5-Star Rating from CMS

On April 29, 2021, Madison Memorial Hospital was given a 5-star rating from the Centers for Medicare & Medicaid Services (CMS), the largest federal agency under the US Department of Health and Human Services.

The Rexburg-based hospital, with its 69 staffed beds, was one of only 3 hospitals in the state of Idaho to receive the coveted 5-star award. The other two were St. Luke’s Magic Valley (213 staffed beds) and St. Luke’s Regional Medical Center in Boise (578 staffed beds).

Nationwide, of 5,382 hospitals registered with CMS, only 8% (455 hospitals) were given a 5-star rating, effectively placing Madison Memorial in the top 8% of all hospitals nationwide.

Altogether, Idaho’s 47 registered hospitals were awarded CMS star ratings as follows:
☆ ☆ ☆ ☆ ☆ No Stars 25 Idaho Hospitals
★ ☆ ☆ ☆ ☆ 1 Stars 0 Idaho Hospitals
★ ★ ☆ ☆ ☆ 2 Stars 5 Idaho Hospitals
★ ★ ★ ☆ ☆ 3 Stars 7 Idaho Hospitals
★ ★ ★ ★ ☆ 4 Stars 7 Idaho Hospitals
★ ★ ★ ★ ★ 5 Stars 3 Idaho Hospitals

TOTAL (47 Idaho hospitals)

The national distribution of CMS star designations for 2021 was as follows:
☆ ☆ ☆ ☆ ☆ No Stars 2,027 Hospitals
★ ☆ ☆ ☆ ☆ 1 Stars 240 Hospitals
★ ★ ☆ ☆ ☆ 2 Stars 690 Hospitals
★ ★ ★ ☆ ☆ 3 Stars 1,018 Hospitals
★ ★ ★ ★ ☆ 4 Stars 988 Hospitals
★ ★ ★ ★ ★ 5 Stars 455 Hospitals

TOTAL (5,382 hospitals)

CMS awards their star ratings based on 48 individual criteria, spread across five categories: mortality, safety of care, readmission, patient experience, and timely and effective care. To achieve the 5-star designation, Madison Memorial was awarded high marks in each of the five areas.

“It’s extremely validating to have our hard work be recognized in this way, particularly during a pandemic year,” said Dr. Rachel Gonzales, Chief Executive Officer at Madison Memorial. “After being ranked in the nation’s top 100 rural and community hospitals last month by Becker’s Hospital Review, this new 5-star rating further confirms the fact that eastern Idaho is fortunate to have a nationally-ranked healthcare institution right here in Rexburg.”

“CMS has been assigning star ratings to hospitals for the past five years,” said Doug McBride, the hospital’s Executive Director of Business Development. “For Madison Memorial to achieve this 5-star result says volumes for the extraordinary quality of care and professionalism provided by our exceptional staff, as well as the amazing doctors who live in this area.”

Top 100 Community and Rural Hospitals Nationwide

Madison Memorial Hospital was named as one of the nation’s top 100 rural and community hospitals by the Chartis Group, a healthcare advisory firm with eight locations across the country. Only 32 states had hospitals scoring high enough to be included in the 2021 rankings. Madison Memorial was the only Idaho hospital to make the list.

Becker’s Hospital Review, widely recognized for its comprehensive hospital rankings, included the Chartis Group’s results in its own announcement of the top 100 rural and community hospitals, further contributing to the validity of the study.2

According to Becker’s, the Chartis Center for Rural Health based their rankings on eight key performance areas defined by the Hospital Strength Index, including the following: inpatient market share, outpatient market share, quality, outcomes, patient perspective, cost, charge and financial efficiency. Madison Memorial scored highly enough in each of these areas to earn inclusion in the center’s exclusive list.

According to the American Hospital Association, there are currently 1,805 rural community hospitals in the United States.3

“To be named in the top 100 is like being in the top 5%, nationwide,” said Dr. Rachel Gonzales, Chief Executive Officer at Madison Memorial. “It’s an incredible honor.”

“We’ve always known that we have something very special here in Rexburg,” said Doug McBride, the hospital’s Executive Director of Business Development. “It’s wonderful to receive this kind of national recognition, to be validated in this way.”

