Memorial Hospital and 

Health Care Center

Based in Jasper, Indiana, and sponsored by the Sisters of the Little 

Company of Mary, Memorial Hospital and Health Care Center 

(MHHCC) provides inpatient and outpatient care through an 

acute care community hospital, which includes 32 outpatient 

primary and specialty care clinics and medical practices, and an 

ambulance service. Memorial Hospital, which opened its doors in 

1951, employs more than 1,700 people and provides medical care 

for 6,600 inpatients; 254,000 outpatients; and 29,000 emergency 

department visits annually. Nearly 950 babies are born at Memorial 

Hospital each year.

Health Care Results

• MHHCC has received a Centers for Medicare and Medicaid 

Services (CMS) 5-star rating for overall quality of inpatient care 

since the ratings were released, and it achieved national top-10%,

 net-positive, value-based-payment performance since 2017. 

MHHCC has also achieved zero early elective deliveries before 

39 weeks (since 2015), zero pressure ulcers in the Skilled Caring 

Center (since 2016), zero central line-associated bloodstream 

infections (CLABSI; since 2016), and zero hospital methicillinresistant staphylococcus aureus (MRSA) infections (since 2015). 

Its top-10% performance includes overall risk-adjusted inpatient 

mortality rates, hospital-acquired conditions, and radial artery 

access in cardiac procedures.

• MHHCC’s nationally recognized benchmark performance is 

demonstrated by an “A” Leapfrog Hospital Safety Grade since 

2016. A 2-year reduction in total harm from 6.2 to 1.1 per 1,000 

patient days from 2016 to 2018 was achieved. Bedside medication 

verification results have exceeded the Leapfrog benchmarks from 

2013 to 2018, sustaining a level of more than 97%, and MHHCC 

has sustained CMS top-10% performance in its PSI-90 patient 

safety composite results since 2017. (PSI-90 is a CMS national 

data set that includes patient safety and adverse events measures.)

Senior Leadership

• MHHCC’s senior leaders cascade the mission, vision, and core 

values through the organization in a faith-based culture focused 

on “Radical Loving Care” and the core competency of “Being 

for Others.”

Financial and Market Results

• MHHCC’s days cash on hand improved from 180 days in FY2016 

to 215 in FY2018. Further, its long-term debt as a percentage 

of capital improved from approximately 25% in FY2016 to 

approximately 21% in FY2018, and its days in accounts receivable 

improved from 48 days in FY2017 to 41 in FY2018.

2018 Award Recipient

Baldrige Performance Excellence Program • National Institute of Standards and Technology • Department of Commerce 

Highlights

• MHHCC has received a CMS 5-star rating for overall 

quality of inpatient care since the ratings were released, 

and it achieved national top-10%, net-positive,valuebased-payment performance since 2017. MHHCC has 

also achieved performance excellence outcomes with 

zero early elective deliveries before 39 weeks (since 2015), 

zero pressure ulcers in the Skilled Caring Center (since 2016), 

zero CLABSI infections (since 2016), and zero hospital 

MRSA infections (since 2015).

• MHHCC’s nationally recognized benchmark performance 

is demonstrated by an “A” Leapfrog Hospital Safety Grade 

since 2016. A 2-year reduction in total harm from 6.2 to 

1.1 per 1,000 patient days from 2016 to 2018 was achieved. 

Bedside medication verification results have exceeded the 

Leapfrog benchmarks from 2013 to 2018, and MHHCC 

has sustained CMS top-10% performance in its patient 

safety composite results since 2017.

• MHHCC’s RN turnover rate has remained below 2% 

since the first quarter of 2016, well below the top-10% 

national level of 8%.

 
2018 Award Recipient

Memorial Hospital and Health Care Center 

• Since 2015, MHHCC’s inpatient market share in Dubois County 

has been greater than 70% and its outpatient market share greater 

than 80%, with no competitor having more than 10%. In its larger 

primary service area (which includes Dubois County), its inpatient 

market share has been approximately 60% and its outpatient 

market share has been approximately 70%, with its closest 

competitor having approximately 10%. This sustained leadership 

performance is supported by an annual overall increase of 31,151 

in total office clinic visits and a 12% growth in total outpatient 

surgical procedures since 2014. 

