The Leapfrog Group shines bright light on need to improve safety

But some quality managers find standards unrealistic

In just a few short years, Business Roundtable’s The Leapfrog Group, a Washington, DC-based organization formed in the wake of the Institute of Medicine (IOM) report on medical errors, has brought the issue of patient safety to center stage in the health care quality arena. Quality managers agree that The Leapfrog Group has become a major force in health care, especially with its recent hospital survey and its announcement that the results would be published on its web site and that consumers would be encouraged to use those facilities that met their standards.

"Yes, The Leapfrog Group has become very significant," says Chris Goeschel, RN, MPA, MPS, senior director of health care quality for the Michigan Health & Hospital Association (MHA) in Lansing. "Major purchaser coalitions, including The Leapfrog Group, have heightened awareness of the concerns purchasers have for the quality and safety of health care."

"I think the concept came out of the frustration that buyers had with the rising costs of health care and the diminishing perception of value — that more complications are occurring than should be occurring. Of course, when the IOM reports came out, that really triggered a lot of activity," adds Eugene Fibuch, MD, professor and chairman in the department of anesthesiology at the University of Missouri at Kansas City School of Medicine, and associate director of medical affairs at St. Luke’s Hospital. (St. Luke’s is one of the founding institutions of VHA — Voluntary Hospitals of America — a 1,000-hospital buying consortium.)

"Conceptually, Leapfrog has the idea right; in order to change a huge boat’s direction in the water — that is, to change what happens in terms of health care quality — there has to be external pressure. [The IOM report To Err Is Human] said that, too," Fibuch notes.

While in nearly unanimous agreement philosophically, however, some quality managers say the Leapfrog standards may be too stringent, or even unrealistic, which makes the publishing of its survey results a bit unfair. "Leapfrog is asking its members to change how they do business to add pressure — to only do business with those facilities that meet their standards," notes Patricia Drury, MBA, of Drury & Associates, a consultant in health care management and strategy based in Minneapolis. "They’ve made certain information requests, and in the last year they have begun to display that information publicly, which has led the member companies to put quite a bit of pressure on hospitals to report that information so it can be posted on the web site. That probably does raise some awareness, but some refinement of their standards is needed."

Quality managers emphasize that it is not the underlying philosophy of The Leapfrog Group they object to, but the specific means to the ends set forth in its three safety standards. "Leapfrog chose CPOEs [computerized physician order entry], intensivists, and high-volume procedures," Fibuch notes. "You can debate this selection."

But even accepting those three standards, Fibuch has some qualms. "CPOEs are a great idea," he says. "The problem is, the hardware and software are not yet mature enough to do the job. I was at an IHI [Institute for Healthcare Improvement] seminar recently, and of those institutions that have a system, only a small number of the physicians use it because it slows them down on rounds. It’s cumbersome; it’s time-consuming; and it has lots of menus and screens. In other words, it doesn’t fit smoothly into the work flow of the average physician."

There also is room for "creative" responses to Leapfrog survey questions, Drury notes. "I talked to folks from one hospital who swore they had a CPOE, but the doctors still wrote down their notes, which were then computerized by the nurses."

"This adds another step in the system and actually creates another opportunity for error," Fibuch notes. "And it’s very expensive. To put a CPOE system in a 500-bed hospital, you’re talking $25 million to $30 million. You have to hardwire your nursing units and build in interfaces to the lab, the pharmacy, and to your general data systems."

Drury also takes issue with the intensivist standard. "As it currently stands, it’s simply a question of do you or don’t you use intensivists? We simply don’t have enough to go around, and it will take a whole generation to train that many. I suspect Leapfrog knows that, too, but they are still raising awareness that this would be a good thing to do."

Fibuch also is troubled by the shortage of intensivists. "The intensive care requirement can be really problematic for hospitals to meet, even large hospitals, because there are not enough of them out there," he observes. "Throughout the 1990s, reimbursement systems were so negative that many left the field because of liability, lack of reimbursement, and politics. Now, all of a sudden, it’s popular to be an intensivist. There will not only be a huge lag time, but also there are not enough highly qualified training programs, so this has not been well thought out. Leapfrog just didn’t look at the dynamics in the training arena; [the group says] we should meet the standard by 2004-2005, but in my opinion, the profession is not mature enough to do it."

"I’m very pleased the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) got involved [with Leapfrog] in intensive care standards," Drury adds. "I believe they will now become sophisticated about what you can realistically look for in terms of increasing safety." (Leapfrog’s association with JCAHO and other quality organizations will lead to further refinement of its standards, says its executive director Suzanne Delbanco.

Finally, Fibuch says, the volume standards (awarding favorable recognition to facilities that perform a certain number of designated procedures) can be prejudicial. "For example, if you are a smaller hospital in a town of 25,000 and you had a cardiac program and did 100 bypasses a year, you’d really be on the cusp in terms of Leapfrog’s standards," he notes. "That may not be fair; you might not be able to participate because of your location. Besides, you might be sending the really sick patients to a university hospital nearby."

Drury ponders, "Are they in fact intending to stop dealing with any high-end provider who doesn’t do the requisite amount of procedures?"

Show us the money

Fibuch also has some reservations about the financial incentives alluded to in Leapfrog’s public statements. "We’ve not yet seen the incentives," he says. "For example, [General Motors] might say they offer incentives for meeting the standards, yet their contracting groups go out into the marketplace and buy the health care products with the lowest cost. We have to go out into the marketplace as an institution and compete in that low-cost arena. We’ve not seen any managed care organization come to us and say, Because you’re the top provider in cardiac surgery in Kansas City, we’ll give you a 25% incentive margin on your premium.’ So, they’re saying one thing, but they have not yet put the money on the table. Nor have they outlined a strategy by which to do it that is clear and unambiguous."

