One Giant Leap for Quality
By Karen Sandrick
When Boards Get Behind Quality Initiatives, Patient Care Benefits
Soon after the Institute of Medicine released its disturbing report about safety in U.S. hospitals in 1999, the board of 400-bed Meritor Hospital in Madison, Wis., realized it needed to understand quality and safety issues more fully and how they might affect some upcoming decisions about major expenditures and strategic planning. So in 2001, vice chair Regina Millner formed an ad hoc board committee to learn about safety and quality and how to make improvements, what costs might be involved, and how corporate culture needed to change. Based on their analysis, in 2002, Meritor trustees took a fairly revolutionary step for a hospital board: it approved spending $8 million to $9 million over five years to install a computerized physician order entry system (CPOE).
CPOE is one of the key tenets of the Leapfrog Group, formed in 2000 by the Business Roundtable, Washington, D.C., an association of CEOs from major U.S. corporations that advocates public policies to ensure a well-trained and productive workforce as well as vigorous economic growth. The Business Roundtable launched Leapfrog to spur giant leaps forward in health care affordability, quality and safety by promoting high value health care. (Leapfrog is now a separate 501 © (3) organization.) According to Leapfrog's 2004 survey of 1,019 hospitals that agreed to participate, only four percent have fully implemented CPOE, while 16 percent plan to implement it by 2006.
Although the American Hospital Association has partnered with many of the same employer members of Leapfrog in the Consumer Purchaser Disclosure Group (which includes leading employers, consumer and labor groups that are working to ensure that all Americans have access to publicly reported information about health care performance), it has not been on the same page with Leapfrog regarding its initial "leaps," particularly CPOE.
"We fully support the notion that CPOE, electronic health records, bar coding and other information technologies can be important tools for hospitals and other health care providers as they strive to provide more effective and efficient care to their patients. But we know hospitals need to be able to exercise judgment in choosing which technologies, which strategies are going to be most effective for their own patient populations. So the thought of requiring that particular strategies, such as CPOE, be implemented is not one we can support," says Nancy Foster, the AHA's vice president for quality and patient safety policy.
Survey results were similar for two other Leapfrog measures. Nineteen percent of 914 hospitals with intensive care units (ICUs) met Leapfrog's criterion for staffing intensive care units with trained ICU specialist physicians or "intensivists," and 13 percent plan to have intensivists on board by 2006.
Fewer than 20 percent of hospitals met the group's standards for high-risk procedures, which are based on volume and a proven track record. Basing the decision to perform high-risk procedures on volume is a good first step, says Edward Walker, M.D., chief medical officer of the University of Washington Medical Center, Seattle. Data do show a crude correlation between volume of procedures performed and mortality. However, other measures of quality around volumes need to be considered. After all, says Walker, "If you are doing something wrong and you do a lot of it, you just do it wrong multiple times."
And, despite the merits of CPOE, it is fraught with problems, Walker believes. He explains that CPOE is actually a series of processes beginning with the physician's initial decision to administer a drug, followed by entering the order into a computer. That command then triggers a software interface that checks for drug interactions and treatment substitutions and compares the current prescription with the patient's present and past history. From there, the system has to link both with the pharmacy to control inventory and the drug management process and with the nursing stations on hospital floors to govern drug delivery through a bar coding mechanism.
Some hospitals may have an electronic prescription system that computerizes drug ordering, but all it really does is send an e-mail to the pharmacy. Everything else is manual. "The only safety issue that's being improved is that the physician's handwriting isn't getting in the way anymore," Walker says. "But every other error that can come with medication administration, with interactions of drugs, [or a drug] going to the wrong patient, is still there."
This is not to say that Walker eschews Leapfrog's efforts. Quite the contrary. He is an enthusiast. But he acknowledges that both hospitals and Leapfrog are still finding their way.
When Walker first became medical director of the University of Washington Medical Center in 2002, he and his colleagues on the medical staff, both rank and file and department leaders, weren't fully informed about Leapfrog, nor did they understand it in context. The overall feeling was that the group focused too narrowly on a subset of safety standards.
