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Samantha Collier, M.D., is the vice president of medical affairs at HealthGrades, Golden Colo. Collier is a board-certified internist and former assistant professor of medicine at OUHSC-Tulsa, Okla.
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With so much attention and effort being placed on patient safety, the industry is still seeing overall increases in patient safety incidents, according to a study by HealthGrades, Golden, Colo., a national health care ranking firm.
In the Third Annual Patient Safety in American Hospitals report, HealthGrades found that incidents grew from 1.18 million to 1.24 million between 2002 and 2004 among the 40 million hospitalizations covered under Medicare.
The study’s lead author, Samantha Collier, M.D., HealthGrades’ vice president of medical affairs, explains that although the numbers aren’t good as a whole, there are some positive signs in the report, which ranks the best and worst states, and also provides a list of the “Best-Performing Hospitals for Overall Patient Safety.” The study is based on 13 patient safety indicators developed by the Agency for Healthcare Research and Quality (AHRQ), Rockville, Md., and applied to the most recent MedPar file of Medicare admissions at almost 5,000 hospitals from 2002 through 2004. All the data was risk adjusted, so hospitals with sicker patient populations could be compared equally with others.
Q How is the data for the study compiled?
A HealthGrades looked at the performance of patient safety that is defined by the Agency for Healthcare Research and Quality (AHRQ) ... which has defined 20 patient safety measures such as developing post-op sepsis, respiratory failure, blood clots, etc. We used 13 of those indicators. Four of the original 20 were obstetrics measures, and we looked specifically at the Medicare, 65 and older population, so that’s why we didn’t use the OB indicators. The three remaining measures relied too heavily on, or were too affected by, variations in documentation and coding, so at the guidance of AHRQ we excluded those. So, basically we have 13 patient safety measures that came from the original AHRQ list that we use to assess hospitals.
Q With the number of initiatives available to help hospitals address patient safety, why did the number of incidents increase?
A The study was from 2002 to 2004, and although 2004 was five years after the Institute of Medicine (IOM, Washington, D.C.) released its report (To Err is Human, which highlighted 98,000 patient deaths annually due to medical errors), I think that patient safety is just now taking hold. Although outcomes have not yet changed, I see widespread adoption that shows patient safety is a top priority for administrators and clinicians, and there’s been a real shift in attitude. So, we’re at the point of acceptance, which now means we can change and implement processes. In the study, we identify some real leaders, some distinguished hospitals for patient safety. Minnesota is taking the lead on patient safety and doing a lot of extraordinary work at the state level. So, the good news is that things are changing—we just haven’t seen the results yet.
Q How did Minnesota fare on the report and what has it been doing to improve patient safety in the state?
A We identified the performance of every hospital across the country, then rolled up the hospital performance to the state level where we’re looking at every hospital in that respected state. In the survey, which ranked all 50 states and the District of Columbia, Minnesota ranked No. 1. Minnesota didn’t just squeak in, they were strongly No. 1. And after we dug in, why became obvious. They legislated not only mandatory reporting, but also public reporting on the National Quality Forum’s (Washington, D.C.) 27 adverse events. Most states have some form of mandatory reporting, but they tend to be on the more egregious types of things such as wrong-site surgery or a patient catching on fire. Minnesota was the first state to adopt all 27 of the National Quality Forum’s consensus measures on patient safety and also to report publicly those measures on every hospital.
Minnesota just released its second annual report on these 27 events for every hospital. I think that’s a big leap that other states are just starting to look at.
Q What else sticks out about Minnesota’s health system?
A Despite their major competitive differences, there is a lot of collaboration in the state. Hospitals have come to the table—including the CEOs—to identify things that have happened in the organizations that are not so good. In that forum, they explain what has been done to improve things, and the hospitals share those process improvements with their competitors, again, with the goal of improving patient safety for all patients in the state.
Q Has Minnesota come out on top of the survey in the previous years of the study?
A This is the third year that we studied patient safety in hospitals across America; but this is the first study in which we looked at it by state, so this is the baseline year.
Q In the area of postoperative sepsis, there’ve been several national campaigns aimed directly at this problem, but the number of incidents increased by nearly 25 percent, according to the study. Why?
