The headline on the front page of USA Today, “Deaths Plague Even Top Hospitals,” came as hard news to defenders of certain U.S. health care facilities proclaimed to be among the best run in the world.
Several mainstream news outlets ran alarming stories about the patient experience data released in August by Medicare administrators showing that the same institutions given the highest marks by patients were experiencing high death rates for conditions such as heart attacks and pneumonia -- afflictions that could be managed with proper practices.
The report was less an indictment of health care providers than a surprising revelation that customers’ appraisal of what was happening to them in hospitals wasn’t necessarily accurate. How could patients in high-end institutions feel safer but not fare better than those in “lesser” facilities unlikely to attract the best medical talent?
USA Today’s version of the story quoted Don Berwick, director of the Centers for Medicare & Medicaid Services, as saying the data was an “important finding” that demonstrated that perceptions were an incomplete measure of the quality of hospital care.
Berwick would know. Before President Obama used a recess appointment to make him head of CMS, Berwick was CEO of the non-profit Institute for Healthcare Improvement. IHI helps providers around the world understand proven health care practices that are supported by data and research, but not always followed in practice. The work Berwick started before leaving for his federal post has been continued under new CEO Maureen Bizognano.
IHI’s charter is a “no needless” list: no needless death, pain or suffering, helplessness, waste or exclusion. If global health care conditions make these ideals impossible, standards for improving the safety, timeliness, efficiency and effectiveness of health care are documented, proven -- and not always adhered to.
The Medicare data cited in news stories underscored the point. Not only patients but doctors could be misled by perceptions that their practices were the right ones for managing common hospital events.
IHI’s holds live events and consults with providers for part of its funding, but the group’s main engagement tool is the Improvement Map, a research supported matrix addressing 72 common processes that are the mainstream business of care facilities. They range from heart attack to ventilator-associated pneumonia, or VAP, and are available to anyone visiting IHI.org. The matrix can be sorted by domains for patient care, support care and management processes, and prioritized by a specific goal, such as safety, effectiveness or efficiency.
“The map says, for example, if you do six documented things when treating VAP and make other specified changes to your process, you will have numbers that allow you to measure the effect of those changes,” says Paul Hamnett, VP of engineering at IHI.
IHI gives hospitals the ability to plot the inputs of their own performance, such as the numerators and denominators of process adherence that can be calculated from daily work with patients in the intensive care unit, plotted on a graph and display statistical improvement over time.
The results can dislodge some deeply held attitudes about care. For example, hospitals and clinicians have suggested that they can never get VAP to zero because pneumonia is just one of the things that happens when people are on ventilators, Hamnett says. Yet IHI has data to confirm that VAP can be reduced to an extremely unlikely occurrence and stay there if care providers adhere to evidence-based practices.
“It's kind of scary that there's a set of interventions within the improvement map which show you exactly how to get VAP down to virtually zero, and yet people every day die in the United States from pneumonia associated with being on ventilators,” Hamnett says.
Proven clinical data is applied to all 72 use cases in the Improvement Map, for cancer, central line bundles and host of other common care practices. IHI helps care facilities ask themselves who controls and enforces the care practices leading to their own metrics and where the buck stops.
IHI’s position is, where there's variation, there's an opportunity for improvement. IHI doesn’t do actual data collection in the field; the processes and analytics that populate the Improvement Map come from data that is already widely collected in accredited institutional research. Doctors already can’t keep up with this kind of information themselves, analysts say, and the Improvement brings process to the raw data.
Andrea Kabcenell, IHI’s vice president of research and development, splits her time distilling the Improvement Map and working in hospital projects where administrators are trying to respond to requests for data or new reporting requirements that are chaotic.
IHI's work with hospitals includes courses and seminars and demonstration projects, where a group of hospitals comes together on a particular topic like prenatal safety or reducing death from sepsis. “We work intensively with a group of people and disseminate the best observations we find widely,” Kabcenell says. Everything learned in small groups and seminars goes public through the website or Improvement Map, where processes are stitched together.
The improvement cycle is refreshed for all process categories every six months and through follow-up “watchers” -- faculty or subject matter experts expert person assigned to each process who keep an eye on developments that could require s special update to the Improvement Map.
“There was a time sick people would be admitted or readmitted and get a hospital acquired infection that caused them to have to stay another week,” Hamnett says. “Where it was once a cash cow and bad incentive for hospitals, reimbursement for HAI has been eliminated by law and now everybody is focusing on stopping hospital infections.”
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