New American Quest: Hospital Patient Safety And Quality Care

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New American Quest Hospital Patient Safety And
Quality Care
Charles N. Kahn III Workshop on The Future
Hospital December 19-20, 2004 Hotel Galei
Kineret, Tiberias
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Agenda

• Unanticipated Challenges to the American
  Hospital Patient Safety and Care Quality
• American Hospital Characteristics and Oversight
• Medical Litigiousness Stumbling Block to Patient
  Safety and Care Quality
• First Do No Harm Making the Hospital Safer
• The Quality Formula Providing the Right Care and
  Promoting Quality Through Payment for Performance
• Key Lessons

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Feeling Thermometer
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Perception of Recent Hospital Experience
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While a slight decline from 2002 has occurred,
one out of four express a high degree of concern
over receiving the wrong medication during their
hospital stay.
How concerned are you that you might get the
wrong medication while in the hospital? Would
you say you are
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Concern regarding contracting an infection while
hospitalized has grown significantly since 2001.
How concerned are you that you may contract an
infection while in your local hospital? Would
you say you are
15 have either personally contracted or had a
family member contract a staph infection while in
the hospital.
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Wednesday, February 19, 2003 Answers sought in
botched transplant By Emery P. Dalesio /
Associated Press
Duke University Hospital
DURHAM, N.C. -- One of the country's top medical
centers is trying to find out how it botched a
heart-lung transplant that was supposed to save
the life of a 17-year-old girl but instead put
her closer to death. Jesica Santillan was in
critical condition early today at Duke University
Hospital after mistakenly being given organs that
didn't match her type O-positive blood. The
hospital has acknowledged making the mistake --
although it still does not know how it happened.
Dr. William Fulkerson, Duke's chief executive
officer, said the hospital is investigating the
mistake and will determine whether any staff
should be disciplined.
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Identifying Safety/Care Problem

• Institute of Medicine (IOM) To Err is Human
  (1999)
• 44,000 to 98,000 Americans Dying Annually
• Adverse Events in 4 of Hospitalizations
• Wennberg Brook
• Wennberg 30 years of Findings of Mass,
  Unexplained Variations in Practice Patterns
• Brook 30 Acute, 20 Chronic Patients Receive
  Contraindicated Care
• IOM Crossing the Quality Chasm (2001)
• Delivery System Fundamentally Flawed
• Too Frequent Harm and Routine Failure to Deliver
  Well Documented Services That Benefit
• Quality Concerns Pervasive, Affect Many Patients
• Three Themes Emerge
• Patient Safety
• Delivery of Quality Care
• Medical Practice That is Unnecessary

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Agenda

• Unanticipated Challenges to the American
  Hospital Patient Safety and Care Quality
• American Hospital Characteristics and Oversight
• Medical Litigiousness Stumbling Block to Patient
  Safety and Care Quality
• First Do No Harm Making the Hospital Safer
• The Quality Formula Providing the Right Care and
  Promoting Quality Through Payment for Performance
• Key Lessons

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The American Hospital

• Admissions
• Annual 36.3 million
• Daily Census 662,000
• Hospitals 4,895
• 60 Nonprofit, tax exempt
• 15 Investor-owned
• 25 Government
• Hospital Systems
• 46 of Hospitals in Systems
• 54 Free-Standing
• Hospital Size
• 47 99 Beds or Less
• 37 100-299 Beds
• 16 300 Beds or More

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The American Hospital, Contd.

• Location
• 38 Large Urban
• 31 Small Urban
• 31 Rural
• Type
• 22 Teaching
• 84 Community General
• Payment Sources
• 43.7 Private (Insurance and Out of
• Pocket)
• 40.4 Medicare
• 14.4 Medicaid
• 1.6 Other Government

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Agenda

• Unanticipated Challenges to the American
  Hospital Patient Safety and Care Quality
• American Hospital Characteristics and Oversight
• Medical Litigiousness Stumbling Block to Patient
  Safety and Care Quality
• First Do No Harm Making the Hospital Safer
• The Quality Formula Providing the Right Care and
  Promoting Quality Through Payment for Performance
• Key Lessons

