SD hospital hit with lowest quality rating: Inside the fight for improvement

Leaders at Monument Health in Rapid City said they provide quality care despite receiving a 1 out of 5 federal safety and quality rating.

SD hospital hit with lowest quality rating: Inside the fight for improvement
Monument Health's flagship hospital in Rapid City, S.D., had the state's lowest safety and quality rating from the federal Centers for Medicare and Medicaid Services in 2023. (Photo: Bart Pfankuch / South Dakota News Watch)

RAPID CITY, S.D. – Monument Health's flagship hospital received the lowest federal quality rating possible over the past two years, according to the Centers for Medicare and Medicaid Services, which helps patients evaluate hospital safety and quality of care.

Monument Health leaders said they are working hard to raise the rating by CMS, which gave the Rapid City hospital a 1 out of a possible 5 star rating. No other hospital in South Dakota or within a 200-mile radius of Rapid City had a 1-star rating in 2023, the latest year the ratings were released.

Among the 14 hospitals in the state that received a CMS quality and safety rating in 2023, no hospital had a 2-star rating, two had a 3-star rating, four had a 4-star rating and seven had a 5-star rating.

In an interview with News Watch, Jill Tice, Monument vice president for quality, safety and risk management, said the hospital takes the CMS ratings very seriously and uses them as a guidepost to make systemic improvements in hospital procedures and processes.

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"We certainly approach them as though they are very important because this is what's being projected to our community in terms of our performance, so we can't not take them very seriously," she said. "We do create action around the star rating measures."

The Overall Hospital Quality Star Ratings are based on 46 quality measures within five general categories of health and safety data, which are supplied by the facilities being rated or collected independently by CMS.

Scored high in mortality rates but low in sepsis, ER wait times

According to the latest CMS review of Monument, updated in October 2023, the hospital was at or above national averages in several key areas, including in mortality rates for patients with strokes, heart attacks and chronic pulmonary disease.

The hospital also scored well in regard to patients not requiring readmission for any reason after discharge, a low rate of "central-line" catheter infections, and it had a low rate of complications following surgeries. Costs for many procedures were also in line with national averages.

On the other side of the ledger, Monument was below state and national averages for percentage of patients receiving appropriate care for severe sepsis, in regard to length of time of visits to the emergency room, in the rate of surgical site infections after colon surgeries and in percentage of patients that received advanced breast screening after an initial mammogram.

Health care personnel at Monument had a higher rate of vaccination for influenza than the state and national averages but were well below both the state and national averages in regard to percentage of health workers who received a primary vaccination series for COVID-19, CMS said.

Monument: Old data make rating less accurate

Monument's Rapid City hospital, formerly Rapid City Regional Hospital, did much better on the CMS rankings in years prior to the 1-star ratings in 2022 and 2023, the federal agency said. The hospital received 3 stars in 2016 and 2017, 4 stars in 2018, 3 stars in 2019, and 2 stars in 2020 and 2021, according to a public records request to CMS by News Watch.

Tice said some of the data used by CMS to create the 2023 ratings is from 2018, so the current 1-star rating likely does not accurately represent what is happening now in terms of patient care at the hospital.

"It's a representation of who we were, not a representation of who we are now," Tice said. "It's a considerable amount of time in history when we look at the work that we're doing currently, so any of the performance improvement work that we did in 2023 won't actually hit the star ratings until 2026."

Quote from Jill Tice, VP at Monument Health

Tice also pointed out that the hospital received a better rating from the nonprofit Leapfrog Group hospital rating service, and it has received accolades for quality of care, innovation and improvement from several medical groups and associations.

Monument has implemented a number of quality and safety improvement procedures in recent years, including a "daily huddle" and five-tier prioritization system in which problems are documented and addressed as quickly as possible, she said.

Leapfrog rating higher but deficiencies revealed

Monument Rapid City in spring 2023 received a C grade on a scale of A to F from the Leapfrog Group, a national nonprofit hospital evaluation firm.

Leapfrog noted that Monument performed above average in several areas, notably related to quality of nursing care, high rates of hand washing, safe medication administration, and organization leadership and staff cooperation to prevent errors.

Exterior of Monument Health of Rapid City, South Dakota
The south entrance to Monument Health hospital in Rapid City, S.D., features new facilities that were opened in 2019. (Photo: Bart Pfankuch / South Dakota News Watch)

However, Monument's 2023 review by Leapfrog noted some of the same deficiencies as indicated in the CMS rating.

Monument was rated below the national average in several areas, including in sepsis infections after surgery, accidental cuts and tears, dangerous blood clots, surgical wounds splitting open, site infections after colon surgery, patient falls and injuries, and "deaths from serious treatable complications."

