Patient Safety Focus

If Higher Quality Care Costs Less, Why Does Health Care Still Produce Potentially Avoidable Complications? -- by Francois de Brantes, MS, MBA

 

For years, healthcare services researchers have maintained that there is little, if any, link between the cost of care and its quality. They drew this erroneous conclusion by using both flawed data and flawed methods of analysis.  The researchers used claims data to measure quality (flawed data because quality can only be reliably measured using medical records), and looked at total costs of care (flawed method).

 

During the past several years we have focused on improving our understanding of variation in the total cost of care, using defined windows of time to bound medical episodes of care.  For example, we can reasonably bound a medical episode for acute myocardial infarction within a 30 day time window, including the hospitalization of the patient and any care post-discharge during the balance of the window.  As we’ve performed these analyses, we noticed that we could split the total costs consumed during these windows of time into two components — typical or evidence-informed care (costs that are to be expected in such cases) and costs associated with potentially avoidable complications (costs that should not occur if care were delivered optimally. What we found is that these potentially avoidable costs consume anywhere between 15% and 20% of all dollars spent in the US health care system.  More importantly, we also found that higher quality providers had far fewer costs associated with potentially avoidable complications and that, as a result, their episode costs were also lower.

So if better quality costs less, why aren’t we seeing providers rush to improve the quality of care they deliver and lower overall costs? Because the way they’re paid encourages them to do the opposite. If a patient develops an infection during a hospital stay, the hospital gets more money due to a longer stay and the attending physicians bill for more services. No wonder then that health care costs are rising faster than the general rate of inflation.  And until we get the payment incentives right, it’s hard to see how we will ever achieve a high-performing health care system. The bottom line today is that what we call potentially avoidable costs, someone else in the industry is calling revenue.  That has to change.

 

Francois de Brantes, MS, MBA is CEO of Bridges to Excellence and Prometheus Payment, Inc.

 

 

Leapfrog Group Issues List of Top 2009 Hospitals

  On December 3, 2009, The Leapfrog Group issued its annual list of "Top Hospitals."  For the first time, The Leapfrog Group added efficiency measures into the equation.  Across three categories including urban, rural and children's, Leapfrog recognized 34 hospitals, among the 1206 who participated in the voluntary Leapfrog Hospital Survey, as hitting high marks on quality, patient safety and efficiency.

Arrowsight Featured in American Medical News

In this week's American Medical News, Kevin O'Reilly explores the various ways hospitals are attempting to conduct patient safety surveillance.  The article was inspired by new state-based plans mandating the monitoring of hand hygiene practices (Maryland) and surgeries (Rhode Island).  Arrowsight is highlighted as offering services and technology proven to be effective in measuring and improving hand hygiene practices. The Joint Commission's Mark Chassin suggests that such tools are important in trying to increase accountability for patient safety among health care providers.

 

Arrowsight Referenced in NEJM Sounding Board Article on Accountability -- by Suzanne Delbanco, Ph.D.

In this week's New England Journal of Medicine, nationally-recognized patient safety experts Peter Pronovost, MD, Ph.D. and Robert Wachter, MD argue that the "no blame" approach to improving patient safety needs to be balanced with accountability.  While refraining from blaming individual health care workers for making preventable medical mistakes makes them feel more comfortable to report mistakes, it may not be enough to propel forward efforts to improve care that are stalled.

Citing poor hand hygiene practices as an example, the authors review the structural changes and information campaigns that hospitals have implemented and conclude that they have not done enough to bring hand hygiene compliance to an acceptable level.  What's left to do? Hold health care workers accountable when they fail to adhere to patient safety practices known to protect patients from adverse outcomes.

There are certainly different ways to assess how well workers comply with critical protocols as well as myriad ways to hold them accountable.  But the authors highlight, in the case of hand hygiene, that one prerequisite is to have in place a fair and transparent auditing system of which clinicians are made well aware.  By way of footnote, Arrowsight is referenced as providing one methodology - video - that can be used both to measure and to provide feedback to clinicians.  Pronovost and Wachter cite the fact that meatpacking plants use remote video to hold workers accountable for performance (also Arrowsight's work) -- isn't it time we offer the same protection to patients?

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

HHS Allocating $25 Million to Address Patient Safety and Medical Liability

The U.S. Department of Health and Human Services has announced that it is allocating $25 million to address patient safety and medical liability.  Through the Agency for Healthcare Research and Quality(AHRQ), HHS will provide grants of up to $3 million each to states and health care systems wanting to implement or evaluate demonstration projects aimed at improving patient safety while fixing the problems with the liability system.  There will also be smaller planning grants available for up to $300,000.  AHRQ will also conduct a "review of what works," to be done by December 2009, of initiatives to improve quality and reduce medical liability to help guide HHS' work and investments in this area.

The Funding Opportunity Announcement will be available on www.grants.gov by October 17, 2009.

AHRQ Updates Data Standards for Patient Safety Organizations

The Patient Safety and Quality Improvement Act of 2005 aims to improve the safety and quality of health care in the U.S. through voluntary reporting by clinicians and health care organizations of patient safety and quality information without fear of legal discovery.  The basic idea is that if every health care provider shares information about incidences in which patients were adversely affected, we can aggregate and analyze these experiences to gain more insight into how to improve care. 