In the last year, however, the Leapfrog Group has expanded its scope to include all 30 safety practices endorsed by the National Quality Forum (NQF), Washington, D.C. It has operationalized its assessment of hospitals' compliance with its own safety criteria as well as those of the NQF, by asking hospitals about four key aspects of meeting quality and safety standards: awareness, accountability, ability and action.
As a result, Leapfrog's Hospital Quality and Safety Survey is now able to provide a comprehensive assessment of hospitals' progress in meeting Leapfrog criteria as well as the NQF safety practices. The latest Leapfrog survey found that 80 percent of the 1,019 surveyed hospitals had procedures to prevent surgeries on the wrong body part, and 70 percent required a pharmacist to review all medication orders before a drug was dispensed to a patient.
The survey also points to trouble spots: 70 percent of surveyed hospitals lacked an explicit protocol for ensuring adequate nurse staffing; 60 percent had no procedures for preventing patient malnutrition; 50 percent had not established procedures for preventing bed sores; and 40 percent lacked policies governing handwashing by all members of the staff.
Leapfrog's efforts have helped align hospitals with employers' concerns. "In our dialogue with employers, they are interested in how we are doing on Leapfrog criteria and what we are doing to improve quality and safety," says Gary R. Yates, M.D., chief medical officer of Sentara Healthcare, a six-hospital system in southeastern Virginia.
Although Leapfrog has not provided a platform on which hospitals and employers can engage in cross-cultural collaboration, it has raised hospitals' awareness of the employer community, which is leading to some interesting initiatives. For example, Sentara is working with members of the nuclear power industry to learn about and adapt some of the safety techniques used in other high-risk industries. The hospital system is working to create a culture of safety among employees and physicians in its acute care facilities, nursing homes, and medical group office settings by developing a series of behavioral-based expectations. "The idea is to change our culture by practicing safe behaviors throughout the organization. By having these behaviors become habits, we will help to make sure that an adverse event will be less likely to happen to a patient," Yates says.
Leapfrog's work has also spurred innovations. Sentara was the site of the first electronic ICU (e-ICU), which uses technology, intensive care specialist physicians and critical care nurses to monitor patients in multiple ICUs across several facilities. This provides a heightened level of care to patients whose conditions can change quickly and dramatically. The e-ICU includes cameras to observe patients, as well as data and imaging monitors to collect and display vital signs, laboratory values and radiology scans.
Since it instituted the e-ICU system five years ago, Sentara has seen a 20 percent reduction in mortality among ICU patients. "Using the e-ICU, we're able to provide this intensive specialist [type of] care to more patients, use scarce resources wisely, and meet the Leapfrog criteria," Yates says.
Now that Leapfrog has removed the first barrier to data quality by standardizing responses to its survey questions, the accuracy of reporting about compliance to Leapfrog criteria should improve. Walker believes the group needs to institute an auditing mechanism to substantiate that responses to survey questions are based on reality. "You want to be sure people take the quality analysis seriously and they are representing quality as it exists in their hospitals, not some dream vision of where they want it to be," he says.
Adherence to Leapfrog criteria also needs to be linked more directly with employer contracting. Although more than 160 Fortune 500 companies and other large private and public sector purchasers have joined the Leapfrog Group, hospitals interviewed by Trustee have not seen that employers are basing their health care purchasing decisions on quality and safety.
In some markets, it may be just too early to realize a benefit in contracting. "We are doing safer, higher quality care. I don't know that you need much more of a reward than that. Whether or not that translates into dollars is to be seen," Walker says.
However, in many markets, employers are basing their contract decisions on price. Over the last few years, Exempla Healthcare, Denver, has negotiated a pay-for-performance contract with one of the city's major employers that provides financial incentives to the hospital system for meeting specific quality measures in several service lines, including cardiac and respiratory care. The system was able to earn additional revenue by meeting the goals, says William Jessee, M.D., chair of the board's quality committee.
