles with industrywide problems of underfunding and low staffing. Nevertheless, St. Bernard’s commitment to better patient care shows in the hospital’s hallways dotted with bulletin boards detailing its quality improvement achievements and goals.

A wake-up call

The ‘F’ from Leapfrog Group in the spring of 2021 proved to be a major wake-up call for hospital leaders.

“We thought we were doing a great job, so when we got that ‘F’ grade, it was like, ‘That can’t be right, they made a mistake,’” said Yolanda Penny, vice president of nursing services. “We really felt our impact in the community during [the COVID-19 pandemic], and to come out still standing was important. But it didn’t show on paper.”

While the hospital had a quality department to report data and follow regulatory requirements set by the Centers for Medicare and Medicaid Services, there wasn’t one person overseeing safety efforts or coordinated leadership to improve certain areas of patient care, Penny said.

St. Bernard added a position for a chief quality and patient safety officer, and after Michael Richardson started the job, he rapidly convened a committee of key stakeholders that included nurses, pharmacists and physicians to determine why the hospital was getting low scores and identify quality barriers with quick fixes. The hospital also established a role for a quality manager/sepsis coordinator.

“One of the first things we noticed was that safe medication administration wasn’t where we needed it to be,” Richardson said.

The committee determined that pervasive equipment failures, internet outages and staff members’ bad habits were preventing clinicians from routinely scanning patient wristbands and medications to avoid errors, Richardson said. After retraining nurses, fixing faulty equipment and bolstering the Wi-Fi system, St. Bernard’s rate of barcode medication administration now sits at around 98%.

To tackle hand hygiene, the hospital invested in an electronic hand hygiene monitoring system that allows management to track how often staffers cleanse their hands. All hospital employees wear a device that changes colors each time they leave a room, reminding them of the need to sanitize. Data from the electronic badges is automatically sent to the cloud for leadership to look at daily.

“Since we’ve had the system in place, which is just over a year now, we’ve seen over a million episodes of hygiene opportunities, with a compliance rate of around 92%,” Richardson said. “We set our goal at 95%.”

St. Bernard has also trained managers and directors on how to establish a “just culture” where staff feel comfortable reporting safety risks and leadership is responsible for analyzing mistakes and addressing system issues, he said.

By developing live data dashboards, hospital leaders see lapses in compliance in real-time and talk with clinicians about safety and quality concerns one-on-one or in daily unit huddles.

These changes, in addition to making improvements to staffing ratios and infection prevention protocols, helped the hospital earn a ‘C’ in the spring of 2022 and an ‘A’ this spring.

Changed mindset

In 2021, St. Bernard made $104 million in revenue, including nearly $26 million it received from the COVID-19 provider relief fund. The hospital had more than $109 million in expenses.

Despite operating in the red, within the past year it has purchased an electronic health record and renovated its emergency department.

In a change from past practices, any costs associated with patient safety and quality—including personnel, service fees and equipment—are routinely baked into the budget, said Robert Springer, the hospital’s chief financial officer at St. Bernard Hospital. Annual quality improvement expenses typically cost the hospital at least $100,000, he said.

“We try to prioritize patient safety and quality while budgeting because without quality, reliable care for patients, there is no need for anything else,” Springer said in an email. “The ramifications and costs of providing poor quality care far outweigh the costs of safety initiatives.”

Room to do better

Other areas still need to be addressed. The hospital has a one-star quality rating from CMS, largely because of its long emergency room wait times and high percentage of patients who leave without being seen.

“We’re going to continue our journey on patient safety, making sure that we have zero harm, zero central line infections, zero catheter-associated infections, zero MRSA infections,” Richardson said.

St. Bernard also has trouble getting its patients to respond to surveys about their care, and may hire a director of patient experience and retain an external company to follow up with patients after discharge.

Other priorities include developing a more efficient discharge planning process and helping community members understand the hospital’s service offerings, said Felicia Slaton-Young, community board member at St. and executive director and co-founder of the Greater Englewood Chamber of Commerce.

For years, the hospital has engaged with locals through mobile health units in the neighborhood and an annual community baby shower where St. Bernard partners with other clinics to provide resources for first-time parents.

While external measures of quality and safety can play a valuable role in helping providers focus on certain risk areas, some say the metrics aren’t always the best reflections of performance for facilities that only see high-risk, complex patients.

This is true for Westchester Medical Center, a referral academic medical center in Valhalla, New York, which has received D’s from Leapfrog Group for the past three years.

As an institution that does virtually no primary or preventative care and receives more than 12,600 patient transfers from local hospitals, it is often extremely difficult to meet certain standards, said Dr. Renee Garrick, executive vice president and chief medical officer at Westchester Medical Center Health Network.

Even so, the center still uses CMS measures and Leapfrog Group scores as guides to enhance care and uses its data on infections and adverse events to identify areas for improvement, Garrick said.

“We may not always be able to successfully improve every score,” she said. “But what we care about is, ‘Did the patient get great care?’”

Low performers

Of the more than 2,800 hospitals graded biannually by the Leapfrog Group, less than 1% receive an ‘F.’ The grade indicates that a hospital is not performing well on numerous safety standards, including communication, infection prevention and surgical error, said Missy Danforth, vice president of health care ratings at The Leapfrog Group.

It is “extremely rare” for hospitals to go from an ‘F’ to an ‘A’ as quickly as St. Bernard, Danforth said.

The secrets to success for facilities able to undergo rapid improvement often include talking to frontline staff about technology barriers, retraining clinicians on safety processes and changing structural measures.

“In our mind, the sustaining of high performance is almost as important as achieving it for the first time,” she said.

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