US News and World Report 2012 Results and Analysis Thomas W. Feeley, MD Head, Division of Anesthesiology and Critical Care Victoria Jordan, PhD, MS, MBA Director, Quality Measurement and Engineering Office of Performance Improvement November 14, 2012

Results MD Anderson ranked number 1 with overall score of 100. Also achieved national ranking in 4 other specialties: gynecology 6, urology 26, ENT 5, and pediatric cancer 15 MSK number two with score of 93.8 (down from 94.7 last year) 2 Was 9 Was 6 Was 10 Was 16 Was 3 Was 4

Summary of Scoring Outcomes % of score –O/E Mortality (30 days from Admission) –MDACC had the best survival score - 10 Process - (Reputation) 32.5% of score –MDACC had highest score % Structure - 30% of score –MDACC had the highest possible score in each category (with two exceptions – discharge volume and nursing index) Patient Safety Index - 5% of score –MDACC scored 1 of 3 3

4 USNWR Reporting Period Outcome Analysis (32.5%) Our performance Other top 20 cancer programs

Impact of Transfers on Outcome Major problem for our future outcome scoring Transfer patients have been excluded from USNWR mortality index calculation since 2007 Error in our data discovered by USNWR in 2009 –We incorrectly coded Emergency Center patients as transfer patients since mid-2004 –Incorrectly coded patients account for 40% of admissions Mortality rate higher for admitted Emergency Center patients (which were inappropriately excluded) leading to a lower mortality ratio Error corrected in 2009 resulting in incremental increases in our mortality ratio that will progressively worsen our outcome score through

2011 US News & World Report 6 Observed/Expected Mortality Rate

2012 US News & World Report 7 Observed/Expected Mortality Rate Time Period of O/E data Included in Survey

2013 US News & World Report 8 Observed/Expected Mortality Rate Time Period of O/E data Included in Survey

2014 US News & World Report 9 Observed/Expected Mortality Rate Time Period of O/E data Included in Survey

Process Analysis (32.5%) Reputation used as surrogate for our processes of care - determined by a survey Surveyed physicians asked to list the “best hospitals” in their specific field of care, irrespective of expense or location, for patients with serious or difficult conditions Up to five hospitals can be listed 200 board certified physicians in 4 US regions. Includes medical oncology, surgical oncology, gynecologic oncology, radiation oncology and hematology Three year average used and response rate is about 40% - in three years that is 228 individuals for this year’s results Future will likely include results of Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) and other data available from CMS on Hospital Compare 10

Structure Analysis (30%) CategoryScore Weighted ValueComment Advanced Technologies 7/7 14.2% Includes full-field digital mammography, image- guided radiation therapy, PET/CT scanner, robotic surgery, shaped-beam radiation, stereotactic radiosurgery, and transplant services Volume High 18.9% Second patient volume in the group (4597 compared to MSK’s 4628) Nurse Staffing % Higher is better. Range Last year MDACC was 2.0 within a range of 1.0 – 3.2 Patient Services 8/8 9.6% Includes genetic testing/counseling, hospice, infection isolation room, pain-management program, palliative care, patient-controlled analgesia, translators, and wound-management services Intensivists 1 9.6% Best score that can be received is 1. All 50 cancer centers received this score NCI Cancer Center Yes 9.6% 44 out of 50 cancer centers have an NCI designation (including all of the top 20) Nurse Magnet Yes 9.6% 38 out of 50 cancer centers have a Nurse Magnet designation (including 15 of the top 20) FACT accreditation 2/2 9.6% Includes accreditation for both autologous and allogeneic transplantation 11

12 Patient Safety Analysis (5%) MD Anderson scored 1 out of 3 (higher is better)

Calculation of the Patient Safety Score Medicare data from the MedPar file Not a count, but an index, standardized and grouped into terciles (three’s) Based on the following (equally weighted, same as 2011) : –PSI 04 – Death Among Surgical Inpatients (16.7%) –PSI 06 – Iatrogenic Pneumothorax (16.7%) –PSI 09 – Post op Hemorrhage or Hematoma (16.7%) –PSI 11 – Post op Respiratory Failure (16.7%) –PSI 14 – Post op Wound Dehiscence (16.7%) –PSI 15 – Accidental Puncture or Laceration (16.7%) Difficult to reconstruct actual score received but likely a function of issues related to documentation and coding, methodology, and practice issues 13

Major Recommendations 1.Conduct independent external review of documentation and coding to ensure that coding reflects the acuity levels of our patients. (Scheduled for Dec 4-5.) 2.Implement a comprehensive internal review process for Medicare deaths and Patient Safety Indicator (PSI) events before submission of final coding. 3.Develop automated documentation templates and supporting education for physicians, mid-levels, and trainees to assist in electronically documenting appropriate “coding specific” terminology. 14

Additional Recommendations 1.Develop displays and report performance to a Clinical Operations leadership group on a quarterly basis. 2.Consulted with RTI regarding 3 methodology issues: –PSI calculation – they will look into impact – –Nurse staff index that appears to favor predominantly inpatient facilities – they are looking into it. –Process for possibly including Blood and Bone Marrow diseases as a separate category like ENT, gynecology and urology where we are also nationally ranked – they do not include sub specialties 3.Improve institutional awareness of the program via clinical leadership to optimize performance in reputation and clinical documentation. 15

Heidi Albright Thomas Aloia, MD John Bingham Eduardo Bruera, MD Thomas Feeley, MD Lewis Foxhall, MD Lyle Green Victoria Jordan, PhD Hagop Kantarjian, MD Leslie Kian Eugenie Kleinerman, MD Edward Miller, MD Sarah Newson Raphael Pollock, MD John Skibber, MD Steve Stuyck Barbara Summers, PhD Ron Walters, MD 16 USNWR Workgroup