Montgomery County Councilmember Marc Elrich is running for County Executive with public financing and plans to take on developers. Kim R. Ford is challenging fourteen-term Congresswoman Eleanor Holmes Norton for her seat. We talk to both of them about their campaigns and look at the biggest political news of the week.
Patients can comparison-shop when considering doctors, but doing so with hospitals is much more complicated, as there are no common standards or reporting requirements for publishing data on medical errors and facility-borne infections. Now, that may be changing and Maryland may be leading the way. We explore efforts to develop quality and performance measures for hospitals and health care facilities locally and nationwide.
- Brad Winters, MD/PhD Anesthesiologist and Assistant Professor of Anesthesiology & Critical Care Medicine, Neurology and Surgery at Johns Hopkins School of Medicine
- Lisa McGiffert Senior Policy Analyst on Health Issues at Consumers Union; Project Director, www.StopHospitalInfections.org
- Janet Corrigan President and CEO of the National Quality Forum
MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. In the debate about healthcare, we often hear that America has the best healthcare system in the world. And indeed, we've got some of the most advanced medical equipment anywhere and many of the best medical minds in the world choose to practice here.
MR. KOJO NNAMDIBut what does that say about your local hospital? While law schools and colleges are routinely ranked, rating hospitals and doctors can be more difficult. It's not that there are not objective ways to evaluate hospital performance. You can measure things like re-admission, mortality and complication rates and the number of hospital-acquired infections. But in many cases, hospitals are not required to report this information or make it public. That may be changing.
MR. KOJO NNAMDIA number of non-profit private and government organizations are working to develop standard performance measures for healthcare and to make sure that all facilities collect and report the same information. Here in our studio to discuss that is Janet Corrigan, president and CEO of the National Quality Forum. Janet Corrigan, thank you for joining us.
MS. JANET CORRIGANThank you.
NNAMDIAlso with us is Brad Winters. He is an anesthesiologist and professor of Anesthesiology and Critical Care Medicine, Neurology and Surgery at Johns Hopkins School of Medicine. Brad Winters, thank you for joining us.
DR. BRAD WINTERSThank you.
NNAMDIAnd joining us from a studio in Austin, Texas, is Lisa McGiffert, senior policy analyst on health issues at Consumers Union. She is the project director of StopHospitalInfections.org. Lisa McGiffert, thank you for joining us.
MS. LISA MCGIFFERTThanks for having me.
NNAMDIJanet, what are we talking about when we talk about hospital quality?
CORRIGANWell, hospital quality is -- it's variable. We have some exemplary organizations that provide very high quality care in particular areas, but we also see that there's a tremendous variability both across communities as well as within any given community.
NNAMDIYour organization is working to set standards and performance measures. What are some of the standards that hospital performance is measured by now?
CORRIGANWell, the National Quality Forum is a not-for-profit standard-setting organization that endorses performance measures as well as what we call serious reportable events. So there are many performance measures. For example, there are measures of hospital outcomes. There are death rates for pneumonia, heart failure, heart attack, 30-day re-admissions. There's also what we call process measures, whether or not a patient received appropriate antibiotics prior to surgery, which is a very good for preventing infections that might occur.
CORRIGANSo we endorse the performance measures. We also identify these serious reportable events which are things that are largely or entirely preventable. So for example, wrong-side surgery or patients who have serious bed sores or pressure ulcers as they are called which develop during a hospital stay. And they are important metrics. They are used by the federal government, by state governments, by private purchasers and others to be able to monitor quality as well as within healthcare institutions to improve.
NNAMDIWe'd love to have you join this conversation. You can call us at 800-433-8850. What matters most to you in terms of quality in a hospital? 800-433-8850 or go to our website, kojoshow.org, and ask a question or make a comment there. Brad, it's important to have objective data if you want to compare hospitals. What information can you give in addition to some of the things that Janet has already told us? What information can give you an idea of a hospital's performance?
WINTERSWell, as Janet pointed out, we like to have as accurate and as high-quality data as possible because if you don't have that, you're going to be making comparisons that are potentially erroneous. One of the areas that we're particularly interested in at the Johns Hopkins Quality and Safety Research Group is the prevention of hospital-acquired infections which create a tremendous amount of harm in patients.
WINTERSThe problem is getting the lay public to be able to get their hands on this kind of information for making decisions about which hospitals they would prefer to have their elective procedures or elective surgeries performed at, are not particularly accessible. And that is beginning to change because people are beginning to demand it. But at the same time, it's not easy to access that kind of information. Of course, unfortunately, when people have to go to the hospital for emergent care, you really don't get a lot of choice in that regard, unfortunately.
