Wednesday, May 05, 2010

Not enough, AHA

The American Hospital Association does excellent work in representing the views and interests of hospitals across America, and it genuinely seeks to help frame medical and hospital issues in a way that serves the public interest.

But because it is a membership-based organization, it can be hard to be as aggressive on some issues as the times call for. One such discussion is going on right now. The Association is considering a number of strategic performance commitments, one of which is to "advance a health care delivery system that improves health and health care."

I can't argue against that goal, but the manner in which it would be pursued and quantified is weak. See the slide above. It is the draft of what is being discussed by hospital associations across the country.

The first two items are certainly worthy, but the manner in which they are measured is problematic. The metric is a three-year running average produced by CMS and published a year after the year is over. Accordingly, no one will know if the 2012 target is met until 2014.

Why rely on administrative data collected by CMS when every hospital has its own data in real time? Why use a three-year rolling average when we are trying to demonstrate progress over the coming year or two?

The third goal, to achieve improvements in central line infection rates, is simply inadequate on its face. The idea of taking three years to move from the 2009 baseline of 5 cases per thousand patient days to a new target of 1 in 2012 does not reflect the deadliness of hospital acquired infections nor the progress that any hospital can make to reduce them in just in a few months.

The target for central line infections should be zero. That is the only intellectually compelling goal. The time period for doing this should be much, much shorter.


Anonymous said...

Could you tell us what the current rate is right now for these 3 things for BIDMC or what the most recent rates have been please?

Paul Levy said...

Go to and click on quality and safety, hospital-wide measures, for the central line infection rate.

Go here for the readmission update:

I'll dig up the cites for the others in a while. Need to run to a meeting right now.

Anonymous said...

Paul; (warning, long comment) I am afraid that rather than using the word inadequate to describe the AHA’s target/time goals for central line-related infections, I would characterize them as outrageously indefensible.

Peter Pronovost reported that in 2003, after implementing a bundle of process improvements in 108 ICU’s in Michigan, “the median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months.” Zero. (NEJM, 12/2006) That was 7 years ago!

Now, the just-issued AHRQ Report on Healthcare Quality says that nationally, “from 2005-2007, there was no change in the number of bloodstream infections associated with central venous catheter placements.” It is practically criminal that more progress has not been achieved in this time frame given the data available.

As you note, any hospital can make progress on this issue in just a few months. Not sure how to get started? Go to the Institute for Healthcare Improvement website ( and download their step by step,how-to guide,


Even more damning, the AHRQ report also noted that, Of the 33 hospital measures related to safety, 12 (36%) improved at a rate greater than 5% per year. In contrast, of the 19 hospital measures not related to safety, 16 (84%) improved at a rate greater than 5% per year.

What does this tell you about the relative importance of safety measures versus non-safety (probably financial) measures to the average hospital leadership?

I know I am starting to sound like e-patient Dave, but I share his impatience. People are dying while hospitals are fiddling. The public should accept this no longer.

Nonlocal MD

Anonymous said...

Apologies, I messed up the IHI how-to guide link:


Paul Levy said...

BIDMC's 30-day mortality associated with heart failure for June 2006 - June 2009 was 8.6%, compared to the national rate of 11.2%.

Our pneumonia mortality figure was 8.0%, compared to the national rate of 11.6%