“As a hospital administrator,” said Gonzales, “I can truly say, this recognition has been earned by the highly capable health care professionals and staff of the entire Madison Memorial organization. I feel very fortunate to be able to be associated with such amazing individuals and live in the vicinity of a nationally-ranked, outstanding local hospital. It’s such a privilege. It enhances the quality of life of all of us – myself, my family, my neighbors, my friends.”

DNV GL Certified Hip & Knee Replacement Center

Rexburg, Idaho, April 18, 2019 – Madison Memorial Hospital has been recognized as a DNV GL Healthcare certified Hip & Knee Replacement Center.

DNV GL – Healthcare certification as a Hip & Knee Replacement Center validates the hospital’s excellence across the spectrum of hip and knee replacement care, from diagnosis to treatment, rehabilitation, education and outcomes.

The Hip and Knee Replacement Program Certification requirements are based in part of the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP) and consideration of guidelines, recommendations and practices recognized by the American College of Orthopaedic Surgeons and the American Association of Hip and Knee Surgeons. The Certification Survey process audits an organization’s Hip and Knee Replacement Program in the following areas:

  • Quality Management System 
  • Program Management 
  • Nursing Services 
  • Staffing Management 
  • Infection Prevention and Control 
  • Hip and Knee Replacement Program Service Delivery 
  • Evaluation of the multidisciplinary approach reaching from pre-hospital care through discharge planning

“This certification tells our community that we have the resources and commitment to provide the best possible care for Hip and Knee replacement,” says Nolan Bybee, Risk Management Director at Madison Memorial Hospital. “It’s a combination of the right equipment, personnel and training to exhibit excellence in orthopedic surgery within the scope of Hip and Knee Replacement and related procedures.” 

Angie Hathaway, Nurse Manager said, “Each patient is vitally important to us. Attaining certification validates all the effort we have put into this program to ensure the health and safety of our patients.”

Achieving certification shows commitment to excellence,” says Patrick Horine, CEO of DNV GL Healthcare. “It helps demonstrate to your community that Madison Memorial is performing at the highest level.”

ISO-9001 Certification

Rexburg, Idaho, August 8, 2018 –has been awarded by DNV GL – Healthcare full accreditation to the NIAHO standards and full certification to the ISO 9001 Quality Management System. 

“Madison Memorial Hospital is dedicated to providing the safest and most effective healthcare services possible,” says Nolan Bybee, Risk Management Director at Madison Memorial. “ISO certification and NIAHO accreditations not only reflects that mission, but helps to empower it. The certificate is just a piece of paper, but the effort required to achieve it fundamentally transforms the way we do business. ISO 9001 is ideally suited to the complex, people-intensive challenges of running a hospital.” 

ISO 9001 is the most widely-accepted quality management system in use around the world, and is quickly gaining acceptance among US healthcare providers as a foundation for their quality and patient safety programs. 

The U.S. Centers for Medicare and Medicaid Services (CMS) requires accreditation for hospitals seeking reimbursement for care provided to patients covered by Medicare and Medicaid. Without accreditation, most hospitals would only be able to support a fraction of the patient populations they now serve.  

CMS maintains a highly rigorous process of assessing and approving accreditation providers, which more than 60 years since the inception of Medicare still numbers fewer than five.

DNV GL’s accreditation program, called NIAHO® (Integrated Accreditation of Healthcare Organizations), involves annual hospital surveys – instead of every three years – and encourages hospitals to openly share information across departments and to discover improvements in clinical workflows and safety protocols. 

“Madison Memorial has worked hard to achieve this certification, and they have done so with unwavering commitment from their top leadership to make their hospital the best it can be,” says Patrick Horine, President of DNV – GL Healthcare. “ISO certification isn’t just an award or trophy for something you’ve done, it’s public evidence that you are at the top of your game with an obvious plan in place to make excellence an every day objective.” 

ISO 9001 brings science to the art of caregiving; it helps to standardize processes around things that are proven to work, by the people doing the work, thus empowering frontline workers while creating an environment of predictability for the entire organization. The ultimate impact of ISO within hospitals is the reduction or elimination of variation, so that critical work processes are done consistently and the “best ideas” aren’t held by one person or one department, but are ingrained in the organization itself.  

