A safety record to be proud of

In terms of safety, would you rather spend a night in the hospital or on the redeye flight from Los Angeles to New York?

Choose the flight.

While hospitals continue to struggle with quality and safety issues, an industry-wide example of improvement is on display:

For the first time since the dawn of the jet age, two consecutive years have passed without a single airline passenger death in a U.S. carrier crash.

No passengers died in accidents in 2007 and 2008, a period in which commercial airliners carried 1.5 billion passengers on scheduled airline flights, according to a USA TODAY analysis of federal and industry data. (USA Today)

It’s obvious that the vast majority of airlines are awful-awful-awful when it comes to customer service (everyone has a story…; I’m a staunch advocate of not using the airline industry as an example of how to treat people, ever ever!).  But they do get safety (much of the awful customer service stems from focusing on safety, btw).  Surely mistakes are still made, but they’re also corrected before harm is caused.

The Institute for Healthcare Improvement tells us that nearly 100,000 patients die annually because of preventable medical errors.  Or as some have analogized it, the equivalent of killing everyone aboard one jumbo jet every day. 

The good news from the domestic airlines comes as a result of a concentrated safety effort according to Arnold Barnett from MIT (CNN), “The manufacturers of the air frame are making better equipment. The power plant people, the engine manufacturers are doing the same. The crews are better trained. It’s just an all-around effort.”

Improvement efforts and transparency initiatives have increased hospitals’ attention to these matters.  The IHI’s latest concentration is the Improvement Map—its most encompassing safety and quality effort to date.  A grand continuation of its improvement agenda.

We’ve still a long way to go.  The checklists now being instituted in operating rooms have been borrowed from the cockpit and as the most recent statistics show, there’s room to borrow even more.

The (dis)incentives of transparency

Paul Levy (CEO of Beth Israel Deaconess Medical Center in Boston and health care transparency champion and CEO blogger): “Shouldn’t there be some correlation between what you get paid for doing something and the quality of what you do?”

That quote from an intriguing exposé of sorts in The Boston Globe (a fair presentation of the situation in my opinion).  The bottom line: Partners Healthcare in Boston (generally) makes quite a bit more (around 30 percent) than other hospitals in the state (Massachusetts has lots of good hospitals, especially in Boston).  So the question is: why?  Here’s the secret: it’s less about quality and more about market control.  What’s more is that it is happening in nearly every corner of this country.

Okay, so the free market is the United States of America.  Economists have a list of conditions in order for markets to be “perfectly competitive;” they include: large numbers of anonymous buyers and sellers, easy mobility of resources, homogeneous goods, and perfect access to information.  Health care, more or less, fails on every condition.

It is very difficult to efficiently, effectively, and equitably distribute resources when a market fails.  What that translates to is that health care costs more than it needs to (for a multitude of reasons).  But the argument here is that more information would prevent such wide disparities in payment (especially when a requisite increase in quality is not the reason for a higher price).  If insurers knew what hospitals collected from other insurers; if hospitals knew what insurers paid other hospitals; if patients and payers could effectively compare quality; if hospitals could benchmark quality against other hospitals; a more efficient, effective, and equitable distribution of health care dollars would occur.

All of that above summed up in one word: transparency.  We need: complete financial and quality of care transparency.  Watch health care costs fall and quality improve as hospitals start competing on outcomes and cost effectiveness instead of on market share and perceived notoriety.

Ross Dawson at Trends in the Living Networks writes:

Secrecy has its place in business, but it is highly over-rated. In most cases there is no valid reason not to share information, just a disinclination to give away things. We are going to see transparent models increasingly favored moving forward.

A disinclication indeed.  Transparency is the future.  It’s how we’re going to improve our health care system.

Hospitals Should Compete on Quality

What would happen if hospitals competed on quality?

Competition is rare in health care. Really. Health care is full of rivalry. There’s a difference.

From the trusty Merriam-Webster OnLine: competitor: “one selling or buying goods or services in the same market as another;” rival: “one of two or more striving to reach or obtain something that only one can possess.”

I would suppose that rivalry is similar to what Porter calls zero-sum competition.

Competition is healthy and it should force prices down while improving the product delivered. Here’s the problem: prices are not decreasing. And quality is improving—because it is the right thing to do—not because of the forces of competition.