NNAMDIHow important are things like re-admission rates, how many people end up back in the hospital after a procedure?
WINTERSRe-admission rates are important, but you also have to look at the underlying reasons why those re-admissions occur. If the re-admissions are occurring because of process problems, i.e. when a patient is discharged, they aren't necessarily discharged with a proper medication reconciliation. That is they haven't had their medications that they're supposed to be taking at home thoroughly checked out, such that they may be missing some medications or they may have an interaction between the medication they should have stopped and one that's been added on to their regimen. Those are problems and those are, unfortunately, re-admission reasons that could have been avoided.
WINTERSOccasionally, though, re-admissions are because of new processes or new problems that can occur in a patient either related to or in addition to their underlying diseases. Some of those are not preventable, but many of them are.
NNAMDIHow about complications from procedures while in the hospital?
WINTERSWell, there are all kinds of different complications that can occur from procedures in the hospital. One of them that gets tracked quite closely are things like iatrogenic pneumothorax. What that is, is when a needle is placed into part of the body, it causes one of the lungs to drop. That gets tracked pretty closely. But some of the other more, shall we say, the ones that have the greater impact or harm, include, again, the hospital-acquired infections. Those do need to be tracked and they need to be tracked accurately. The problem is we don't always have good measures for keeping track of those and reporting them. And that's an area that we feel very strongly that we need to develop good tracking and good reliability measures so people can have that information.
NNAMDILisa McGiffert, in terms of what happens now, can you tell us what kinds of statistics and outcomes are reported now and what's made public?
MCGIFFERTSure. And I think I want to talk a little bit about these hospital-acquired infections.
CORRIGANIn the context of what's been said, it is something that happens too often in the hospital. Almost 2 million people get infections while they're hospitalized every year and nearly 100,000 of those people die from those infections. Most of those are preventable and we think people have a right to know, should know about the safety of their hospital and that they, the public, really does understand this concept of preventing hospital infections and they see the hospital infection rate as a measure of the hospital's safety so...
NNAMDIYes, last year in June we had a specific conversation with Brad Winters about that topic, hospital-acquired infections. But please go ahead, Lisa McGiffert.
CORRIGANYes and I noticed that, you know, one of the things that we've done in our campaign is to make sure people understand what we're talking about and I know Dr. Winters referred to iatrogenic, which means hospital-acquired or healthcare-acquired or caused by healthcare and so we've felt that it's very important to speak about it in plain terms. Right now, we have public reporting of hospital infection rates in -- required in 27 states and we've worked all over the country to try to get these mandatory laws into place so that people will be informed, but also so that hospitals will be more informed and will have systems in place to measure them.
MCGIFFERTPart of the process is, as has been mentioned, to create standardized measures so that when the information comes out to the public, we can compare hospitals in a fair way.
NNAMDIWhat happens right now? Do all hospitals collect and report the same data?
MCGIFFERTWell, it's different from state to state because each state is independent. But for example, in your area, their laws have been passed in Washington, D.C., in Maryland and Virginia, each of them is slightly different, but actually most of the states are collecting a certain kind of infection that has been a focus by many hospitals for years. These are infections that occur in intensive care units and are associated with a central line into the body. And this is a preventable infection for the most part and almost all the states have started by measuring that, plus the surgical infections.
MCGIFFERTAnd starting this year, January 1st of this year, the federal government is requiring virtually every hospital in the country to report these types of infections that occurred from January 1st on, the central line associated bloodstream infections. So we are emerging to a national system which is standardized as you asked.
NNAMDIBrad Winters, Lisa McGiffert just talked about Maryland. State regulators in Maryland started an interesting program in 2009. They're penalizing hospitals with higher than average complication rates. Tell us about that.
WINTERSWell, what they're doing is they're tracking the complication rates that are occurring. There are several different ones and basically what's coming about in the state of Maryland is also probably going to be coming about in other states. What happens is there's additional costs associated with these complications. Patients wind up staying in the hospital longer. And up to now, the system that we've had has sort of rewarded that because if you wound up getting treated for a complication, the hospital would bill for that and they would get paid for the additional care involved.
WINTERSWhat's happening now is it's beginning to reverse in the other direction where when you have these preventable complications occurring, is that you will not get paid for the extra costs and the extra length of stay that the patients had in the hospital. And this is being viewed as a way to create a carrot/stick to try to get hospitals to work on reducing these preventable complications. So not only will you not get paid for them, but you potentially will actually lose money on them.