The incentives are a two-edged sword, he continues. "What about regional health care providers who can’t meet the volume standards? They’ll be shut out of the marketplace because patients won’t be sent to them, or they’ll be sent without incentives. Without those incentives, how will they be able to have the money to do these things The Leapfrog Group would like to see done? It’s a real problem."

More than one way . . .

Initiatives like those of The Leapfrog Group are symptomatic of a larger movement toward improved patient safety, Goeschel notes. It is her hope, she says, that they will not only co-exist, but that they will also serve to strengthen one another. For example, Michigan hospitals chose a different approach, which they say goes even farther than The Leapfrog Group. They established the MHA, which is comprised of all acute-care hospitals and health systems in Michigan. In addition to hospital members, association members include a blend of managed care organizations, insurers, physicians and physician practice organizations, long-term care organizations, home care organizations, and others along the continuum of care.

Membership is available to organizations that support association objectives. The MHA’s primary objective is to link patients, communities, and providers together for better health. The formal mission of the MHA, as approved by members, is to act as the principal advocate on behalf of hospitals, health systems, and other providers committed to improving community health status.

"The Michigan Health & Safety Coalition (MH&SC) exists as a voluntary effort of major health care stakeholders who want to improve health care quality and safety through collaboration and prioritization of statewide efforts," Goeschel notes.

"Michigan hospitals and health plans had some experience with Leapfrog-like questions through company health plans in the auto industry," she says. "Thus, when it became clear that Leapfrog was growing in membership and influence, having our coalition take a look at the Leapfrog standards and help facilitate a collaborative statewide response effort that could be meaningful to everyone seemed a natural fit with our other projects."

Through the MH&SC, members opted to look at the Leapfrog standards and assess them using their own expert panels within Michigan. "The guidelines were completed in December, and we are getting set to launch our own survey," Goeschel says. "Our referral guidelines look at the same clinical areas of care, but they go beyond volume measures and begin to ask questions about structure, process, and outcome."

Hospital referral guidelines
The Michigan Health and Safety Coalition in Southfield organized six expert clinical panels made up of Michigan clinicians — primarily physicians — to study eight areas of care. The panel members, who were chosen based on their clinical expertise and willingness to objectively assess the proposed hospital referral guidelines, were asked to review current scientific research and expert opinions. The yearlong effort culminated in the development of the Hospital Referral Guidelines.
The Coalition is encouraging the use of the guidelines to help improve the safety and quality of heath care in Michigan. (See web site: www.mihealthandsafety.org.)

The eight areas of care studied are:
1. abdominal aortic aneurysm repair;
2. carotid endarterectomy surgery (removal of plaque from the carotid artery);
3. esophagectomy for cancer (removal of part of the esophagus due to cancer);
4. care of infants with congenital anomalies in neonatal intensive care units;
5. intensive care unit physician staffing;
6. care for low birth weight infants in neonatal intensive care units;
7. open-heart surgery;
8. percutaneous coronary interventions (heart procedures or treatments that are performed through the skin, such as angioplasty).

Another difference is that while Leapfrog was focused on urban hospitals, the Michigan coalition will survey all hospitals. "Even if certain clinical procedures addressed in the MH&SC survey aren’t applicable to their facilities, Michigan hospitals want to work collaboratively and collect information that will be useful to them and to their communities," she explains. "At the end of our survey, we will ask hospital providers to agree to participate in what we call implementation work groups.’" In those work groups, Goeschel says, members will examine the guidelines, analyze any gaps between the survey results and those guidelines, and then develop strategies to close the gaps.

Is there a linkage between the emergence of The Leapfrog Group and the Michigan coalition? "The link between The Leapfrog Group and our coalition is one of common interests," Goeschel says. "It’s clear that providers want to be responsive to employers and purchasers in this area. Our hospitals wanted to be at the table, to take the lead. And because of our experience, we wanted to move beyond strictly looking at volume as an indicator of quality."

Goeschel says she is hopeful that Michigan institutions meeting their coalition standards also will meet those of The Leapfrog Group. "Based on our coalition work, Leapfrog elected to delay rolling out their survey in Michigan, although we were one of the six original designated regions," she notes. "We’re communicating with The Leapfrog Group and others to see how our survey information will be most useful. We expect to learn a tremendous amount from this process. The insights of users’ of the information are critical to future enhancements of the survey instrument and to the work of the implementation work groups."

All of these efforts point to a brighter future for patient safety improvement, says Drury. "I think that as the Leapfrog standards get refined, it could be positive," she offers. "It, at least, opens the door to having quality and attention to patient safety be a condition of participating in the market — a cost of doing business. For the most part, the only cost has been the cost of doing business, so potentially, this is a positive force for creating a safer environment."

Goeschel agrees. "Quite honestly, there is a recognition that the industry needs to be responsive to the perceptions and the needs of purchasers and employers," she says. "The best way to accomplish this is to collaborate on initiatives that are of value to both."

For more information contact:

Chris Goeschel, RN, MPA, MPS, Senior Director of Health Care Quality, Michigan Health & Hospital Association, 6215 W. St. Joseph’s Highway, Lansing, MI 48917. Telephone: (517) 886-8384. E-mail: cgoeschel@lanf.mha.org. Web site: www.mha.org.

Patricia Drury, MBA, Drury & Associates, P.O. Box 46026, Eden Prairie, MN 55344. Telephone: (952) 829-9233. Fax: (952) 903-0388. E-mail: pdrury19@skypoint.com.

Eugene Fibuch, MD, Associate Director of Medical Affairs, St. Luke’s Hospital, 4400 Wornall, Kansas City, MO 64111. Telephone: (816) 932-2000.