Leapfrog Group releases its first 'Top Hospitals' list

Survey shows that significant progress still needs to be made

While honoring some of the nation's top-performing hospitals with the release of its first Leapfrog Top Hospitals list, the Washington, DC-based Leapfrog Group also noted that its survey uncovered a number of areas in which America's hospitals still lag behind.

The 59 winners were chosen based on the Leapfrog Hospital Quality and Safety Survey.

The survey, which received responses from more than 1,200 facilities, asked the participants to indicate whether they were aware of the 30 "Safe Practices for Better Healthcare" endorsed by the National Quality Forum (NQF), and whether they had acted upon them. (The complete list of NQF safe practices can be found at: www.ahrq.gov/qual/nqfpract.htm.)

The survey showed that:

  • About 90% of respondents have implemented procedures designed to eliminate wrong-site surgeries;
  • About 80% of hospitals said that all medication orders must be reviewed by a pharmacist before medication can be given to patients.

However, the survey also found a number of areas in which hospitals still have a long way to go. For example:

  • More than 90% of the respondents have not met Leapfrog's standards for implementation of computer physician order entry (CPOE);
  • Nine out of 10 respondents do not meet the established Leapfrog standards for performing coronary artery bypass graft surgery, and 96% do not meet Leapfrog standards for abdominal aortic aneurysm repair;
  • Seven out of 10 respondents said they do not meet the Leapfrog standard for having intensivists oversee patient care in the ICU;
  • Half the respondents said they do not have an explicit protocol to ensure that there is adequate nursing staff. The same percentage also said they do not have a policy for asking patients if they understand the risks of their procedures;
  • According to survey responses, 30% of facilities do not have procedures for preventing malnutrition in patients. The same number said their health care workers are not given the flu vaccine.

(For additional information on the, survey results.) see box

"Those facilities that are on our list really have put a focus on patient safety initiatives that can dramatically improve the quality of care given," says Catherine Eikel, director of programs for the Leapfrog Group. "Hospitals that perform well in these areas deserve as much public recognition as possible."

Explaining the results

Eikel says there are some very good reasons why the vast majority of hospitals still fall short in several key areas. "We have seen the slowest statistics in terms of CPOE uptake, but there are significant barriers to implementation across a hospital," she notes. "One of the biggest challenges we hear about centers around the interoperability of CPOE with other decision support tools a hospital may have in place."

Still, she says, "We are pleased to see that at least some progress has been made, because there are so many preventable medication errors that can be caught." She adds that as vendors move towards greater interoperability, "We hope to see CPOE taking greater hold."

John Byrnes, MD, senior vice president, system quality, for Spectrum Health System in Grand Rapids, MI, which made the Leapfrog list, agrees. "For a lot of average-sized and small facilities, cost is also a problem, but I've heard from a number of friends that they are intentionally waiting until systems become more refined and user-friendly," he says. "Commercial vendors are still working as diligently as they can, but they may have more work to do to get to a broader market appeal."

Evan Benjamin, MD, vice president of health care quality at Baystate Medical Center in Springfield, MA, another Leapfrog top hospital, agrees that CPOE is "an expensive endeavor" but adds that it "probably has a significant bang for the buck in terms of reducing medication and transcription errors, tools for safety, and reminders." Most of the facilities that are implementing CPOE, he adds, really use it as a cornerstone of multiple interventions to improve patient safety. "In addition, it aids compliance with the best practices from the NQF 'nevers,'" he notes.

Benjamin adds the following: "I would guarantee that 100% of the winners have CPOE; that's why they are the winners — they had the best scores."

Not all low scores indicate hospitals are performing poorly, Eikel continues. Take, for example, the two high-risk procedures. "Leapfrog's focus is not necessarily on encouraging hospitals to be good at everything, but we very much encourage them to do well in service lines they are good at," she explains. "We are more engaged in creating centers of excellence around certain high-risk procedures; from the consumer's perspective, it's very important for them to see that certain hospitals are better for them than others, depending on what it is they are being treated for."