Monument Rapid City received a B grade from Leapfrog in 2022 but got a D grade in 2020.

Of the 10 South Dakota hospitals graded by Leapfrog in summer 2023, Monument's C grade was tied with six others for lowest in the state, with higher grades received only by the Brookings Health System (A grade) and Avera St. Luke's Hospital in Aberdeen (B grade).

Tice acknowledged that the Leapfrog ratings are based on data that are "not as robust" as the data used by CMS in its ratings.

Monument Health received other awards

Monument leaders provided News Watch with multiple examples of honors and awards received by the hospital.

Chief among them is that the hospital for at least the past seven years has been fully accredited and has implemented all national safety goals promoted by the Joint Commission, a national nonprofit that examines hospital safety and awards accreditation. Monument hospital received the commission's Gold Seal of Approval for its three-year accreditation.

The hospital's chest pain section has also received a platinum level achievement award for 12 straight years from the American College of Cardiology and upgraded its rating from the American Heart Association (AHA) regarding treatment of stroke patients.

The AHA also bestowed its Silver Award on the Monument Health Heart and Vascular Institute in its first year of operation.

Monument's orthopedic and specialty hospital and its urgent care facility on Jackson Boulevard in Rapid City received the Commission on Office Laboratory Accreditation for applying high standards of qualify and performance in 2022.

Tier system aimed at constant improvement

Monument in 2019 implemented a five-tier quality and safety reporting system in which any and all issues or problems are documented and directed to employees who can best make improvements.

It starts with a series of daily employee huddles regarding quality and safety within the hospital, with topics being prioritized based on importance or immediacy.

The more important the issue, the higher it rises up the tier system, starting with frontline employees at tier 1 and rising eventually up to the 5th tier of top leaders and executives.

"In the earliest hours of the morning, right when frontline caregivers start coming in, we have five tiers of huddles where we cover topics related to patient safety and quality. We talk about incidents that have happened, we talk about infections that have occurred, we talk about any breaks in practice or process that need follow up," Tice said. "And those things are then very easily escalated to the departments that we need to step in and help."

Exterior of Monument Health in Rapid City, South Dakota
Monument Health opened a new emergency room and Heart and Vascular Institute as part of a major expansion in 2019 at its Rapid City, S.D., campus. (Photo: Bart Pfankuch / South Dakota News Watch)

On a recent day, a huge white board in a conference room within the hospital administrative offices was nearly covered with notes on patient census, staffing needs, technology or equipment updates and other challenges facing hospital staff and leadership, with solutions offered on who can fix them and how. The notes are part of a process focused on constant improvement in hospital policies and procedures at Monument and common at other health systems.

For instance, a computer printer problem or slippery sidewalk can be solved at tier 1, whereas issues related to infections or other serious medical or procedural problems might rise up to the level where more systemic change may be needed, Tice said.

In regard to infections, which CMS and Leapfrog ratings have noted as areas of concern, Monument has made improvements that have prevented any "central line" catheter infections in more than two years and just two surgical site infections in the past 18 months, she said.

"Acquired infections is always something that we want to work towards elimination, not just decreasing the numbers, but eliminating them," Tice said. "We can demonstrate that we have started, we have moved towards elimination, which really puts us in line with those top performing hospitals across the nation."

The problem-solving process has had some notable success. When Monument staff recognized a high rate of surgical site infections after colon surgeries, a team approach led to a series of interventions that resulted in a 37% reduction in such infections in 2022.

Also, the infection control team at Monument noticed an increase in anti-microbial infections such as methicillin-resistant Staphylococcus aureus (MRSA) infection and central-line catheter infections, Monument employees devised a plan to improve patient safety and saw a resulting 92% reduction in central-line infections in 2022-23. Hospital-onset MRSA infections were also cut by 75% in the past nine months compared to the nine months prior.

Patients ranked Monument Health higher

On a separate CMS rating scale, based on patient surveys of their personal experiences, Monument hospital in Rapid City received a 3-star rating on a scale of 1 to 5 in 2023.

While the hospital scored well in several areas on the patient survey rating, it was behind comparable patient ratings for hospitals across the U.S. and South Dakota in regard to nurses and doctors always communicating well, rooms and bathrooms always being clean and patients who strongly agreed they understood the care they received.

Overall, the most recent survey showed that 62% of Monument patients surveyed would "definitely recommend" the hospital to others, compared to a similar recommendation level of 77% by patients at all South Dakota hospitals and a national positive recommendation average of 69%.

CMS ratings aimed at public education

CMS provides the public with several ways to evaluate and compare the performance of hospitals and other health care facilities in their communities and across the nation.