The Act charged the Agency for Healthcare Research and Quality (AHRQ) with creating standards for data submitted to Patient Safety Organizations.  Without data standards, aggregating and analyzing the data will be as difficult as comparing the proverbial apple to an orange.

AHRQ initiated standards development process by issuing and working with Version 0.1 Beta, but now has announced in the Federal Register the release of Common Formats Version 1.0.  The Common Formats span definitions and reporting formats and relate to all patient safety concerns, including healthcare-associated infections, falls and pressure ulcers.  This is an important step forward in realizing the goals of the Act.

Protecting Healthcare Workers from H1N1 While They Work

Just before the Labor Day weekend, the Institute of Medicine (IOM) issued recommendations for how health care workers can protect themselves from H1N1 in the work place.  Commissioned by the Centers for Disease Control and Prevention (CDC) and the Occupational Health and Safety Administration, the report has fewer evidence-based recommendations for healthcare workers than it has suggestions for needed research.

For healthcare workers who encounter patients with unidentified febrile respiratory illness or in close contact with those known or suspected to have H1N1, the IOM report suggests they wear "fit-tested" N95 respirators or others equally or more effective.  This recommendation builds on CDC and World Health Organization guidelines, which also point to the importance of vigilant hand hygiene practices in all situations involving H1N1, and to isolation precautions (gloves, gowns, eye protection, masks).

But because the evidence is very limited for what protections to use when, the IOM recommends future research on influenza transmission and respiratory protection, particularly in the clinical setting.

Aetna Tightens Programs Regarding Serious Reportable Adverse Events

Building on its past efforts and those of other public and private health insurance organizations, Aetna announced today that it is taking several steps to strengthen its patient safety programs.

For patient members, Aetna is providing information on its member Web site about how patients can protect themselves from medical mistakes.  Public information with this type of advice is available from the U.S. Agency for Healthcare Research and Quality, which came out with a tip sheet shortly after the publication of the Institute of Medicine's report To Err is Human in 1999. 

Aetna will also require that facilities, physicians and other health care professionals waive charges for care during which the wrong surgery is performed, surgery occurs on the wrong person or on the wrong body part or side of the patient's body, as well as for eight other serious reportable adverse events (also known as "never events").

To encourage hospitals to learn from such mistakes, Aetna also requires that when a serious reportable adverse event happens to an Aetna member, hospitals must:

• Alert Aetna and either The Joint Commission, a state reporting program, or patient safety organization;
• Analyze why the event occurred and how to improve processes in the future to keep such an event from happening again; and, 
• Communicate with the patient or patient's family about the event.

Can Health Reform Work if Focused Only on Coverage? -- by Suzanne F. Delbanco, Ph.D.

In today's New York Times, Paul O'Neill, former Secretary of the Treasury, points out one of the big holes in the health reform debates in Washington, D.C.  While all of the talk about covering the uninsured and creating cost savings from enhancing competition among health insurance companies is very important, what about reducing the financial and human costs from preventable medical mistakes, including hospital-acquired infections?

If we are to aim to reduce current trends in health care costs and simultaneously find new resources to help provide care to a broader population, we best look at all our options.  According to a report by the Centers for Disease Control and Prevention (CDC), the costs of healthcare-associated infections in the U.S. each year range from $28.4 to $45 billion.  On the other hand, the savings from infection control measures could be as great as $5.7 to $31.5 billion.  We literally cannot afford to ignore this financial opportunity.

O'Neill lists a few examples of health care providers that have reduced infection rates drastically.  This means it can be done, and one can extend that fact to argue that there is no excuse for not doing it.  Arrowsight's approach to helping hospitals get it right - such as washing or sanitizing hands every time - is one example of the tools available to hospitals today. 

O'Neill challenges President Obama to add an important audacious goal to his list:  "ask medical providers to eliminate all hospital-acquired infections within two years."  On top of providing health insurance to everyone, that would be real health care reform.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Comparative Effectiveness Research Discussions Begin in Earnest

The American Recovery and Reinvestment Act devotes $1.1 billion to support comparative effectiveness research.  The U.S. Department of Health and Human Services will split the funds between the Office of the Secretary, the Agency for Healthcare Research and Quality and the National Institutes of Health.  The working definition for comparative effectiveness research is "is the conduct and synthesis of systematic research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions."

How each agency focuses its use of the funds is being determined by a Federal Coordinating Council for Comparative Effectiveness Research, which released Monday its recommendations for the Office of the Secretary suggesting that it focus investing in the data infrastructure and patient registries that can support comparative effectiveness research. 

Today, the Institute of Medicine released its recommendations for for the top 100 priority areas for comparative effectiveness research.  Their suggestions are as far ranging as comparing effectiveness of treatments for hearing loss in adults and children to strategies for reducing health care-associated infections and unintended pregnancies.

There is no doubt that the health care system, and most stakeholders participating in it, could benefit from rigorous examinations of how we spend our money and choose to seek and deliver care.  That there will be politics and debates surrounding how this money is spent is just as certain.