The data look so good for the headlines: in 2012-2013, hospital-acquired conditions such as urinary tract infections and falls fell by 9%, saving about $8 billion. Stretching back another year, to 2011, the total cost savings reached an estimated $12 billion, with about 1.3 million cases of harm and 50,000 deaths prevented. All this good news came in a December report released by the Agency for Healthcare Research and Quality (AHRQ).
Tens of thousands of medical records are reviewed for evidence of eight kinds of events, additional costs of which have been estimated as follows:
adverse drug events — $5,000;
catheter-associated urinary tract infections — $1,000;
central line-associated bloodstream infections — $17,000;
falls — $7,234;
obstetric adverse events — $3,000;
pressure ulcers — $17,000;
surgical-site infections — $21,000;
ventilator-associated pneumonia — $21,000;
postoperative venous thromboembolism — $8,000.
The report doesn’t explain why the declines are happening, other than to tout the government’s efforts at rewarding successful efforts and punishing malingerers through value-based purchasing programs, as well as the Centers for Medicare & Medicaid Services (CMS) Partnership for Patients (http://partnershipforpatients.cms.gov/) program, which tries to spread good ideas to attack some of these problems.
A call to action?
There are many organizations that have done great work on quality and safety, says Mark Graban, an author and healthcare quality consultant based in San Antonio. For them, these numbers aren’t a surprise. And there are other organizations that have not been as successful. These numbers may be a call to action — a notice that others are able to make changes that make a difference, so they can, too.
“The hospitals that have been on this bandwagon all along? They know that all of the celebration about good numbers in one report doesn’t mean anything, that the journey is continuous and that one person harmed is too much,” says Graban. “You can’t use this kind of success as an excuse to relax, but rather a way to move forward and build on a good start.”
He worries, though, that some hospitals will take these numbers and use them to tout their achievements to the general public, which is not as invested in digging down into the numbers as a data jockey at CMS might be. For them to imply that the care they provide is wonderful because some lives that never should have been at risk in the first place were, indeed, not put at risk, seems disingenuous, Graban says. Similarly, it’s just as unfair for the media to latch on to numbers and report headlines that scream, “Twice as many reported incidents!” without noting that it doesn’t mean there are twice as many occurrences of something.
Data is complicated, he says. “It’s easier to know how many people are killed by a kind of car than are killed by medical errors, which can be easily explained away by something else or covered up — either maliciously or not.”
Still, these data look like we are moving in the right direction, Graban notes. What’s important now is to dig down further. What actions are hospitals taking that make that movement possible, and how do we spread that around the national healthcare system? “The report doesn’t go into that. What we can be sure of is that the percentages they report are not uniform. That 9% is not true in every hospital or even every unit. Some have gotten safer, and some haven’t. And within the report, the various conditions have had various levels of success.”
Ventilator-associated pneumonia had only a 3% reduction over its 2010 baseline rate, falls just 8%, while bloodstream infections fell by just under half.
Setting a goal of no harm
Graban suggests that hospitals take this report and compare the national benchmarks to internal performance levels. But do not let your performance against that national benchmark make you feel complacent. “We do not want any quality leader to say, ‘Oh, we’re better than average,’ or ‘We’re in the top decile,’” he notes. “The top tenth is still a lot of harm and death. While it’s great to do better than those numbers, it’s better to compare yourself to zero harm and see what you need to get there.”
That may be one of the biggest issues that those who preach quality have with national benchmarks and goals: They rarely set goals of no harm, but only of harm reduction. “If you compare badly against the norm, it should be a wake-up call, because leading hospitals spend less on benchmarking and more on striving towards zero harm, towards perfection. It’s the only ethical goal. You can’t have an ethical goal of two pressure ulcers. What do you tell those two patients? They were ethically okay to be harmed?”
Graban acknowledges some hospital conditions like falls will be nearly impossible to forever keep at a zero. But to those who think that having a goal of zero is demoralizing when it’s often nearly impossible to meet, he says no. “The goals are only demoralizing if you just pay lip service to them, and then it doesn’t matter what they are,” he says. “Good leadership, that doesn’t punish you for not getting to zero when you are actively and honestly pursuing that aim, will make sure that it is not demoralizing. To say that is just an excuse not to aim for perfection.”
The entire Agency for Healthcare Research and Quality report can be seen at http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.html#Summary.
For more information on this topic, contact Mark Graban, Lean and Kaizen Consultant, San Antonio, TX. Telephone: (817) 993-0630.