NNAMDIHospitals are compared to other hospitals in Maryland, but not the national averages?
WINTERSI'm sorry, again?
NNAMDIHospitals are compared to other hospitals in Maryland. They're not compared to national averages?
WINTERSNot right now and that is beginning to change. As Lisa pointed out, the new requirements are for these hospital-acquired infections, particularly the central line ones. And then, the surgical site infections up 'til now it's been up to each individual state legislature to decide whether to report that, to collect and report that data to the CDC. Now, virtually every hospital in the country is going to be required to start doing that so we're beginning to move to that national comparative standard.
NNAMDIBut Maryland is unusual in that it's the only state where regulators set hospital rates and all insurers agree to pay those rates. Does that make Maryland a unique location, a unique place to experiment with performance measures?
WINTERSPotentially because they do have this overarching umbrella rule about how the hospitals will get paid, whereas in other states, you have a variety of different scales. It's harder to organize that sort of structure.
NNAMDIJanet Corrigan, how unusual is Maryland's program?
CORRIGANWell, I think Maryland should be commended for its program. But as Lisa indicated, there have been quite a few states, at least a dozen or more, that have really provided a great deal of leadership in this area in terms of reporting. I also think we should acknowledge, too, that the federal government did start a system of not paying for certain costs associated with healthcare-acquired conditions as they're called back in 2008.
CORRIGANSo for example, if a hospital provides the wrong blood type to a patient or for certain types of infections as well as severe pressure ulcers, under Medicare, the hospital does not get paid for the additional costs associated with treating that complication of treatment. So this is a national trend and I think we can expect to see a good deal more of that as we move forward. And, indeed, to the health care legislation that was just passed has important provisions that will also reduce hospital payments if a hospital has unusually high rates of hospital readmissions.
CORRIGANAnd that starts in 2012. There are also provisions that will reduce payments to hospitals that have sizable numbers of health care required conditions starting in 2015. These are important because these health care required conditions, and infections being one of them, they have a tremendous toll on patients in terms of number who die as well as those that experience harm, but they're very expensive.
CORRIGANAnd, indeed, it's projected that Medicare will save about $8.2 billion from these incentive reductions and payments associated with hospital re-admissions that are too high or unnecessary and an additional three billion or so over 10 years through reduced payments for health care required conditions.
WINTERSJust to give a perspective, for a single condition, specifically the central line associate bloodstream infection, the additional cost per infection is estimated to be as much as $53,000.
WINTERSPer infection, with an additional eight days of hospital stay required for the patient because of that. And that doesn't even include the number of people who die from them.
NNAMDIAnd on that very sobering note, we have to take a short break. If you have already called, stay on the line, I know Mubarak wants to talk about Maryland. We'll get back to you right after this break, Mubarak. We still have lines open, you can call 800-433-8850 or go to our website kojoshow.org. You can send us an e-mail to firstname.lastname@example.org. How do you evaluate a hospital before you visit? What matters most to you in terms of quality in a hostile? Send us a tweet at kojoshow. I'm Kojo Nnamdi.
NNAMDIWelcome back to our conversation about hospital standards. We're talking with Lisa McGiffert, senior policy analyst on health issues at Consumers Union. She is the project director of StopHospitalInfections.org. She joins us from a studio in Austin, Texas. Brad Winters is an anesthesiologist and professor of anesthesiology and critical care medicine, neurology and surgery at Johns Hopkins School of Medicine. And Janet Corrigan is President and CEO of the National Quality Forum.
NNAMDIAllow me to go to Mubarak who is not calling about Maryland who just happens to be an MD. Mubarak, you're on the air. Go ahead, please.
MUBARAKKojo, I think, there is two sides to the story on the hospitals. Remember that what Medicare is doing now, is slowly going toward, as are the other guests said that, Carrington State Policy whether the patients stay longer or if they have complications in the hospital, hospitals don't get reimbursed for that. So in return, though the hospital is improving and reducing complication rates, reducing infections, but they're also trying to discharge patients faster.
MUBARAKSo what we in medicine call, reducing the length of stay and so it may tip the scale the other way where just to save money and we may discharge patients prematurely. So that's a risk we also run and since those patients -- most of the patients who are discharged prematurely may not be Medicare. So if you're a younger patient admitted to the hospital, let's say for chest pain, you may be discharged much more prematurely nowadays than it would be about four or five years ago.
NNAMDIBrad Winters, care to comment on that?
WINTERSWell, certainly, there's a lot of interest in reducing the length of stay. And we know, many years ago, people were admitted for hospital stays that were probably unnecessary based on their medical conditions. But Mubarak has a very good point, is that you have to be careful that you don't have unintended consequences, where in the drive to keep costs down, that you don't prematurely discharge people. That's very likely to have an impact on that re-admission rate.