The Care Compare website tool enables users to examine the quality of a particular medical facility and to compare up to three medical providers at the same time based on dozens of quality metrics. On a simpler level, CMS created the Overall Hospital Quality Star Rating system to enable the public to obtain a snapshot of a facility's quality based on 46 quality measures grouped into five major categories.

The five general areas of review include patient mortality, safety of care, readmission rates, patient experience and timely and effective care, the agency said.

"Patients and families can use the star rating, along with other information on Care Compare, to learn about the quality of hospitals and the services they offer," a CMS spokesman wrote to News Watch in an email. "Overall star ratings are meant to capture a hospital's performance as a snapshot in time."

CMS added that the star ratings are subject to change over time and can serve as motivation for medical facilities to make changes and improvements in procedures and outcomes to boost future star ratings.

To provide a level playing field for facility analysis, the star ratings are also based on comparisons with all other hospitals in the nation, creating a stronger baseline for overall comparisons, CMS said.

East River hospitals fare better on CMS scale

In the region around Rapid City, Monument Health hospital in Spearfish received a 4-star CMS rating in 2023, as did the Veterans Affairs Black Hills Health Care System in Sturgis. The closest 5-star rated hospital to Rapid City was Sheridan Memorial Hospital in Sheridan, Wyoming.

Not all South Dakota hospitals provided enough data to be rated by CMS, but hospitals in eastern South Dakota that were rated by the government agency generally fared well in 2023.

The Avera Gregory Hospital in Gregory and Avera St. Mary's Hospital in Pierre both received 3-star ratings. Avera McKennan Hospital in Sioux Falls and Sanford Medical Center in Aberdeen received 4-star ratings.

The 5-star ratings were awarded to Avera hospitals in Yankton and Aberdeen and the Avera Heart Hospital in Sioux Falls, the Brookings Health System, Prairie Lakes Health Care System in Watertown and the Sanford USD Medical Center and VA Medical Center in Sioux Falls.

Two hospitals within a 200-mile radius of Sioux Falls received 1-star ratings in 2023, including MercyOne Siouxland Medical Center in Sioux City, Iowa, and Montgomery County Memorial Hospital in Red Oak, Iowa.

According to CMS data, fewer than 1 in 10 of all U.S. hospitals rated in 2023 received a 1-star rating. CMS reported that 250 of 3,076 U.S. hospitals rated by the agency in 2023 had a 1-star rating, about 8% of the total.

Meanwhile, 668 hospitals (22%) had a 2-star rating, 872 (28%) had a 3-star rating, 803 (26%) had a 4-star rating and 483 (16%) had a 5-star rating.

CMS ratings a valuable tool for consumers

The CMS ratings are an important tool to allow patients to quickly gain insight into the recent performance of a hospital and its staff, a process that otherwise would be complicated and unwieldy, said Shelly Ten Napel, CEO of the Community HealthCare Association of the Dakotas in Sioux Falls.

“It’s hard for consumers to really understand if they are getting good health care or if a lot of money just being put into fancy buildings and high-cost specialty care,” said Ten Napel, who previously served in health care innovation in Washington and began her career as a health care analyst for former U.S. Sen. Tom Daschle.

“I do think they’re worth looking at for consumers to better understand, ‘Are we paying for high volume or are we paying by outcomes,’ and is there any transparency for consumers into what are truly high-quality services?”

Shelly Ten Napel quote

Ten Napel did not want to comment on the specific CMS ratings for Monument Health and acknowledged that the concept of creating a quality rating for a medical facility can depend on a lot of factors, such as which data is requested and how it is then used by the rating agency.

But she said the CMS star ratings and other ranking services can help medical providers maintain quality or improve areas of deficiency by putting pressure on them to meet a range of quality metrics.

“From a primary care perspective, it can sometimes be the only way to know if you’re doing well,” Ten Napel said. “We really believe in the importance of measuring and pay a lot of attention to how we perform to metrics.”

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Monument strives to obtain excellence

Tice told News Watch that based on current data, Monument leadership – which includes public relations manager Stephany Chalberg, who also serves on the South Dakota News Watch board of directors – expects to see improvement in both the CMS star rating and the grade from the Leapfrog Group when new rankings are released later this year.

"Can we get to a 5 in this next (CMS rating) release? No. Can we get there someday? Absolutely we can, and we will," she said. "We think, unfortunately, the 1-star rating is not what who we are today, that the star rating doesn't tell the story of who we are today, and what our performance looks like today or even last year. So do I feel safe coming and getting care here? Absolutely."

This story was produced by South Dakota News Watch, an independent, nonprofit news organization. Read more in-depth stories at and sign up for an email every few days to get stories as soon as they're published. Contact Bart Pfankuch at