Timidity in Massachusetts

Over three years ago, while posting our rate of central infections, I asked the following questions:

If I can post these rates for BIDMC, why can't people from other hospitals? ... Why can't the insurance companies? ... Why can't the state of Massachusetts? ... Real-time public disclosure of key indicators like this ... can be mutually instructive and can help provide an incentive to all of us to do better.

Well, Massachusetts is getting passed by on this front. Here is a presentation showing the rate of central line infections for all of the hospitals in Illinois for 2009. If you sort on the column "infections per 1,000 central line days" by clicking on that header, you will find 50 hospitals with zero infections, and 31 more with fewer than one per 1,000.

This kind of presentation does not require state action. The Massachusetts hospitals could together decide to do this voluntarily. We all collect the data for our own hospitals. It would impose no administrative burden to forward it for publication to a collective website. (Look here to see BIDMC's figure, posted every quarter.)

What more persuasive way to demonstrate to the public and to legislators that we collectively are serious about eliminating one important form of hospital acquired infection? That we are willing to be held individually and collectively accountable to a standard of care to reduce harm to patients? That we likewise are willing to be held to a standard of care that also saves dollars for an overburdened health care system?

Look at this related story in the Chicago Tribune. An excerpt:

Ten years ago, Dr. Bob Chase would have laughed if someone had told him common infections could be eliminated in hospitals' intensive care units.

"I would have said that's ridiculous, not possible," he said. "As a physician, I was trained to believe bad things just happen."

But Chase, vice president of quality at Norwegian American Hospital in Chicago, doesn't think that anymore. A growing body of research has convinced him that many infections can be prevented if proper procedures are rigorously followed — evidence he's using to reduce higher-than-expected infection rates at his own institution.

The research is prompting a wave of improvements in hospital ICUs, and patients are starting to benefit: At many hospitals, the rates of some common infections have been cut in half or more, saving lives and money and preventing medical complications.
Why are the health care leaders in Massachusetts so timid on this issue?

Not enough, AHA

The American Hospital Association does excellent work in representing the views and interests of hospitals across America, and it genuinely seeks to help frame medical and hospital issues in a way that serves the public interest.

But because it is a membership-based organization, it can be hard to be as aggressive on some issues as the times call for. One such discussion is going on right now. The Association is considering a number of strategic performance commitments, one of which is to "advance a health care delivery system that improves health and health care."

I can't argue against that goal, but the manner in which it would be pursued and quantified is weak. See the slide above. It is the draft of what is being discussed by hospital associations across the country.

The first two items are certainly worthy, but the manner in which they are measured is problematic. The metric is a three-year running average produced by CMS and published a year after the year is over. Accordingly, no one will know if the 2012 target is met until 2014.

Why rely on administrative data collected by CMS when every hospital has its own data in real time? Why use a three-year rolling average when we are trying to demonstrate progress over the coming year or two?

The third goal, to achieve improvements in central line infection rates, is simply inadequate on its face. The idea of taking three years to move from the 2009 baseline of 5 cases per thousand patient days to a new target of 1 in 2012 does not reflect the deadliness of hospital acquired infections nor the progress that any hospital can make to reduce them in just in a few months.

The target for central line infections should be zero. That is the only intellectually compelling goal. The time period for doing this should be much, much shorter.

Non-zero sum

Let's face it. Health care is an odd field. Costs are unknown or indecipherable. Prices for the services offered are hidden from consumers. Likewise, the value (efficacy, quality, safety) of the services received is hidden from consumers. In no sense does it represent other markets, in which transparency of these elements reigns and which therefore have a better chance of reaching the "efficient market" described by economists.

In such an environment, growth in market share by one participant is usually solely at the expense of another: a zero sum game. But even in the dysfunctional world of hospitals and physician marketplaces, such transactions can add value to society. In that case, the result is a non-zero sum game. But only if the "winners" actually do add value.

The business strategy of our hospital is remarkably straightforward. We hope to be the high quality, low cost provider among academic medical centers in our region. We look for community-based partners -- hospitals and physician practices -- for whom we can respectfully help to deliver coordinated care. You have read numerous examples on this blog about how we are trying to do this.

But this is more than a business strategy. It is a matter of values and mission. You won't find this mission statement written in our formal documents or in any strategic plan. Its strength lies in the fact that it is a deeply held belief.

I never told you this story, but when Gloria Martinez, one of our transporters, won our first caller-outer-of-the-month award, she first graciously accepted the award on behalf of herself and the other transporters. Then, with no coaching or prompting whatsoever, she said that she and her colleagues viewed their job as "trying to provide the kind of care we would want members of our own family to receive."