However, when Exempla opened a new hospital, the same payer that had been paying for quality improvement decided not to contract with the facility because it got a better rate from a competing institution. "It was a sobering lesson for us that payers are interested in quality so long as it doesn't interfere with their ability to get cheaper prices," Jessee says.
This showed Exempla that, while Leapfrog has captured the attention of large employers, smaller companies, such as those in their community, are still not on board. So Exempla is now shifting its marketing efforts away from seeking rewards for the quality it is able to achieve and concentrating instead on educating employers. "We'll not be successful with quality as a market strategy unless the employer community starts demanding it. Right now, although a lot of lip service is paid to quality, price is still a more dominant factor," Jessee observes.
Still, Leapfrog, like the Joint Commission and other quality and safety initiatives, helps focus health care professionals' attention on issues they might not think of as important to the quality and safety of the care they provide, Jessee says.
For instance, Leapfrog criteria set Meritor Hospital on a path it might not otherwise have taken. Vice chair Millner recalls that the members of the ad hoc committee spent considerable time educating themselves about quality within their institution as well as about issues related to quality and safety throughout the hospital community. The committee learned about the difficulty of translating CPOE systems developed in other hospitals to their own setting and the "horror stories" about instituting bar coding too soon. The hospital consequently is introducing a CPOE program in phases throughout the hospital and eventually into physicians' offices. It will not complete the installation until trustees are confident that the switch to computerized order entry will not eliminate some existing human safeguards, Millner says.
Exempla is also following a measured approach to CPOE. A computerized system is being rolled out in Exempla's new hospital, Good Samaritan Medical Center, Lafayette, Colo., in a culture where the nursing and medical staffs are committed to electronic order entry and results reporting. By getting the bugs out of the system in that single setting, Exempla believes it will be easier to install in its other two facilities over the next year.
"It's not a matter of being able to take these kinds of tools and plunk them into an existing setting and turn them on, and everyone will be happy. You have to take into consideration the culture of the organization and do it in such a way that you make sure the tool will be used," Jessee explains. Leapfrog has also reminded trustees that they do not only oversee the hospital's fiscal health.
"Trustees need to balance their time on finance and business development with quality and safety and tie the organization's values back to strategic planning," says Charles Denham, M.D., chair of the Texas Medical Institute of Technology, Dallas, which administers Leapfrog's quality and safety survey.
Denham points out that most trustees spend 90 percent of their time on finance, and 10 percent on quality because they don't feel qualified to look into it. But trustees don't need to know all the answers or much about content; they need to know the right questions to ask, Denham believes. In particular, trustees need to ask whether their hospital is pursuing initiatives such as Leapfrog and if not, why not?
Trustees also can gain insight about their hospital's quality and safety efforts through the Leapfrog survey, which reveals gaps in performance--gaps that may go unrecognized by administrators and trustees during routine oversight. But awareness still only goes so far, Denham believes. Management and governance must be accountable for closing those gaps.
"We've been investing in procedures that generate revenue and volume, such as new molecules that turn into new drugs, new devices that take pictures," Denham adds. "We haven't been investing in information systems, communication systems, in how teams work together. But hospitals must be willing to invest the resources and capacity into becoming able to change."
As business and community leaders, trustees have a natural understanding of the sources of system failure. The goal now is to translate that comprehension into action. As Denham notes: "Trustees need to attack inertia and synchronize action with smart targets by picking the area the organization is going to work on, like Leapfrog, and demand disciplined activity."
In addition to Leapfrog's "leaps," there are other strategies that have been shown to improve medication safety and the care of patients in the ICU.
"Hospitals need to look at the evidence and the strategies that are available to them, look at financial and other resources, and make wise decisions in collaboration with their community boards, medical staffs and others,"says the AHA's Foster. "Wise decision-making means looking at all of the options that are available and choosing the one that would be best."
Karen Sandrick is a Chicago-based health care writer.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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