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US Medical Liability System Impedes Patient
Safety And Quality Efforts

• Medical Liability System Foibles
• Fails to Protect or Compensate Fairly
• Retrospective, Relies on Private Action, and
  Remedies Limited
• Judges/Juries Lack Expertise
• Defensive Medicine and Insurance Cost High and
  Result in Unneeded Care
• Medical Liability System Punitive and Anxiety
  Provoking for Physicians and Hospitals
• Inhibits Reporting and Admission of Errors or
  Adverse Events
• Disclosure and Even Remediation May Raise
  Provider Legal Exposure

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Agenda

• Unanticipated Challenges to the American
  Hospital Patient Safety and Care Quality
• American Hospital Characteristics and Oversight
• Medical Litigiousness Stumbling Block to Patient
  Safety and Care Quality
• First Do No Harm Making the Hospital Safer
• The Quality Formula Providing the Right Care and
  Promoting Quality Through Payment for Performance
• Key Lessons

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Hospital Errors and Even Malfeasance Major Problem

• Surgical Mistakes
• e.g., Surgery or Procedure on the Wrong Patient,
  Wrong Organ or Appendage, Retention of Foreign
  Object, or Certain Post-operative Deaths
• Product or Device Contamination or Misuse
• e.g., Death or Serious Injury Due to Contaminated
  Drugs, Devices or Biologics, or Certain Avoidable
  Embolisms
• Care Management Error
• e.g., Wrongful Medication Error, Administration
  of Wrong Blood-type , Post-hospitalization
  Pressure Ulcers
• Environmental Negligence
• e.g., Death or Harm to Patient from Electric
  Shock, Burns Falls, or Exposure to Toxic Gases
• Criminal Activity
• e.g., Care Ordered by Someone Impersonating a
  Bona Fide Care Provider, Abduction, Sexual
  Assault, or Other Assault on a Patient

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Shameless - Blameless Approach And New Systems
Key To Safety

• Voluntary Reporting Re Leapfrog Safe Practices
  and New 100,000 Lives Campaign
• Developing Hospital Culture of Safety
• Establishing Non-punitive Safety Feedback Loop
• Unvarnished Incident Reporting
• Analysis of Events
• Systemized Remediation
• Anticipatory Risk Management Programs
• Structural Reform
• Electronic Medical Record Adoption
• Computerized Physician Order Entry for Drugs and
  Clinical Decision Support System
• Medication and Patient Bar Coding
• ICU with Intensivists

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Federal Patient Safety Legislation To Foster
Culture Of Safety

• No Clear Results from 21 State Mandatory
  Reporting Error Laws
• Federal Voluntary Medical Error Reporting
  Legislation Considered in 2004 and Likely Enacted
  in 2005
• Federal Legislation Would Establish
• Federally-Certified Patient Safety Organizations
• Provide for Public Disclosure
• Direct Consultation With Hospitals
• National Data Base to Develop System Solutions
• Legal Protections for Hospitals for Disclosure
  Controversial

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Agenda

• Unanticipated Challenges to the American
  Hospital Patient Safety and Care Quality
• American Hospital Characteristics and Oversight
• Medical Litigiousness Stumbling Block to Patient
  Safety and Care Quality
• First Do No Harm Making the Hospital Safer
• The Quality Formula Providing the Right Care and
  Promoting Quality Through Payment for Performance
• Key Lessons

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Measurement and Reporting To Ensure Quality Care
Delivery

• Quality Improvement
• Care Metrics Identified for Many Conditions,
  Measurement and Reporting Increases Compliance
  with Guidelines
• Analysis May Lead to Better Guidelines and
  Medical Outcomes
• Public Accountability
• Accreditation Insufficient to Ensure Hospital
  Accountability, Transparency Comes with
  Reportable Measuring
• Consumer-Patient Choice
• Consumer Choice Key to Emerging Payment
  Arrangements, Requires Useable Information
• Value-Based Payment
• Payment Should be for What is Expected, Until
  Collection and Reporting of Metrics Can
  Demonstrate Value of Care Purchased