WINTERSIf people are getting pushed out of the hospital too early, you're more likely to wind up increasing your re-admission rate, which, of course, then becomes a quality measure that will look bad for you. And it's tough to find the balance between the two to make sure that, that doesn't happen.
NNAMDIThank you very much for you call, Mubarak. We move onto Ruth in Rockville, Md. Ruth, you're on the air. Go ahead, please.
RUTHHi, there. Actually my -- I have two questions, the first of which had to do with unintended consequences. I have children in Maryland right now who have been going through state testing to see how data can be used to measure progress toward standards and public education. And while the drive for more data is important and necessary, at the school level, it can almost have a adverse impact on the quality of education.
RUTHIt seems to me that, that has to be something you really consider in the drive for standards in health care. And I'm really not sure what the mechanism is to be able to adjust for these unintended consequences, but they are many. And so I had wanted to address that point that Mubarak raised. The other is really a question that has to do with the central point of patient care. You know, I measure the quality in terms of the people who are there in the hospital room everyday with the bed pans, with the needles, with the respiratory therapy.
RUTHAnd those are also the people who may have different levels of certification or different cultural experiences and they have the most direct time and impact with the patients. And despite the greatest technology and medicines and the most highly advanced doctors, those are the experiences you only encounter in a hospital very briefly. And it's the patient care technicians that seem to have so much to do with quality and comfort and duration of life.
MCGIFFERTCan I comment on that?
NNAMDIYes, please, Lisa McGiffert.
MCGIFFERTThanks. I think she's brought up some interesting points. And one of the things is that, you know, people are being seriously harmed by these infections that are preventable. When we got started, about -- a little bit over seven years ago, pretty much, there was sort of a complacency that we saw in hospitals. They believe that there wasn't really much they could do about these. But now we know that there's a lot that they can do about infections to prevent them.
MCGIFFERTAnd the whole process of reporting and increasing awareness publicly has increased awareness within the hospital systems. And many single hospital systems have become leaders and shown that they can reduce infections to zero. So it's a pretty important point to increase awareness through public reporting. The other thing, I think, that she raised is that everyone in the hospital has to be involved from top to bottom.
MCGIFFERTEveryone in every aspect of the hospital. And what I've seen is that, many hospitals approach these problems in a siloed effect. Like, one ICU takes it on or one division, one floor and we really need a comprehensive approach where everyone is engaged in preventing infections and other harm.
NNAMDIJanet Corrigan, I was fascinated about what Ruth, our caller, was saying about patient care technicians and how they contribute to the quality of care in the hospital. How do you measure that?
CORRIGANWell, it's very, very important to not only measure the outcomes of care, to measure the process of care but also the patient experience of care. There are some very good surveys right now. And one of them called HCAHPS, which has been implemented in hospitals across the country. They query patients about their experience while in the hospital, whether or not there was good communication between the patient and the nurse or the nurse's aide. And whether or not they felt they were listened to.
CORRIGANWhether or not the conditions in the room were clean and the food was appropriate. So there's very important surveys and that is a critical perspective on the quality of care.
WINTERSRuth also brought up a point that I'd like to touch on. She mentioned the issue of culture, the culture of the aides helping out, the culture in the institution. Creating a culture of safety is really what it's all about in terms of changing these adverse events around. As Lisa pointed out, a lot of this gets done in silo's. It gets done in a hierarchal fashion from top down. Instead of frontline staff having ownership and changing the local culture such that safety is number one and that these adverse events are viewed as preventable and untenable.
NNAMDIRuth, thank you very much for your call. We move onto Carol in Bethesda, Md. Carol, your turn.
CAROLHello, I have an idea here which relates to, in one way or another, to all the points that you've been making. And that is a initiative taken recently in the state of Pennsylvania. Then Governor Rendell, we were all concerned with the high costs of health care in all of its facets. He decided on a way to approach that issue in his state and he issued a directive to all the health care workers in his state, that each of them should wash his or her hands after every contact with a patient.
CAROLNow, this is supposed to be standard practice anyway but as we know, it isn't widely observed. There's no -- this was voluntary. There was no reporting, there was no enforcement or anything of that sort. After about a year -- and this -- the whole object, I should say, was to reduce the number of readmissions because of hospital incurred infections. So after a year of this, they in Pennsylvania had reduced their state wide health care very dramatically.
