BY: RHODA WEISS
Ms. Weiss is a Santa Monica, CA–based health care consultant and speaker.
What do Consumer Reports, Fit Pregnancy, Self magazine,
U.S News & World Report, AARP magazine, state governments,
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the
local media, employers, and various health plans have in common? They have all
joined the quality report card bandwagon, bestowing awards for clinical outcomes,
creating "best of" lists, surveying the community for "consumer
choice" awards, and publishing mounds of studies to help their audiences
choose among health care providers and health plans.
While consumers have been slow to respond to this avalanche of data, the impact
of ratings and rankings is growing. Hospitals that appear on the "best"
lists or receive high scores are scrambling to tell the world about their accolades.
Those with low scores quickly enter crisis mode, preparing responses while at
the same time actively identifying activities intended to improve their future
standing.
Yet despite dollars spent on marketing aimed at targeted audiences and the
general public, consumers have in the past largely ignored these quality report
cards. Instead, they have, when choosing a family doctor, relied heavily on
family members, friends, co-workers, and acquaintances. And they primarily listened
to their doctors for recommendations concerning hospitals, health plans, nursing
homes, home health agencies, hospices, and other health-related services.
By and large, consumers have based their satisfaction, or lack of it, on more
human factors. Patients traditionally have made such decisions according to
their interactions with physicians and the hospital staff; how long they have
to wait for medical attention; how quickly staff members respond to their needs;
whether the hospital is clean; and other elements. Consumers evaluate health
plans according to reputation and price. Clinical outcomes have rarely been
part of the quality equation. In fact, a Harris Interactive poll based on 2001
and 2002 data showed that quality ratings have little to no influence on consumer
choices of hospitals, health plans and physicians.1
The public, moreover, often has trouble evaluating the relevance of quality
reports. Many report cards can be challenged on the grounds of inconsistent
and incomplete data collection and interpretation, little use of information
concerning severity of illness and demographics, and excessive delays before
outcome data is released. In some cases, report-card organizations require participating
hospitals to pay a five-figure or higher fee to promote the report card's
results or participate in the survey, raising questions about the validity of
"purchased" results.
However, all this may be changing. As reporting organizations unveil data on
what seems to be a daily basis, consumers are beginning to respond to a much
more reader-friendly format. Today's more sophisticated and savvy consumer — armed
with information from multiple media sources, easily accessible medical journals,
and thousands of websites — have begun to question the U.S. health care system
and seriously examine the ratings and rankings available by a host of government,
medical, research, employer, and popular media organizations. Consumers are
looking at and slowly beginning to act upon comparative quality data on performance/clinical
outcomes, as well as how providers have scored.
The internet and other media fuel this growing interest in provider rankings
by making this information more understandable and easier to access. Even accrediting
organizations are joining the trend. In July, the JCAHO, following the lead
of a number of quality-related associations, unveiled its own online hospital
performance-measurement tool, thereby providing both consumers and providers
with access to information about patient quality, safety, accreditation, and
disease-specific care certification. For the first few days, access to the website
was impossible because of the overwhelming number of people seeking information.
(The majority of those early Web visitors may have been hospital staff wanting
to check out ratings of their own performances.)
CHA recently conducted focus groups to follow up on six years of research into
how the public views hospitals, especially Catholic hospitals. That research
indicates that the public overwhelmingly ranks "quality" as the primary
attribute it looks for in a hospital. Focus group members, in describing the
key characteristics they sought in a hospital, said they looked for the latest
technology, compassionate treatment, and excellent customer service.
Given growing consumer concern over how health care providers are rated, Health
Progress readers might find interesting the following ideas about enhancing
provider quality.
Partnering with Employers
In recent decades, business coalitions have tried to influence employer health
decisions with surveys concerning patient safety and clinical outcomes. But
most of these surveys had little impact and have ceased to exist. However, the
influential Leapfrog Group remains successful. Leapfrog was founded by the Business
Roundtable. Its members, including some of the nation's largest and best-known
employers, spend $50 billion annually for employee-retiree health care.
The results of Leapfrog's hospital patient-safety survey, which can be
found in the media and on employer websites, influence decision making about
health plans. Leapfrog aims to continue measuring quality and rewarding the
best performers, while pressuring hospitals to submit results — those that
do not respond are also listed in its survey. Leapfrog encourages hospitals
to spend millions on information-management technology and improve the clinical
quality of staff and physicians. Efforts like this, on the part of employers
and health plans, arm employers with the outcomes data they need to direct their
workers to quality health care providers; they also present opportunities for
collaborative activities.
In the communications arena, hospitals are persuading employers to use report
cards and outcomes data for provider selection, website links with which workers
can access health prevention information, and as collaborative opportunities
for improvement in the quality of care. Providers are also tapping employer
know-how in their quality-improvement efforts.
Take General Motors (GM), for example. GM, the largest private-sector purchaser
of health care in the United States, spends $4.8 billion on health care for
1.1 million U.S. employees, retirees, and dependents.2
(Together GM, Ford Motors, and Daimler-Chrysler paid $8.5 billion combined in
health care in 2003). For nearly a decade, GM has applied its "lean" management,
fast-track manufacturing process in a way that helps its suppliers improve efficiency,
productivity, and quality. Some health care organizations — the Detroit Medical
Center, University of Michigan Medical Center, Intermountain Health Care, and
the Cleveland Clinic, for example — have benefited from GM-sponsored workshops.