Byrnes has another explanation. "I notice that most hospitals feel they need to be in the cardiology service arena," he observes. "When you have all the hospitals vying for volume, few – if any – will make those volume targets. You are taking an existing pie and dividing it into too many pieces."

There are also challenges in a third area in which most hospitals fell short — the use of intensivists. "One of the biggest challenges everyone mentions is that there are very few doctors trained in critical care, so hospitals have a hard time finding them," admits Eikel. "However, in our survey, we encourage hospitals to use telemonitoring to meet our ICU staffing requirement. It's an excellent way to have the right level of care in the ICU without requiring an on-site intensivist."

Byrne agrees. "The intensivist problem is just one of supply and demand, but telemedicine is definitely an option — particularly for smaller, rural facilities. It's something you should definitely look at."

Making the list

"What it takes to make that top list is a lot of hard work and very specific attention paid to patient safety," says Benjamin. "Our goal is that the patients have a right to expect these safe practices are in place — but to get there takes tremendous work."

"I think for us it came down to a decision around philosophy — did we want to just do the [JCAHO] National Patient Safety Goals, or did we want to push beyond that and put in as many patient safety initiatives as we could — as fast as possible?" says Byrnes. "We looked at publications from AHRQ and NQF, worked off them, and selected 40 initiatives to implement here at Spectrum."

At Spectrum, an integrated delivery system with seven hospitals and a little more than 100 ambulatory sites, this was a tall order. "Our biggest groups of stakeholders included about 1,600 physicians and over 3,000 RNs," notes Byrnes. "The initiatives were chartered by our safety committee — the executive team and many nurse directors. When they were chartered, the team lead for each initiative would be a nursing director and/or a manager, and these initiatives were our deliverables."

From the beginning, he says, the initiatives were "owned" by the nurse directors and front-line staff.

"The quality team would supply support staff and data, and we would then roll the initiative up through the organization," Byrnes explains. "If the initiative was heavy on the physician side, one of the medical directors would lead it, and if it was equally shared by both camps it would be co-led."

Baystate also has implemented a number of patient safety initiatives, including one to evaluate each surgical patient before surgery to make sure he or she is receiving the correct prophylactics to prevent heart attack or blood clots.

"For example, we evaluate each patient upon admission and then periodically thereafter for their risk of developing blood clots," says Benjamin. "It sounds very simple — clots cause very significant morbidity in hospitals in the U.S. — but we believe most could have been prevented if every patient were evaluated for risk and given meds or other preventive measures."

In order to improve safety in this area, he shares, a system needed to be created. "We had to decide who would evaluate the patient, when it would happen, how often it would happen, what preventive measures should be taken, and we then standardized this and put it in place," he explains.

The facility has used its CPOE system as a reminder, so when a patient is admitted, if there has been no order for deep vein thrombosis or blood clot prevention, the system will actually remind the provider. "It will say, 'We notice you have admitted so and so, and we see they are high risk; do you want to provide preventive measures?'" Benjamin notes.

Baystate also has created multi-discipline rounds as reminders. These involve physicians, nurses, and case managers.

"To sum it up, we are very gratified to be recognized by Leapfrog as one of the safest hospitals," Benjamin says. "To achieve patient safety really starts with leadership. What Leapfrog recognizes is that you have to start creating a culture of safety — and that comes from the top of the organization."

[For more information on the Leapfrog Hospital Quality and Safety Survey, go to: www.leapfroggroup.org.]

[For more information, contact:

Catherine Eikel, Director of Programs, The Leapfrog Group, c/o Academy Health, Suite 701-L, 1801 K Street, NW, Washington, DC 20006. Phone: (202) 292-6713.

Evan Benjamin, MD, Vice President of Healthcare Quality, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199. Phone: (413) 794-2527.

John Byrnes, MD, Senior Vice President, System Quality, Spectrum Health System, Grand Rapids, MI 49546. Phone: (616) 391-9164.]