CAROLAnd seems to me that if this simple directive were issued nationwide and applied widely throughout the United States, we would reduce the cost of our health care very seriously. The beauty -- further beauty of it, is that it is -- doesn't cost anything to issue the directive. There's no follow-up, no reporting, no enforcement and so forth.
CAROLBut even without that, it is effective.
NNAMDILisa McGiffert, simple measures not taken?
MCGIFFERTHand hygiene is very important and most studies have shown over the years that about half the time health care workers and doctors do not clean their hands. So that is a very basic thing that has to happen. But I really want to make the point in Pennsylvania because it is quite a model for the rest of the nation. They did this hand hygiene directive but they also were doing many, many other things.
MCGIFFERTThey were one of the first states to do public reporting and they do it hospital wide. They report virtually all infections and give that information to the public. But they also had very supportive leadership in government, very supportive leaders in major health care systems that got out there and did much more than just hand hygiene. It was a comprehensive approach.
MCGIFFERTIt was supported from all levels and there were resources behind it and, you know, they did a lot of issues like screening incoming patients for MRSA, which is a virulent antibiotic resistant bug that causes infections in the hospital and identifying those patients that would be at more danger themselves or pose a danger to others if the bug is carried to other patients. So they did -- that's just one of the many things that they did in that state and I think it's a very good example...
NNAMDIIn case you're just joining us...
MCGIFFERT...of (word?) of approach.
NNAMDIIn case you're just joining us, we're discussing hospital standards. Lisa McGiffert, who you just heard, is the senior policy analyst on health issues at Consumers Union. She's project director of StopHospitalInfections.org. Brad Winters is an anesthesiologist and a professor of anesthesiology and critical care medicine, neurology and surgery at Johns Hopkins School of Medicine. And Janet Corrigan is President and CEO of the National Quality Forum.
NNAMDIJanet, your organization is working with a number of organizations and the government to set priorities for health care nationally. Tell us about the National Priorities Partnership?
CORRIGANWell, the National Priorities Partnership was established three years ago. It includes 42 major national organizations, both public and private sector. There are organizations that represent consumers like AARP and Consumers Union. There are organizations that represent major purchasers as well as hospitals, physicians, nurses and others. They came together a few years ago because we wanted to identify high leverage areas where improvement would translate into very significant gains. In terms of better patient outcomes.
CORRIGANAs well as ridding the system of waste. We waste a lot of health care resources. So it's about improving quality and safety and identifying some very high priority areas. The...
NNAMDIYou identified six priority areas.
CORRIGAN...we identified six priority areas and one of those is safety. And there the emphasis is on hospital readmissions, reducing hospital readmissions as well as a limited number of, what we call, serious reportable events. Such as wrong side surgery or pressure ulcers or things that simply should not occur in health care settings. And the National Priorities Partnership is important because in order to tackle this problem, we really do need many different stake holders to come together.
CORRIGANIt's not often times recognized that -- it was about two decades ago when we had some landmark studies released that really identified safety as a very, very critical national priority with large numbers of patients being injured everyday in institutions. And it took a long time to get some action focused on this issue. So it is critical to have all of these different stake holders together focusing on a limited number of high priorities. We can't improve on all things at once. We need to strategically identify those areas.
WINTERSIt really took...
WINTERS...the, "To error is human," paper that came out about a decade ago now to really energize this movement, as Ms. Corrigan said. Almost 20 years ago we started knowing it was a problem. It really didn't come to the forefront 'til about 10 years ago with that seminal paper.
NNAMDIHere is Kim in Fairfax, Va. Kim, you're on the air. Go ahead, please.
KIMHi, thanks for taking my call. I'm well aware of the initiatives that are being talked about because I work currently as a nurse at a hospital in (word?), Va. And I'm happy about them because I do feel like it's making a difference for patient care and if I happen to be a patient, I'm hoping that it'll make my care better in the future. My question for the panel, however, is, I feel like there's a disconnect between what my patients expectations are for care and what we're actually providing.
KIMAnd if I may just briefly explain that, to say that my patients think that by caring for them, I'm going to make them comfortable, when really, I have to make them uncomfortable a lot of the time to care for them. I have to force them to, say, turn every two hours to make sure their skin stays intact, take deep breaths and cough even though it's uncomfortable to prevent pneumonia, get out of bed, etcetera.
KIMAnd they also see caring as being able to stay in the hospital and have other people care for them even when Medicare says, they no longer meet the criterion. I'm just wondering what's being done to educate the public about how health care is changing in that sense? We're no longer having these long extended periods in the hospital. And so caring, I think, has actually changed. And I don't think the public understands that.