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Metrics Covered In Measurement And Reporting
Initiatives

• Structural
• Identifiable and Proven Resource Hospitals Adopt
  and Use to Ensure Proper Care Delivery
• e.g., CPOE or Bar-coding
• Process
• Established Rules and Guidelines for Medical
  Practice to Ensure Proper Care Delivery
• e.g., Guidelines for Emergency Room Patients
  Presenting With Chest Pains
• Adherence to Guidelines Should be Reflected in
  Medical Record, Simpler to Report
• Most Measures in This Category, Little
  Justification for Non-compliance

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Metrics Covered In Measurement And Reporting
Initiatives, Contd.

• Outcomes
• Results of Actual Patient Care
• Often Difficult to Capture With Current Data
  Collection Capacity
• Measures Less Established with Exceptions such as
  CABG and Mortality Rates
• Variation in Patient Risk and Other Factors
  Outside Care Givers Hands, Makes Comparisons
  between Results More Difficult
• Ultimately the Gold Standard Measure of Quality
  For a Hospital and its Care Givers
• Patient Perception
• Patients Views of Care and Hospital Service
  Environment
• Collected Through Surveys of Patients

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Criteria For Measure Development

• Credible Process Valid, Reliable, Passes 3rd
  Party Audit
• Evidenced-based Based on Irrefutable Scientific
  Research
• Clinical not Administrative Requires
  Resource-intense Medical Record Abstraction
• Specifically Identifiable Activity or Service
  Measure Must be Actionable
• Practical to Abstract Number of Measures
  Limited Without EMR

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Questions For Assessing Measurement And
Reporting Strategies

• Benefit/Cost Do the Benefits of Establishing a
  Measure, Abstraction and Processing Outweigh the
  Costs?
• Usefully Inform Does a Metric as Reported
  Actually Inform Hospitals, Physicians,
  Consumer-Patients, Regulators, and Payers, and
  Can Action be Taken or Decisions Made Based on
  the Reports?
• Affect Medical Practice Are the Metrics
  Persuasive to Physicians, other Care Givers, and
  Hospitals to Prompt Change in Medical Oversights
  or Ineffective Practice?

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Most important factor in selecting a hospital
Seniors
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Current Reporting On Individual Hospital Quality

• U.S. News and World Reports Annual
  RankingTraditional Approach Using Ratio of RNs
  to Beds, Presence of Specific Technologies,
  Number of Intensive Care Beds, and Expert Opinion
  to Rank Nations Hospitals.
• JCAHOLaunched Quality Check July 2004 with
  Virtually All U.S. Hospitals Performance on 4
  Clinical Conditions and Compliance with
  JCAHO-Established Patient Safety Goals.
• HealthGradesPrivate, For-profit Free to
  Consumers, Subscription for Providers and Payers
  Reports on Clinical and Patient Safety
  Performance For All U.S. Hospitals Using Largely
  Medicare Data.
• HHS September 2004 StudyIdentified 47 Websites,
  Public and Private, Mostly State Level, With
  Utilization and Clinical Information.

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Major Public-Private Sector Hospital Reporting
Initiative Hospital

• Joint Provider, Government, JCAHO, NQF, Employer,
  and Consumer Initiative
• Intended Originally to be Voluntary
• To Align Hospital Measures, Collection, and
  Reporting
• CMS Sets Measures, Receives and Validates Data,
  and Operates Website for Public Reporting
• Hospitals Reporting Validated Data Get Medicare
  Bonus Payments (With Bonus Participation up to
  98)
• 10 Initial Measures
• Heart Attacks
• Aspirin at arrival
• Aspirin at discharge
• ACE Inhibitor for left ventricular systolic
  dysfunction
• Beta Blocker at arrival
• Beta Blocker at discharge
• Heart Failure
• Assessment of left ventricular function
• ACE Inhibitor for left ventricular systolic
  dysfunction
• Pneumonia
• Oxygenation assessment
• Initial antibiotic timing
• Pneumococcal vaccination

