Reform Sharpens Focus on Quality Outcomes

Joe Cantlupe, for HealthLeaders Media , March 16, 2011
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Before changes were made, the health system’s LOS approaches were bogged down by delays and lack of necessary teamwork, Toledo says. There were no set procedures for the inpatient team and clinical pathways were not clearly defined. There were also delays in obtaining physical therapy information and in transferring patients out of the ICU after orders were written to do so. In addition, there was a low number of discharges on the weekend. In fact, Toledo says, inpatient team members weren’t even aware of LOS goals.

Over time, flaws in the system were resolved, as each element in the system involving clinical communication and education of patients was explored, Toledo says. Each week, members of the liver transplant quality improvement team—which includes a patient-flow coordinator and the surgeon—review its work to have a better handle on length of stay, Toledo adds. Overall, “our improvements did not come at the cost of a higher readmission rate,” he says.

Curtailing bloodstream infections

One of the most paramount areas of concern in hospitals involves catheter-related bloodstream infections. Bloodstream infections constitute such a serious problem in healthcare facilities that the Centers for Medicare & Medicaid Services this year is beginning to require hospitals that accept Medicare and Medicaid to report central line–associated bloodstream infections to the Centers for Disease Control.

Bloodstream infections are associated with a central catheter line if the line was in use at the time the bloodstream infection developed. A decade ago, UNC leaders believed that the health system’s rate of bloodstream infections was a troubling issue that needed to be addressed. In 1999, the overall central line infection rate for ICUs at UNC hospitals was 8.9 infections per 1,000 catheter days. The infections related to catheter use per day basis are routinely measured to determine infection rates.

At that time, hospital officials started a process to continually monitor for bloodstream infections and implement changes, says William A. Rutala, MPH, PhD, director of hospital epidemiology at UNC Health Care. Over time, the UNC staff has monitored the process closely and has seen major changes and improvements. By 2009, the UNC hospitals reduced overall infections for ICUs to 1.3 infections per 1,000 catheter days. 

One of the most significant techniques involved eliminating most infections with a tube that enters a large blood vessel close to the heart and is used to deliver medications or fluids to monitor vital sounds.

Over a 10-year period, an estimated 887 infections and potentially 244 deaths were prevented in the hospital system, according to Rutala and Vickie Brown, RN, MPH, associate director of hospital epidemiology, among the coauthors of a study published in the August 2010 issue of the journal Infection Control and Hospital Epidemiology. 

At the outset Brown says that nurses in each department work with physicians to monitor any changes. The UNC hospitals began using the infection prevention practices, which include using friction applicators like the one to scrub a patient’s skin with a formula to prevent infections.

Over the past decade, multiple interventions were made in the hospital system to reduce the rate of control-line bloodstream infections, according to Rutala.

Among them, he says, were baseline measurement and practice observations; enhanced education of medical staff regarding proper catheter IV line site care and use of central-catheter insertion kits; and removing unnecessary catheters.

Reducing malpractice exposure

There are many important aspects of patient care, and one of the most costly in terms of specific expense and hospital morale involves medical malpractice claims. An estimated $4 billion is paid nationwide in medical claims each year, with about $300,000 for each healthcare facility, according to Press Ganey, a healthcare performance improvement company, which says that improving patient satisfaction has an impact on financial payments.

Advocate Good Samaritan Hospital (part of Oak Brook, IL-based Advocate Health Care system) has drastically reduced malpractice expenses with a focus on overall patient care, says David Fox, president of the 333-licensed-bed facility in Downers Grove, IL, a suburb of Chicago.

Malpractice risks can be reduced throughout the hospital, no matter what the service line, Fox says. “Minimizing malpractice starts with working very closely with the medical staff [and] having a very collaborative and trusting relationship” with patients.

Effective care and seeking to continually attain patient satisfaction are key elements in malpractice avoidance, according to Fox. “We benchmark a lot, always on the lookout [for] who is doing it better, so we will benchmark everywhere and anywhere to measure the effectiveness,” he says.

Good Samaritan’s total insurance expenses paid to the insurers for malpractice declined from $11.5 million to $2.4 million between 2006 and 2010. In the process, Good Sam, as the hospital is known, received a $2 million refund from its primary payer due to a reduction in malpractice expenses overall. “Although we have seen a reduction in our insurance costs for ‘umbrella’ coverage due to a soft insurance market, most of our costs for malpractice expenses come from a self-funded malpractice reserve,” Fox says.

Fox says the reduction in malpractice expenses reflects Good Samaritan’s focus on “improving the consistency and level of clinical practice and creation of a culture of safety.” That includes a “full deployment of proven behaviors/practices known to minimize the potential for avoidable harm to patients,” he says.

“Because these clinical and safety practices have been under way many years at Good Samaritan and elsewhere at Advocate Health Care, our actuaries have been able to validate highly favorable trends in claims filed and claims paid at Good Samaritan versus the greater healthcare community of Illinois,” Fox adds. “Our experience shows that explicitly focusing on the creation of a culture of safety is not only good for our patients, but also good for the economics for the healthcare enterprise.”

As hospital leadership benchmarks its work, Good Samaritan develops quality report cards on various elements of care, including cardiology, women’s health, and behavioral health. The hospital also features a Level 1 trauma center and a certified Level 3 neonatal intensive care unit, whose work is also benchmarked. Fox says the hospital uses those benchmark systems to constantly measure its work—not only to confront illness but to evaluate patient satisfaction.

In that way, Good Samaritan takes steps to thwart potential malpractice costs. A key is a high level of performance through a variety of service lines, as well as attaining patient satisfaction, Fox says. In data compiled by the Surgical Care Improvement Project, a quality partnership interested in improving surgical care, Good Samaritan meets or exceeds the levels of local competitors in outcomes for pneumonia, heart failure, and heart attack, he says. Good Samaritan also has attained high patient satisfaction scores in areas including outpatient, emergency, ambulatory surgery, and convenience of care.  

Good Samaritan, with its location in the middle of DuPage County, is particularly sensitive to Chicago’s location as a central tort litigation area, says Fox.

Malpractice expenses are “extraordinarily high even if you have a small number of compensatory events,” Fox says. “Malpractice is a huge expense. In our expense structure, we wanted to reduce our malpractice expenses and by doing so be good business managers.”

Ultimately, the measure of quality rests with patient care, Fox says, whether through reducing admissions, LOS, blood stream infections, or medical malpractice.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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