NNAMDIBrad Winters and then Lisa McGiffert.
WINTERSI would agree with that. I think we've done a very poor job of educating the public about why these changes have come about. I think, people unfortunately get the feeling that, you know, they're being pushed out of the hospital too early and that the system doesn't care about them and, you know, why can't they stay a few more days with the help and the support they need. Along the lines of that, we need to educate them that, not only is it not necessary for them to stay in the hospital sometimes for these extended periods of time but the longer you stay in a hospital, the more you're exposed to the risk for having one of these adverse events or one of these infections happening. But I agree, we have not done a very good job of explaining it to people and people just sort of feel like they're being pushed out the door too fast.
MCGIFFERTI agree with what was just said. And I think one of the key elements is to have continuity of care after somebody leaves the hospital. We have pretty poor systems of follow through when somebody leaves a hospital after, say, a serious operation. Sometimes they never hear from anyone from the hospital again, or any, you know, continuity of contact. And so I think that is something that's lacking in our system, and certainly a lot of people are addressing that.
MCGIFFERTThe other thing I think that needs to happen is -- and we've seen this actually with patients asking these questions, but also nurses who have been told, okay, you have to raise the head of the bed of a ventilator patient to prevent ventilator-associated pneumonia. They question why do I have to do that? Why are you doing this kind of thing? And we have to have a little bit more conversation while it's happening to explain to people what can happen to them if they aren't moved every so often.
MCGIFFERTMaybe show them some pictures of some really bad bed sores that could happen if they didn't move around, would go a long way to letting them know why it's happening.
NNAMDIJanet Corrigan, because the perception persists that if I'm going into the hospital, I'm going to be getting a great deal of rest, I can't tell you how many people who have been hospitalized have complained to me, I never get any rest. They're turning me every 10 minutes. They're getting me up to give me a shot every 15 minutes. I never got any rest at all. It's not about rest, is it?
CORRIGANNo, it's not. And -- but we have to bring patients into the care team. They're an integral part of the care team. They have to be a part of the dialogue. And if we think we have trouble in the hospital environment, when patients leave the hospital, the errors that occur in hospital institutions are only the tip of the iceberg. We've just started to look at errors outside of hospitals. Patients and their family caregivers deliver the bulk of healthcare services once they leave the hospital.
CORRIGANIt's not a professional healthcare provider. If they don't understand the medications that they are on, the potential interactions and problems, if they don't understand their care plan, that's one of the reasons that we have so many people coming back to the hospital or to the emergency department within a short time after they've been discharged.
NNAMDIGotta take a short break. When we come back if you've called, stay on the line. We'll try our best to get to your call. We're discussing hospital standards. If the lines are busy, go to our website, kojoshow.org, or send us a tweet @kojoshow. E-mail can go to email@example.com. I'm Kojo Nnamdi.
NNAMDIOur conversation on hospital standards and what's being done to make them national in scope, is joined by Janet Corrigan, president and CEO of the National Quality Forum, Brad Winters, an anesthesiologist and a professor of anesthesiology and critical care medicine, neurology, and surgery at Johns Hopkins Medical School and Lisa McGiffert, senior policy analyst on health issues at Consumers Union, and project director of StopHospitalInfections.org.
NNAMDILisa, there are ways for patients to get information if a patient wants to compare hospitals on measures like hospital-acquired infections or complications rates. Could you tell us a little bit about what resources there are available?
MCGIFFERTThe resources are growing. I think we still are not at a place where people can see a comprehensive view of their hospital's safety, but rather snapshots of safety environments within the hospital. In both Maryland and Virginia, people can look at reports that are hospital specific on the central line associated bloodstream infections, and the rates of those infections. Hopefully soon in D.C. that will be available.
MCGIFFERTAnd also, later this year or maybe early next year, we'll be able to see even more systems in the national hospital compare. But there are also things that I think consumers need to have at their fingertips, and that is whenever a hospital has been sanctioned because they've got an unsafe environment, that information should be readily available to the public, and it's pretty darn hard to find it.
MCGIFFERTComplaints from consumers are a really good window into what's going on in the hospital, and I think people should have -- be able to see those complaints, and there should be some way for the licensing agencies to give that information out to the public so that they can see where there have been problems. And I think finally, the one thing that is lacking in our reporting systems, is that it takes too long to get to us, the public.
MCGIFFERTOften the information is a year old. So hopefully, as times goes on, maybe more electronic medical records will enable us to have the information in a more timely manner so we can really see what progress a hospital is making or is not making. But there -- there's beginning to be information out there. I'd like to talk about some of the public reporting, because sometimes people think, oh, well, what am I seeing here? Why I don't have a choice, for example.
