The Road to Transparency
By Susan Meyers
The drive to improve health care and reduce errors is on hospital radar screens everywhere. Standardized benchmarks and quality indicators provided by initiatives from the Joint Commission on Accreditation of Healthcare Organizations, Leapfrog, the National Institutes of Health and The Centers for Medicare and Medicaid Quality Project are being hailed as the answer to improving hospital performance nationwide. But is it enough?
That's the question being posed by many hospitals since the bombshell news from the Institute of Medicine's 2004 follow-up report to 1999's "To Err is Human" reported that essentially no progress regarding patient safety has been made since the first report was published. Disappointing? Yes. Surprising? No, says Jeffrey Selberg, president and CEO of Exempla Healthcare, which owns and manages three hospitals and a physician network in the Denver area. Not when you consider that most hospitals are still not being held accountable to their communities for their safety records, patient satisfaction, clinical performance and cost-effectiveness.
Exempla Healthcare and a number of hospitals around the country are putting accountability and transparency at the forefront of their strategic agendas in the hopes of redefining how health care organizations compete, moving away from responding to a market driven primarily by health care plans focused on cost and price, to one driven by the consumer, focused on quality and value.
Transparency in reporting how a hospital does its job is critical if we are going to see a shift in the way the market operates, notes Selberg. Not only is it a hospital's responsibility to report quality information, but it is a patient's right to have the information needed to make educated decisions about what type of health care services he or she uses, from whom and why. Only then, says Selberg, will providers become more conscious of quality and service, more price competitive and more accountable, and consumers and practitioners alike will begin choosing hospitals based on their performance.
Not only does transparency hold the key to better hospital performance, it is also the cornerstone of community trust, says William Jessee, M.D., board member for Exempla Healthcare and chair of the board's quality committee. Making hospital information easily accessible to the public "is the only way for health care organizations to maintain the public's trust," he says.
Daniel deRoulet, chair of North Shore-Long Island Jewish Health System, in Long Island, N.Y., concurs. "We overlay the word trust with transparency. There is a lot of trust that goes on between the board, the community and the hospital. The notion of transparency says that as volunteers of the community, trustees need to make sure all areas of the health care institution are clear to us so that we, in turn, can act in the best interest of the institution and the community."
Taking Steps
The health care system is beginning to take small steps in this direction, but it is going to take a few leaders taking giant strides before most health care institutions make transparency a priority. When this happens, others will follow suit, believes Selberg. Case in point: Exempla was one of the first hospitals in the Denver area to participate in the Leapfrog Group Hospital Quality and Safety Survey.
The Leapfrog Group was formed to encourage hospitals to report health care quality and outcomes to the public in order to reduce preventable medical mistakes and allow consumers to make more informed health care choices. Leapfrog rates participating hospitals with a "quality index" based on the hospital's implementation of 27 procedures that have been shown to reduce preventable medical mistakes.
In the Leapfrog Survey's first year (2001), Exempla was one of a few hospitals to release quality data, including data for specific procedures and conditions, Selberg notes. Exempla was also the first hospital in the area to release quality data on all 10 of the CMS metrics. This spring, all Colorado hospitals released mortality data for six conditions and five procedures. Colorado is one of the first states to voluntarily report these outcomes, and Exempla has been working diligently with the Colorado Healthcare Association and other hospitals in the state to make this information available to local communities.
It is this public sharing of performance data in such initiatives that will start to make a difference in how hospitals perform and will be the barometer by which hospitals are judged in the future, says Jessee.
At North Shore-Long Island Jewish Health System, accountability and transparency grew out of the hospital's strategy to become a leader in quality health care.
"When Michael Dowling was appointed CEO in 2001, he realized that in order to become a leader, we had to begin defining and measuring our performance as well as reporting it to the public," says Jeffrey Kraut, senior vice president of strategic planning and marketing at North Shore-LIJ.
Creating Transparency from the Inside Out
North Shore-LIJ is the third largest, not-for-profit, secular health care system in the country with 15 hospitals, nine of which are accountable to a single board of trustees. The board realized from the beginning that before a hospital can become transparent to its community, it must first be internally transparent. That requires employee and board support and involvement as well as regular sharing of key strategic and performance information between board members and all employees.
The importance of board involvement cannot be underestimated. At North Shore-LIJ, the board is very much attuned to the health system's eight strategic initiatives: quality, service excellence, operational performance, education, research, physician relations, workforce development, and community health and advocacy. At each monthly meeting, all initiatives are discussed in detail, Kraut says, and every two months, a strategy progress report, based on input from all facilities and key departments is made available to board members and employees. Additionally, a monthly report on strategic performance metrics is available on the system's intranet, posted in employee lounges and mailed to board members. Excerpts relevant to specific departmental areas are also posted at nurses' stations as well as other areas. Finally, an annual "state of the health system" report is mailed to every employee and trustee detailing the health system's progress in meeting each of the system's strategic goals and outlining the challenges for the coming year. A community service report, which is prepared annually and mailed to employees and board members, tells about the progress and plans of each hospital with respect to its strategic goals, how it meets the needs of its community and pertinent financial data.