A I think, again, it’s because this is a national rate. There are going to be hospitals where there are reductions in incidents, but at the same time there are hospitals that have gotten worse—below the 25 percent mark. At hospitals where things are worsening, they need to say, “What is the best practice out there, and are we doing that?” They need to look at everything from the basic stuff like sterile technique and address all the things that break the normal barriers for sepsis.
Q What were the areas that had overall improvements?
A One of the most impressive improvements was in “failure to rescue,” meaning, the inability to diagnose and treat a patient before a death occurs. For example, a total knee replacement patient gets admitted to a hospital, develops acute renal failure, which is really an unexpected complication, and dies from that. In the case of a patient who’s deteriorating, our first eyes are nurses. How a nurse communicates that deterioration is important, and so is how a physician works collaboratively with a nurse. What that translates to in the last couple of years is in the Institute of Healthcare Improvement’s (IHI, Cambridge, Mass.) 100,000 Lives Campaign, which has listed as one of the major components Rapid Response Teams to address this very issue. The campaign states, “Let’s decrease failure to rescue at the first signs of demise.” The problem has been that sometimes the nurse doesn’t feel comfortable that he or she could trigger this Rapid Response Team and essentially bypass the physician, who might be stuck in private practice in the office setting, or across town. We saw that decline by 13 percent.
Q What’s another category that showed improvement?
A Postoperative hemorrhage and hematoma, especially hematomas after angioplasty. That’s an important quality indicator the American College of Cardiology database has tracked, and there’s been a lot of effort around that. So, it’s good news that we’re seeing the rate decline by almost 9 percent.
Q Now, what about some of the areas that have gotten worse?
A Post-op sepsis, which we talked about. I think that the fact that it’s worsened by 25 percent can imply several things: that we’re not doing all that we can, No. 1; and No. 2, we need to learn from those who are doing well and adopt those practices quickly. Also, another area that worsened where I also saw some of the widest gaps between the top hospitals and the bottom hospitals was in post-op physiologic and metabolic derangements, which is basically a big component under post-op delirium.
We’re all so used to seeing patients get delirious in post-op that it’s almost the norm, but whenever you look at the literature, post-op delirium is associated with bad outcomes, especially with the Medicare population and a patient who already has some mild dementia, and we saw that rate worsen by 17 percent. There’s a lot of best practice information out there about how to prevent post-op delirium because it does affect mortality. It also can increase complications because patients might not be able to articulate other symptoms. It’s also associated with tremendously increased length-of-stay and costs.
Q Who is this report geared toward?
A All stakeholders, which includes hospitals, clinicians, employers, payers and patients or consumers, so it’s really for everybody. Traditionally, we haven’t had performance feedback on the provider side. We don’t know how we do, and of course, we always think we do better than we did. Consumers, payers and purchasers also need to know how the industry is doing as well as the government, so it’s really for all stakeholders.
Q What kind of feedback did you get from the reports?
A The first report came out three years ago, and there was quite a bit of negative feedback from providers. I think that the consumers and employers were thankful for the information because this has not been available previously. The second year there wasn’t as much negative feedback from providers, and that may have been due to the fact that there were so many patient safety initiatives coming out. This year, that type of feedback was really minimal. What we saw was the states that did not rank well did push back, and that’s to be expected.
Q Have you seen that doing well in relation to the patient safety indicators has an effect on worker satisfaction?
A I can’t determine that from our study, but you can say it in a reverse way. There’ve been a lot of studies that show nursing turnover—assuming nursing turnover is from dissatisfaction—definitely impacts quality and safety. If you don’t have nurses who know the system well, and you don’t have good critical thinkers in nursing, the failure-to-rescue rate goes up postoperatively. If you have a lot of turnover, if you don’t have an adequate RN ratio to patients, your failure-to-rescue rates go up.
Q After providers read this report, where would you suggest they go to find programs and help to improve in areas that are not performing well?
A Certainly they should go to the AHRQ Web site (www.ahrq.gov) to look at quality tools and patient safety tools. I think most states have some type of patient safety organization or alliance that is statewide, and they can probably contact their peer-review organization at the state level to identify some of those. They can also go to different national meetings and get on listservs of meetings where they’re talking about new, innovative things.
Last, look at the Institute of Healthcare Improvement site where they have tool kits, and consider, if they haven’t already signed up for the 100,000 Lives Campaign, signing up for a program that creates some accountability.
A copy of the HealthGrades report can be downloaded from www.healthgrades.com.
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