MCGIFFERTI may not have a choice of which hospital to go to. But in some cases you do. Take something simple like choosing a hospital when you're giving birth, and you might want to look at things like their cesarean section rates. And it would certainly be really important to be able to see the rate of infections with C-sections, because this might change the system a little bit. It is an invasive procedure, and it might create a little bit more danger for people going in having surgery when they're delivering a baby. So that's just...
NNAMDILisa McGiffert mentioned Hospital Compare. You can go to our website, kojoshow.org, you'll find links to Hospital Compare, WhyNottheBest.org, HealthGrades.com, as just a few of the places you can look to for information. Brad Winters, and if you just go online to look at hospitals for doctors, you're very likely to find ratings based on patient surveys. How helpful is that?
WINTERSYeah. It's become very common. You probably heard it advertised, for example, on services like Angie's List. They now have doctors as well as plumbers. And the problem with those is they can be one of two sort of categories. People can complain because they were unhappy with their experience, or people can be, you know, effusive about how great their doctor was. But rarely do those particular pieces of information actually contain any real data to help you make an objective decision about whether this doctor or hospital or clinic is offering high-quality care because it's just not rigorous enough.
WINTERSAnother area that people get a lot of their information from, to be quite honest, is the U.S. News and World Report issue that comes out every summer, along with their other issues that rank colleges and engineering schools and all that sort of stuff. They rank the best hospitals. And only two years ago did they actually start including patient safety as part of the calculation, and yet it only counts as about five percent of their quality measure of those hospitals.
WINTERSAnd I think, as Lisa will also underscore, is when you actually look at the methodology about how they calculate that patient's safety, the biggest threat to patients that are -- that is the hospital-acquired infections, make up a minute part of that calculation. So the problem is, people aren't getting the information they really need. They're not getting these measures either through things like Angie's list, or even through fairly venerable venues like U.S. News and World Report that really tell them about how safe it is to go to a hospital.
WINTERSHow likely are you -- are you likely to wind up with a C-section if you go there for labor and delivery? How likely are you to wind up with a central line infection if you wind up in the ICU with a central line? It's very hard for consumers to tease this out through Internet resources, and I think that's an area we really need to do a much better job is providing central repositories in a clear and easy-to-understand structure that people can look at and understand. It gets very much into the gobbeldy-gook of a lot of science sometimes.
CORRIGANYeah. I think we also, though, need to put this in a broader perspective because if you go back about ten years, there was almost no information at all available. Now, we do have a major federal initiative, the -- it's called Health Care Compare, which has Hospital Compare, Nursing Home Compare, Home Health Compare, and soon they'll have Physician Compare, all websites.
CORRIGANAnd each year, the information becomes more informative. The measures get better and they better reflect the full gamut of care. We also now have the majority of states that are doing some activity in this area. You can also find -- there's a website maintained by the Informed Patient Institute, which is a small non-profit organization located in Annapolis. And they have catalogued many of the websites that provide information on quality and safety across the country. And there's well over 100 of them.
CORRIGANSo we have a flowering of these reporting systems at the community level, the state level, and that national level. So I just think it's important to recognize we're in a very different place now than we were a decade ago. It has changed.
WINTERSWe're leaps and bounds ahead of where we used to be, but we still have a way to go.
NNAMDIHere is Mark in Vienna, Va. Mark, you're on the air. Go ahead, please.
MARKThanks, Kojo. I'm enjoying the discussion. I have a simple question. I recently learned that many hospitals are for-profit or investor-owned hospitals, and I wondered if your guests could comment whether their quality levels are the same as the not for profits.
MARKAnd I'll take off...
NNAMDILisa McGiffert, can you comment on that?
MCGIFFERTI personally have not analyzed the for-profit versus non-profit. I think that when we look at institutions like teaching hospitals that are big, big trauma centers, that there are issues about being sure that they have the resources to be as safe as the fanciest for-profit hospital. We think that people who go to each of those facilities has a right to believe that they're going to be safe, and that those facilities should work towards that.
MCGIFFERTBut I, you know, mainly, I think it's one of the issues, unfortunately, that has risen is that money speaks louder than harm to patients. You know, just having a bunch of people harmed wasn't enough to motivate many hospitals. But once the money that they're paid starts being connected to what they deliver, what kind of outcomes, for example, do they -- if they have high infection rates, they're gonna get paid less in Maryland right now, but also across the country in a few years.
MCGIFFERTThat is what's gonna make a difference more than whether a hospital of for-profit or non-profit, I think.