These procedures are another step toward transparency, deRoulet explains. "We were early adopters of the CMS measures so that we could have a standardized reporting methodology," he says. "There has been full support from our board to adopt these measures as a standard part of our quality reporting infrastructure."
At Dana Farber Cancer Institute in Boston, a committee comprising medical staff, trustees, patients and their families helps shape decision-making about patient care initiatives. "An educated patient is the best ensurer of safety," says Vincent O'Reilly, vice chair of Dana Farber's board.
The New England Healthcare Assembly recently selected O'Reilly for its 2004 Trustee Leadership Award. O'Reilly was Dana Farber's board chair when a Boston Globe medical reporter died from a medication error at the hospital in 1994. O'Reilly subsequently led an extensive patient safety effort that led to significant reforms at Dana Farber and elsewhere.
The board insisted on open and forthright communications and on expansive investigations that went beyond specific near-miss or error incidents to address systemic issues related to patient safety. A number of potential problem areas were identified, including the pharmacy dispensing system, emergency department admitting procedures for immunocompromised cancer patients, prevention of bed falls, and accuracy and thoroughness of patient records.
Cultural Change
Developing transparency within an organization requires a cultural change among employees, says Judy Mitchell, senior vice president of strategy and organizational effectiveness with Exempla. "It's about creating an environment that allows our employees to raise issues and identify problems without fear of reprisal," she says.
Understanding Exempla's commitment to the full, accurate and timely disclosure of information begins during the recruiting process for potential new employees. Exempla's goal is to be recognized as providing the absolute best care and service by its patients, physicians and staff, says Mitchell, and it assesses its progress through patient safety and satisfaction measures, employee and physician engagement, and compliance with clinical excellence and overall value benchmarks. As part of their orientation and training, new employees are introduced to Exempla's commitment to public accountability and performance excellence. They are also introduced to the system's five service behaviors: act safely, communicate effectively, act respectively, project professional image and promote teamwork--and then given two days of training on how to translate these behaviors into their daily work.
Key to Exempla's cultural transformation has been the creation of a patient satisfaction report for each department. The reports are designed to remove walls between departments and promote information sharing and positive processes. "Traditionally, departments [have tended] to keep performance within departmental walls," explains Mitchell. "In the past, sharing this kind of information often created fear and peer criticism. It took a year to implement this survey process and to reach a point where employees felt comfortable with it. Since then, we feel we've been able to create a sense of team reporting--a desire among staff between departments to help each other improve."
Exempla has since added a higher level metric to the satisfaction report, adding information on harmful occurrences, adverse drug effects, infections and mortality. "We've had such a powerful commitment to this tool that we've been able to work [past] personal feelings of not wanting to share mediocre scores, to identifying problems and putting the processes in place to improve scores," says Mitchell. Judging from patient satisfaction score results, the culture change seems to be having its desired effect.
At Dana Farber, patient safety has become a way of life for clinicians and employees. For instance, a sophisticated pharmaceutical auto-entry system can detect prescription errors to reduce pharmacy-related mistakes. A redundant system used at the bedside allows the clinician administering the medication to perform a detailed cross-check of the patient's medication plan before actually administering a medication. Other changes include the addition of a separate room in the emergency department designated to protect immunocompromised patients seeking ED care, and a hospitalwide campaign to educate patients and remove conditions that could result in bed falls.
Dana Farber is also focusing on building an environment that encourages employees to come forward with mistakes, O'Reilly says. "Our goal is to have as complete reporting of errors as possible. If people don't report mistakes, you can't fix them."
For example, the hospital implemented a no-fault reporting system to ensure that the messenger is not inappropriately punished for revealing errors, and representatives from the quality assurance-risk management department regularly accompany physicians and nurses on their morning rounds to discuss potential system problems. "They pose the question, 'What has impeded your ability to provide patients with the best care possible?'" O'Reilly explains. "Very explicit conversations about more serious complications are held at the governing board level and at medical staff meetings. The reasons why the problem occurred and how it can be prevented from happening again are addressed in detail," he adds.
Communicating to the Public
Once a hospital has built an environment that embraces transparency within, it is ready to begin communicating this information to the public, says Mitchell. "The challenge is in translating very complex metrics into everyday language for the consumer," she explains. "When CMS published its first-year indicators, we thought it was going to generate a lot of attention and interest from the public, but it was actually a non-event. People couldn't relate to the data. Translating this information so that it is understandable and useful is not easy to do in health care."