Customer Process and Results

• MHHCC expands service offerings by acting on market intelligence 

gathered via techniques such as patient and family advisory 

councils, analysis of Truven and Crimson data as well as Hospital 

Consumer Assessment of Healthcare Providers and Systems 

(HCAHPS) and other patient surveys, and MHHCC’s website and 

diverse social media tools. Leveraging this intelligence, MHHCC 

introduced a new stroke telemedicine product to prevent market 

share loss and expand access; gained insight into the opportunity 

for secondary market entry into Davies County, including the need 

for the construction of a new clinic to provide services to the Amish 

community; and targeted the expansion of the oncology service line. 

• Inpatient overall satisfaction and HCAHPS Rate the Hospital 

have remained in the top 10% nationally since 2015, and overall 

satisfaction with outpatient primary care has been in the top 10% 

since 2016—all with 80% or greater of “top-box” scores. During 

this same time, MHHCC’s likelihood to recommend scores for 

obstetrics, post-surgical, and the Inpatient Rehabilitation Center 

each attained nearly 80% top-box scores and have been at or near 

top-10% national levels of performance.

People Process and Results

• MHHCC’s Servant Leadership System and associated leadership 

attributes encourage open communication, high performance, and 

engagement to empower the workforce.

• MHHCC’s percentage of RNs with bachelor of science degrees 

rose from 50% in 2015 to 62% in the first quarter of 2018, and 

its RN turnover rate has remained below 2% since the first quarter 

of 2016, well below the top-10% national level of 8%. Moreover, 

volunteer hours have been at or near 20,000 annually since 2015. 

Tuition reimbursement also rose from $100 thousand in 2013 to 

approximately $300 thousand in 2017.

Strategic Planning

• MHHCC’s strategic planning initiatives have contributed to the 

opening of a nurse practitioner-staffed clinic to enhance access to 

primary care. They have also led to the formation of an innovative 

collaboration with local competitors and Indiana University to 

design, develop, and open a graduate medical education program 

and family medical practice residency in rural Indiana to address 

the shortage of physicians.

Citizenship Process and Results

• MHHCC’s community benefit grew from $1.5 million in 2014

 to $2 million in 2017, with a 40% increase in Medicaid 

application acceptance since 2015. In addition, funds raised 

through its foundation gala grew from approximately $150,000 

in 2013 to approximately $200,000 in 2017; its paper recycling 

efforts grew from approximately 87,000 pounds in 2015 to 

155,000 pounds in 2017; and donated supplies and equipment 

grew from 500 pounds in 2015 to 2,000 pounds in 2017.

Process Efficiency/Effectiveness and Results

• Individualized care plans are developed with patients/families to 

help set realistic expectations and enhance communication with 

members of the care team. Whiteboards and senior leaders 

routinely visiting patients further engage patients and families in 

care and decision making. 

• MHHCC employs multiple approaches to ensure high performance 

regarding patient safety. Its efforts include creating a nonpunitive 

or “Just” culture that encourages the reporting of occurrences, 

preemptive mitigation, analysis of near-miss events, assignment of 

a patient safety officer, and institution of safety-focused huddles.

• MHHCC’s Emergency Department’s “left without being seen” rate 

has been below 0.5% since 2014, and 100% of lab specimen turnaround times and radiology report addendums have met targets 

since 2015. In addition, since 2015, greater than 90% of 

pharmacy order verifications have occurred within 30 minutes, and 

approximately 90% of Emergency Department radiology exams 

have been read within 1 hour. Moreover, rates of computer 

tomographic (CT) exams performed with and without contrast 

(relative to all exams) have been half of the CMS benchmarks 

since 2015; chart delinquency rates have fallen from 10% to 1% 

since 2012; and Medicare cases with physician concurrence 

have exceeded the benchmark of 80% since 2015. 

For more information:

Memorial Hospital and Health Care Center

800 W. 9th Street

Jasper, IN 47546

mpowell@mhhcc.org

www.mhhcc.org

Baldrige Performance Excellence Program

The Baldrige Program educates organizations of all sizes and 

from all sectors in organizational performance management and 

improvement. We also administer the Malcolm Baldrige National

Quality Award. Our key services are to identify and recognize 

role-model organizations, share best management practices, 

and help organizations achieve best-in-class performance levels.

We are the only public-private partnership and Presidential award 

program dedicated to improving U.S. organizations. 

For more information on the Baldrige Program: 

www.nist.gov/baldrige | 301-975-2036 | baldrige@nist.gov

Baldrige Performance Excellence Program • National Institute of Standards and Technology • Department of Commerce