NNAMDIIndeed, Janet Corrigan, things are changing. New federal regulations require hospitals to publically report certain hospital-acquired infections. That's something your organization has been working for in several states.
CORRIGANWell, it -- we've been working really nationwide to encourage much more reporting of healthcare-acquired conditions, infections in particular, as well as other aspects of quality and safety. This has been a huge cultural change within healthcare to accept this notion of transparency as well as accountability. What we're seeing is across the healthcare industry, clinicians and hospitals and others recognizing that it's important to be transparent. You can't improve unless you measure. It's the first step to making things better.
CORRIGANAnd second, that providing that information to patients, if something goes wrong, they should be the first to know. And they have a right to know. That's a critical part of the doctor-patient relationship, a trusted relationship, is to make information available on how safe care is.
NNAMDIWe got an e-mail from Theta, Brad Winters. "What important questions regarding quality and safety in their hospital should I ask my surgeon at my office visit prior to surgery?"
WINTERSExcellent question. Just some of the nuts and bolts one, what are the infection rates in your hospital for surgical sites? You know, how likely am I for this particular kind of surgery I'm going to have, likely to get a surgical site infection?
NNAMDIWould all doctors have that information?
WINTERSThey should. Their hospital knows it. Their hospital should know it.
WINTERSWhether the particular surgeon knows their hospitals data, you know, that depends on the individual surgeon. But the hospital collects that data, and they should know what the rate is for surgical site infections for that particular surgery. Surgical site infections will vary a little bit depending on the kind of surgery.
WINTERSThe other things they should also ask are about things like team culture in their operating rooms, doing things like time outs to ensure that the right equipment is there, that the right side is being operated on, that it's the right patient, that the right type of blood is available should the patient need a transfusion during the surgery. They should ask not only about some of those nuts and bolts measures of rates of things, but also does the culture in the operating room support a safe and high quality environment.
WINTERSBecause we know from the literature, that having a high culture of safety translates to improvements in these other areas.
CORRIGANAnd they should ask questions once they're in the hospital. They should speak up. If a provider comes into your room and they do not wash their hands, the patient should feel empowered and speak up. Say, please wash your hands.
NNAMDIHere is Jack in Alexandra, Va. Jack, you're on the air. Go ahead, please.
JACKYes, Kojo. Interesting show. But the question I raise is with all these performance indicators and other subjects, where is the value of management systems? ISO 9,000 equivalents, or ISO 14,001 or (word?) 18,001, which many of the chemical and petroleum companies have instituted.
CORRIGANIt's a wonderful question. We've talked a little bit about how important it is to have a culture of safety, but the other critical thing for a hospital or nursing home, or other institution to be safe is to be well designed, and to have care processes that adhere to what are sometimes called (word?) or other techniques that carefully design that care process in ways that it makes it difficult for clinicians to make errors.
CORRIGANRight now, we have a health care system that is highly fragmented, poorly organized, and it's easy for nurses, doctors and others to make mistakes, and to make errors. We need to build into the system checks and balances, redundancies, use of checklists to make sure that everything happens before the surgery begins. Those are all important techniques that have been used in other industries for decades. But the healthcare sector has been very slow to learn from other...
NNAMDIWe're almost out of time, but we got an e-mail from George who cannot find information on quality of cancer care at local hospitals. Any suggestions for George, Dr. Winters?
WINTERSI would go to the Cancer Foundation and look on their website. Actually, I was just there the other day, but I'll be honest, I wasn't there looking at quality indicators so I couldn't tell him exactly where to find them. But perhaps Janet has some idea. I would go to the National Cancer Foundations.
NNAMDIThat's all the time we have. Good luck to you, George. Brad Winters is an anesthesiologist and a professor of anesthesiology and critical care medicine, neurology, and surgery at Johns Hopkins Medical School. Thank you very much for joining us.
NNAMDIJanet Corrigan is president and CEO of the National Quality Forum. Thank you for joining us.
NNAMDIAnd Lisa McGiffert is senior policy analyst on health issues at Consumers Union, and project director of StopHospitalInfections.org. Thank you for joining us.
NNAMDI"The Kojo Nnamdi Show" is produced by Brendan Sweeney, Tara Boyle, Michael Martinez and Ingalisa Schrobsdorff, with help from Kathy Goldgeier, Elizabeth Weinstein, and A.C. Valdez. Diane Vogel is the managing producer. Our engineer today, Andrew Chadwick. Dorie Anisman has been on the phones. Thank you all for listening. I'm Kojo Nnamdi.
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