For instance, one significant quality indicator is the mortality rate for specific conditions or procedures, explains Mitchell. However, two hospitals could have the same mortality rate for a given condition and still not have the same quality of outcomes because of differences in the seriousness of conditions or simply the number of cases upon which the rate is based. "While we realized that these differences can be accounted for with statistical tests, the general public may find statistical analysis confusing," she says.
O'Reilly agrees, maintaining that before this type of information can be made available to the public, hospitals need to have predictive measures that health care professionals can rely on and that can be interpreted in a way that the public can understand. "This is not like a baseball score," he notes. "We have to be very careful how we provide this information. I see it acting more as a guide that consumers can discuss with their physician when making health care decisions."
Using the proper channels to communicate to the public is another issue. "Our platforms for our communications and marketing next year will all be on education and information regarding quality of care," says Kay Taylor, Exempla's marketing and communications vice president. "We also plan to engage our employees and physicians in helping us educate the community." Taylor says Exempla is redesigning its Web site to incorporate quality and performance data, while working with employees to make sure they have the proper comfort level and tools in place to provide this information to the public.
Exempla has also been working with the local business community to communicate hospital performance data--but they'd like to see that data expanded. For instance, the Colorado Business Group on Health requested mortality data from Exempla to use as a basic measure of hospital performance. Later, the Colorado Health and Hospital Association released mortality data on a select number of conditions and procedures for all hospitals in the state.
While mortality data constitute one measure of hospital quality and performance, Exempla believes that employers and health care plans should ultimately have access to information on a range of different performance measures, including safety, satisfaction and financial measures.
"Our hope is that companies will begin to consider a hospital's performance data before making a decision about which insurance company to use," says Selberg. With this goal in mind, Exempla is pushing health care plans to develop tiered benefit systems in which all hospitals' performance would be assessed in terms of quality. Insurance plans would then provide increased benefits to patients who choose to go to hospitals that outperform their competition for specific types of care.
"Now if all hospitals understood tiering--which is payment based on their quality performance and overall results, and where those performing the best get paid the most and those performing at the lowest level will be paid the least--they would make sure their performance was at the level that health plans would require," explains Selberg.
Accountability Toward Community Needs
In its quest to become more accountable to the community, North Shore-LIJ has also made community health and advocacy a primary initiative. "If a hospital provides quality care, but is not meeting the needs of its community, then it's not doing its job," says Kraut. Each hospital within the North Shore-LIJ system actively seeks the input of community groups and leaders to determine local health care issues and trends through quarterly and semiannual community meetings. "These discussions are very important," notes Kraut. "It's our way of listening to the voices of our community. Sometimes issues that are happening out there aren't necessarily on our radar screen."
For instance, a meeting among local school nurses revealed a high rate of autism in one community with very few resources for intervention. As a result, North Shore-LIJ established an autism program to provide professional medical assistance to those families. And, when hospital research revealed that a section of a Long Island town comprising many illegal immigrants was being medically underserved, North Shore-LIJ funded a pediatric mobile unit, staffed by the system's doctors and nurses to provide "no-strings attached" primary health care services. The health system follows up their discovery of this information with a community service plan for each hospital in its system and for the hospital system as a whole. The report identifies the key community health issues along with an action plan to address those issues.
Impact on the Field
What does the health care field stand to gain as a whole from transparency?
"Right now, all of us are underperforming," notes Selberg. "If we start really competing with each other by improving our performance, all boats will rise."
Selberg says that since Exempla made accountability toward safety and quality performance a priority several years ago, the health care system has seen solid improvements in patient satisfaction, employee turnover and safety. "We are working on the CMS clinical dashboards of 10 publicly reported items and we have made real progress toward our goal of performing in the 90th percentile," he adds.
A greater commitment to quality care has also translated into a 23 percent drop in employee turnover, which now stands at about 14 percent systemwide. "When we hire new employees, we tell them that we want them to be part of a journey--that they are part of a team," explains Mitchell. "By creating an open environment, this allows employees to raise issues. They feel like they can make a difference and this translates to a greater commitment to their jobs and to the health system."
Patient satisfaction scores have also increased at Exempla since it began its journey. Since 2001, overall patient scores have moved up from the mid-80s to scores in the 90s. "What is especially noteworthy about the changes in scores, is that we are seeing a clear movement toward the 'strongly agree' end of the scales," says Taylor. "The degree of patient satisfaction is clearly getting stronger."
At North Shore-LIJ, the health system consistently comes out on top in surveys regarding hospital quality, says Kraut. The hospital was also the first to receive the Codman Ernest Award from the JCAHO for its approach to quality.
"The key to revolutionizing health care is to have the market demand higher performance and to choose hospitals based on their relative performance," says Selberg. "Only then will we see very significant improvements on the part of hospitals because they will have to change."
Susan Meyers is a writer based in Omaha, Neb.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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