These workshops show the organizations how to improve themselves in many areas,
including imaging, radiation oncology, surgery, and emergency departments.
Enhancing Physician Communications
We have heard a good deal lately about the role of poor physician penmanship
in negative medical outcomes — and about hopes for improvement through information
technology. But related issues are receiving increased attention. A recent issue
of Annals of Family Medicine reported that miscommunication, rather than
incompetence, usually figures into errors at the primary care level.3
A study of 75 error reports from 18 family physicians in five states concluded
that 80 percent of errors were initiated by miscommunication, including breakdowns
between physician colleagues, misinformation in medical records, mishandling
of patient requests and messages, inaccessible medical records, and inadequate
reminder systems. Steven H. Woolf, MD, one of the report's authors, suggests
that more initiatives should focus on management systems to enhance the quality
of information transfer. For quality and safety efforts to succeed, they must
be led by physicians and involve as many members of the medical and hospital
staff as possible, all working in interdisciplinary teams to identify and act
on these issues.
Involving Internal Audiences
Employees, who are on the front line of quality and safety issues, should be
involved in identifying problems and crafting solutions; they should also be
rewarded for their efforts. Quality and safety activities can be discussed in
columns in internal newsletters, promoted on an organization's website,
and mentioned in every staff and departmental meeting. Because hospital executives
and boards are also critical team members, safety and quality should be a regular
item on every board meeting agenda. Safety and the quality of patient care are
as much a fiduciary responsibility as is business operations and financial management.
Implementing and Promoting Best Practices
A growing number of hospitals are developing and disseminating report cards
among employers, payers, and the general public; these cards contain information
about clinical outcomes and best practices covering nearly every disease and
medical condition. Hospitals and health systems use national, statewide, and
regional benchmarks accessed through universities, medical associations, quality
organizations, and federal and state health divisions. In various categories — for
example, mortality and infection rates, readmission and patient satisfaction
rates, treatment effectiveness, patient functionality, and others — these
report cards are being distributed among physicians, employers, health plans,
and consumers; the cards appear in advertisements, brochures, newsletters, and
other marketing materials. At the same time, staff physicians, nurses, and other
clinical and ancillary staff are creating clinical guidelines to be implemented
on hospital-wide and systemwide bases.
Sharing Clinical Guidelines
In some cases, treatment guidelines are shared with patients to help guide treatment
decisions. In 1999, for example, the American Cancer Society partnered with
the National Comprehensive Cancer Network to release the first patient version
of the latter organization's breast cancer treatment guidelines. Originally
designed for oncology specialists, the guidelines provide breast cancer patients
with clear, easy-to-understand information on all aspects of the disease. Since
1999, other cancer guidelines have been formatted for patients — a critical
practice for a disease that often offers its victims a large, confusing array
of treatment alternatives.
Viewing Patients and Families as Allies
The Institute of Medicine's 2001 report, Crossing the Quality Chasm: A New
Health System for the 21st Century, focuses on the free flow of information
readily available to patients and their families for informed decision making.4
To facilitate this flow of information, hospitals are extending visiting hours
throughout the facility, including critical care units, and offering a full-chart
review with patients before discharge. Some hospitals are also involving patients
and families in staff team meetings; appointing them as members of quality care
and safety committees; including them in classes on lifestyle, prevention, and
follow-up care; offering them caregiver training; and asking them to participate
in patient-family friendly task forces.
A major cause of medical error involves mistakes made by foreign language interpreters,
who are usually either staff members, friends or members of the patient's family,
or even bystanders. According to a 2001 study conducted by Medical College of
Wisconsin researchers, 63 percent of interpreter errors at a Boston clinic were
considered serious enough to have medical consequences.5
Health literacy is another major contributor to medical errors: Patients often
cannot understand or follow basic health care information. Because this is so,
hospitals should involve patients and family members in monitoring the communications
skills of health care professionals and in testing the efficacy of educational
materials. By doing so, hospitals can gauge whether those professionals and
educational material are well comprehended.
CHA, as ministry engaged, will be delving deeper into the quality issue through
its initiative, Envisioning a Future Health Care Delivery System. Quality is
a vital element of the initiative, which will suggest ways to transform the
health care system so that it is less episodic in nature and more responsive
to prevention and patient well-being, than the system we have today.
For more information, contact Ms. Weiss
at 310-393-5183.
NOTES
- www.harrisinteractive.com/news/newsletters_healthcare.asp
- Danny Hakim, "Carmakers
Face Huge Retiree Health Care Costs," New York Times, September
14, 2004.
- S. H. Woolf, A. J. Kuzel, S. M. Dovey, et al., "A String of Mistakes," Annals
of Family Medicine, July-August 2004, pp. 317-326.
- Institute of Medicine, Crossing the Quality Chasm: A New Health System
for the 21st Century, National Academies Press, Washington, DC, 2001.
- Marilyn Marchione, "Language
Linked to Medical Mistakes," Milwaukee Journal Sentinel, January
5, 2003.
Copyright © 2004 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.