I know I do not violate confidences when I tell you that this simple statement from Gloria left tears in the eyes of our Board members. That a person who pushes beds and wheelchairs and delivers specimens -- who in another institution might be anonymous and ignored -- could simply and elegantly express the community purpose of our hospital was a very moving moment.

We fully engage clinical transparency because we view openness in such matters as the best way to hold ourselves accountable to the standard of care we -- the Board, the clinical leaders, and the administrative leaders -- have set for ourselves. We do not do this for competitive purposes, but if the health care marketplace recognizes our progress and rewards us with a growing market share, we are happy to contribute to a non-zero sum result for society.

Progress in the ICUs

Our Medical Executive Committee recently received a report from our Critical Care Committee. I cannot be more proud of our staff and the progress they have made to reduce harm and improve quality of care in our ICUs. I include two of the charts.

Let me translate the implications of the reduction in Ventilator Associated Pneumonia (VAP). Preventing 744 cases over three years -- at a treatment cost of about $20,000 per case -- translates into a societal savings of $14.9 million during this period.

The rate of central line infections also dropped from 4.14 to 0.52 cases per 1000 patient days between FY2003 and FY2009, a reduction of 83%.

This probably reflects lost revenue for the hospital under the fee-for-service reimbursement system. So why do we do it? First, because it is the right thing to do and saves lives.

Hundreds of lives.

On the business front, it has contributed to a reduction in length of stay in our ICUs. We were able to avoid the multi-million dollar capital cost of expanding our ICU capacity. Indeed, we were able to create capacity out of the existing facilities and improve throughput.

I hope that those who argue that global payments (i.e., capitation) are a necessary condition to create societal cost savings and improve patient care will read this. I do not deny that such a payment methodology may be worth implementing for other reasons, but there is a lot that can and should be done under the current payment system.

While the state debate goes on about cost control, why can't we get all of the hospitals in Boston to release information like this about their quality improvement efforts to provide the public and public officials with a sense of confidence that we care about these matters and are willing to be held accountable.

When a great big zero is A+

On several occasions, I presented data here on this blog about the efforts of BIDMC to eliminate central line infections. You can now view those data on our hospital website.

Our community hospital, BID~Needham, operates under its own license and has a staff and Board highly committed to quality and safety improvements. It also chose to engage in a program to eliminate central line infections. The Needham effort had several components:

-- Develope guidelines for the prevention of blood stream infections;
-- Work with procurement to create a standardized supply kit;
-- Use a standardized protocol for maximum sterile barrier precautions;
-- Use Chlorhexidine-based antiseptic for skin preparation;
-- Use a standardized protocol for catheter hub and port disinfection; and
-- Educate both health care worker and patients.

Well, the results for this small hospital are pretty spectacular and are presented above. They have demonstrated that a sustained rate of zero is possible. I say that this is one case where zero warrants a grade of A+!

Cooley-Dickinson vanquishes VAP

About a year ago, I wrote about the great progress made by Cooley-Dickinson Hospital in Northhampton, MA with regard to eliminating ventilator associated pneumonia. I now hear from Daniel J. Barrieau, RRT, CPFT, Director of Respiratory Care Service, that "we are now counting our time between incidences of Ventilator Associated Pneumonia in YEARS instead of days. This week we passed the 2 year mark and took a moment to celebrate the milestone. Here is a pic of the cake. . ."

Congratulations!

Caller-Outer of the Month Award #9

Our Board of Directors awarded this month's caller-outer award to Tinea Simpson, Practice Representative in our GI department.

GI staffers on Tinea's floors are practicing a “Leaner” way to conduct their day to day business thanks to her call-out, and the resulting reorganization that came from her work with Resource Nurses Mary Ellen Johnson and Christine Hunt.

As you may know, there is a patient packet for every procedure that happens in a hospital. For the past several years BIDMC volunteers have assembled these packets covering the entire demand of our GI unit – over 100 procedures a day.

As medical practices are revised and forms become obsolete or go unused, the end result can be a tremendous waste of paper and money. These three women evaluated the situation, decided what forms were necessary and what were not, and with the help of Volunteer Services, took action to correct the packets and reduce the use of hundreds of forms.

They created a path of action to include creating new sample packets for volunteers to follow and purging forms that were no longer warranted. Congratulations to Tinea for demonstrating the concept that each person should feel encouraged and empowered to recognize and go about seeking solutions to inefficiency and waste that he or she sees in the workplace.