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Hospital Spending About 38 Of Total Spending,
Growing Too
Billions
Sources Centers for Medicare and Medicaid
Services, Office of the Actuary and U.S.
Department of Commerce, Bureau of Economic
Analysis and Bureau of the Census.
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CMS Hospital Quality Incentive Demonstration
Project

• Three-year Demonstration Using Quality Measures
  to Reward Top Performing Hospitals Out of 278
  Participating Hospitals
• Quality Measures for patients with
• Heart Attack
• Heart failure
• Pneumonia
• Coronary Arty Bypass
• Hip and Knee Replacements
• Data Will be Publicly Reported
• Hospitals Scores on Quality Measures Aggregated
  and Scores Distributed into Deciles
• Top 20 of Hospitals in Each Clinical Area Will
  Get Bonus (2 DRG Bonus for Top Decile and 1 for
  Next)
• 3rd Year Hospitals Below Floor Cut 1 for
  Conditions in the 9th Decile and 2 for those
  below the 10th Decile

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Medicare Payment Advisory Commission Consider Pay
For Performance

• Medicare Establish Pay for Performance for
  Hospitals, Physicians, and Home Health Agencies
• Measures Based on Severity of Illness
• Performance Bonus Payment 1 to 2 of Rates
• Funds Taken from Pool of Anticipated Spending
• Anticipate Private Sector Will Follow
• Final Decision on Recommendation January 2005

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Private Sector Pay For Performance Initiatives

• Harvard Pilgrim and Partners Hospitals
• Starting 2001, Payment of All or Part of Annual
  Provider Update Payment Based on Care Improvement
  Re Adult Diabetic Care, Pediatric Asthma,
  Leapfrog Standards, Pharmacy Use and Inpatient
  Use
• Anthem (KY, IN, OH, VA CO)
• Payment for 363 Hospitals Linked to Clinical
  Data, Patient Safety and Patient Perception of
  Care Criteria
• Payment and Performance Standards Contractual

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Private Sector Pay For Performance Initiatives,
Contd.

• Independence (PA)
• Payment Adjusted for Standards Re AMI, heart
  failure, pneumonia, pregnancy, Readmission rates,
  Mortality, and Leapfrog Standards
• Payment and Performance Standards Contractual
• Leapfrog Group Hospital Rewards Program
• 2005 Launch
• CMS Hospital Quality Incentive Demonstration
  Project Model
• Five Clinical Measures (CABG, AMI, PCI,
  Pneumonia, and Pregnancy)
• Efficiency Measures to be Determined
• Health Plans Evaluated on Migration of Patients
  to Hospitals That Meet Standards

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Agenda

• Unanticipated Challenges to the American
  Hospital Patient Safety and Care Quality
• American Hospital Characteristics and Oversight
• Medical Litigiousness Stumbling Block to Patient
  Safety and Care Quality
• First Do No Harm Making the Hospital Safer
• The Quality Formula Providing the Right Care and
  Promoting Quality Through Payment for Performance
• Key Lessons

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Key Lessons

• Current Rate of US Hospital Errors and
  Substandard Care Unacceptable
• Non-punitive Approach to Reporting and Adverse
  Events as well as Appropriate Culture for
  Remediation and Adoption of New Systems Key to
  Patient Safety
• IT and Other Technological Capacity Must Catch Up
  With Imperative to Measure, Report and Correct or
  Improve Hospital Practices
• Physicians Critical to Improving Care Delivery in
  Hospitals, Measuring and Reporting Must be Geared
  to Affect Their Medical Practice as well as Other
  Care Givers in Hospitals
• Payment Can Drive Change in Care Giver and
  Hospital Behavior Re Patient Safety and Ensuring
  a Standard of Care
• Incentives for Following Evidenced-based
  Standards May Affect Variation in Practice
  Patterns.

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American Quest For Hospital Patient Safety,
Quality, And Value
Charles N. Kahn III Workshop on The Future
Hospital December 19-20, 2004 Hotel Galei
Kineret, Tiberias