It may be possible to compete on price at some point in the future. But until health insurance is reformed so that patients know how much health care really costs, I just don’t see it happening. If we’re really interested in competition, and competition sooner rather than later, it is going to have to be quality of care that leads the way.

This isn’t a new idea, but I like it, and I think it could go somewhere.  The prevailing question has been “will competition improve quality?” But why not just compete on quality since we’re having such a difficult time competing on price?

CMS is working toward a quality comparison solution.  But its development is slow and functionality minimal.  Quality measures are difficult to agree upon for comparison purposes.  Difficult is the key word here, it is not impossible.  It is another opportunity to be proactive about positive change.  Hospitals are already late: Health 2.0 companies are pushing the comparison tools forward.  Thankfully.

Here’s the question: is your organization hiding behind a rock or leading the way in quality reporting?  Competition on quality could very well be the future.  And if so, the transition will be swift (it won’t be phased in by CMS, it will be forced in by outside forces).  Will you be ready?

Real Quality: no more lip service

Hospitals have most likely responded (let’s hope) to CMS’s decision to not pay for a number of medical problems arising from hospital mistakes.

Good news. CMS has come out with a proposal to not pay for nine more preventable conditions.

Is quality getting the attention it deserves at your hospital?

My guess is (and probably dependent upon your role in the organization) that the answer is “not really.” We all know it is important. BUT! Some hospitals take quality very seriously. Most are just trying to figure out how to prevent the conditions CMS won’t reimburse for. And some hospitals probably shouldn’t be in business. It’s the bell curve. We need to shift that curve to the right.

Hospitals have been entangled in an epic struggle to stay clean since the days of Semmelweis (maybe a few years later). We’ve all seen the posters, maybe participated in a class, possibly evaluated the data. It’s been going on for years.

We know what hand washing (or alcohol sanitizing) can do. Here’s quick refresher if you have forgotten. Yet compliance rates are still poor. What is the problem? My take: accountability.

It’s time to stop paying lip service to quality. High quality is not adding a sentence to a mission statement. It’s not reporting required data to CMS. It’s not telling employees that quality is our top priority.

It is action. As an extreme, think of how good hand washing compliance would be if the person in charge said, “You will wash your hands at every appropriate moment or you will not have a job tomorrow.”

I’m a big fan of a blame-free environment. Report, report, report! But there needs to be balance. From the the New England Journal of Medicine, “But if we really are serious about making care safer, I would argue that we need to find the right balance between blaming mistakes on systems and holding individual providers accountable for their everyday practices.”

We must find the resources to make quality our top priority. Period. In an era when patients will demand to know everything quality-related about our services, we must be ready and willing to comply. CMS has provided the “business case” by ending reimbursements for hospital mistakes (and are working to reinforce the issue by extending the list). The question is, do you want to lead the way (and by proxy, define what high quality is) or slowly follow? The right side of the curve will be filled with leaders. Organizational success will follow.

UPDATE: Coincidentally, two quality related stories today: Cigna is following the CMS lead and the GAO says the feds haven’t done enough to establish quality and infection control guidelines in hospitals

Following medical error(s)

Quality of care (and by proxy medical errors) is probably topic number two behind insurance reform on the nation’s health care agenda.  The Institute for Healthcare Improvement’s 100,000 Lives Campaign was dramatically successful.  In fact, since reaching the 100,000 lives threshold, IHI has introduced The 5 Million Lives Campaign (“a voluntary initiative to protect patients from five million incidents of medical harm over the next two years”).

Medical errors happen (a lot).  But we don’t always hear a personalized story.  And the story is often what brings the issue into focus.  So with great interest, I’ve been following the events of multiple medical errors at the non-health care blog Nine Shift.  It’s an amazing account of a series of improbable events.  Thankfully, the story has concluded positively.  Go, here to read it (you can probably figure out what to do from there but just in case: successive posts here, here, here, here, here, here, here, here).

By the way, while we’re somewhat on topic, look into their book (“Nine Shift – Work, life and education in the 21st century”), “Nine Shift explores the uncanny parallels between today and 100 years ago, examining the changes between the two transition periods and the forces that restructure society in the new economic era. Discover each of the major nine shifts currently taking place and find out the implications of each shift for business and work, life and education.”  The book was one of my earliest introductions to the topic of universal health care.

Thank you William Draves for sharing your family’s very personal story, our thoughts and prayers are with all.