Businesses that implement ISO do so for both the internal and external benefits. Internally it helps staff create clear and consistent processes of patient care, and ensure that progress is constantly being made toward specific quality objectives. Externally, it tells the public, as well as insurers and regulatory agencies, that the hospital is not only talking about quality, but is pursuing it with discipline and transparency.  

“ISO 9001 is like sheet music for an orchestra; it gets everyone on the same page and helps us achieve our objectives,” says Bybee. 

2017 Qualis Health Quality Award

Rexburg, Idaho, May 25, 2017 – Award of Excellence: Hospital – Madison Memorial Hospital, Rexburg, for their project “Quality-Driven Medication Reconciliation”

Qualis Health, one of the nation’s leading population health management organizations, has recognizes healthcare organizations from across the state of Idaho for their achievements in improving healthcare quality and outcomes. The award recipients were recognized during a ceremony at the Idaho Patient Safety and Quality Improvement Conference in Boise, Idaho. Kelly McGrath, MD, MS, Qualis Health Idaho Medical Director, presented the awards. The awards recognize those who demonstrate outcomes to the three broad aims outlined in the National Quality Strategy:

  • Better healthcare (for individuals) 
  • Better health (for populations) 
  • Reduced costs through improvement

“Our changing healthcare landscape requires increasingly vigorous efforts to improve healthcare delivery and health outcomes in Idaho and across the nation. The Qualis Health Idaho Quality Awards celebrate organizations that have transformed healthcare delivery for their communities – making a real difference for their patients and their families,” said Jonathan Sugarman, MD, MPH, President and CEO of Qualis Health. “Their achievements exemplify progress towards critical aims for healthcare: better quality of care at a lower cost.” 

Madison Memorial Hospital received the Award of Excellence: Hosptial, for their project “Quality-Driven Medication Reconciliation. According to Mikel Barr, RN, Director of Quality at Madison Memorial, “Medication safety is crucial during times of care transition. But when a patient is admitted to the hospital, it is not uncommon for their primary care physician to be uninvolved with their care. In cases like these a patient may experience interruptions in medications for chronic conditions, variations in the dosage of those medications, or even be prescribed new medications. These changes can result in flare-ups of the chronic condition, may affect the patient’s ability to recover from the acute condition for which they were hospitalized, or cause dangerous drug interactions”. 

To address this disconnect, Madison Memorial Hospital piloted an innovative medication reconciliation program, with the aim of improving patient safety by preventing adverse drug events, and reducing hospital readmissions. At the focus of the program, certified pharmacy technicians complete a medication reconciliation review with patients and families on admission. Their goal is to fully communicate with patients and families so that the patient has a clear understanding of the medications they should be taking when they leave the hospital or move to the next level of care. As a result, Madison Memorial has reduced its number of medication reconciliation errors significantly, with the effect of reducing the number of adverse drug events from 30 in 2015 to 12 in 2016, and readmissions from 92 in 2015 to 70 in 2016.

Healthstream Excellence Through Innovation Award

Rexburg, Idaho, August 22, 2016 – Madison Memorial Hospital was recently recognized with an Excellence through Innovation Award for the Talent Management Category by HealthStream, Inc.

The Excellence through Innovation Awards honor customers who have used HealthStream solutions to support initiative within their organization that resulted in improved outcomes. To qualify for an award, hospitals submitted descriptions of their initiatives, enumerated their positive outcomes, and provided data to verify their achievements. A panel of judges verified the data and selected the awards winners.

HealthStream CEO Robert A. Frist, Jr., said, “We applaud Madison Memorial Hospital’s high-level commitment to excellence in healthcare, and are pleased to recognize their achievement through our presentation of an Excellence through Innovation Award.

Madison Memorial Hospital is passionate about improving patient care. We have been focusing our attention on improving value for our patients. Healthcare is leaving us with some unprecedented challenges and as we move forward we have identified some cultural challenges and a tremendous desire to have total alignment of our organization providing critical tools and creating an infrastructure that can support all of the changes we face in healthcare. Misty Gordon, Madison Memorial Interim Director of Medical/Surgical Unit commented, “Achieving these goals has required an enormous amount of teamwork and has brought our hospital working together with a degree of teamwork like we have never experienced before. This award is received due to a hospital wide initiative we call The Quality Revolution.”