Comparability doesn't matter

I was talking about public reporting the other day with an MD colleague.  He pointed out that hospitals often have different definitions for a variety of measures, like ventilator associated pneumonia (VAP).  Therefore, he pointed out, public reporting of such measures can be problematic.  I said, "No, it's not a problem."

Why not?

Let's look at what we are trying to accomplish.  Simply put, we want the hospitals, doctors, and nurses to engage in systemic process improvement in their institutions.  What are the elements of doing that?  Brent James lays them out quite clearly, based on the concept of shared baselines:

1 -- Select a high priority clinical process;
2 -- Create evidence-based best practice guidelines;
3 -- Build the guidelines into the flow of clinical work;
4 -- Use the guidelines as a shared baseline, with doctors free to vary them based on individual patient needs;
5 -- Meanwhile, learn from and (over time) eliminate variation arising from the professionals, while retain variation arising from patients.

That is the essence.  Now where does public reporting come in?  The impetus for transparency of clinical outcomes can be found in the writings of MIT's Peter Senge.  In The Fifth Discipline, he discusses creative tension.

[T]he gap between vision and current reality is . . . a source of energy. If there was no gap, there would be no need for any action to move toward the vision. Indeed, the gap is the source of creative energy. We call this gap creative tension.

Imagine a rubber band, stretched between your vision and current reality. When stretched, the rubber band creates tension, representing the tension between vision and current reality. What does tension seek? Resolution or release. There are only two possible ways for the tension to resolve itself: pull reality towards the vision or pull the vision towards reality. Which occurs will depend on whether we hold steady to the vision.

So the deal is this.  You establish an audacious goal for your organization, one that truly stretches everyone.  You publish that target for the world to see, and you also regularly publish your progress towards that target.  The gap between the current state and the future state helps to drive your organization towards the target.

As I have mentioned: 

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

There is nothing in this construct that requires one hospital to use the same metrics as another.  Indeed, I would suggest that having an external authority (e.g., a regulatory agency) establish a common metric will often undermine, rather than support, process improvement.  Why?  Because the internal constituencies who must buy off on the need for process improvement will question the applicability and accuracy of that metric.  Resentment will arise, and progress will slow down.

I can feel people getting antsy now.  "We need comparability in public reporting so consumers will know how to choose among hospitals."  Nonsense.  There is virtually no evidence that the public uses clinical information from websites to make choices as to where they get treatment.  Jeez, when Bill Clinton needed heart surgery in New York, where mortality rates of the hospitals are publicly available, he went to one that had among the highest figures.  (OTOH, maybe Hillary sent him there . . . but that's another story!)

I have addressed this point before, also.

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Seriously, are you really likely to decide on where to get ICU care based on the rate of VAP?  Even for elective surgery, you are most likely to go to the hospital or specialist recommended by your primary care doctor.  If you have cancer, you don't choose hospitals based on infection rates.  You do your research and make your choice based on many other factors (e.g., empathy of doctors, availability of clinical trials.)

I want to be clear that there is value in having a government requirement for transparency, but -- in most cases -- I would leave it up to the individual hospitals to use the definition of each metric that most suits them.  If we tell them what metric to use, we have taken away the self-accountability that we want.  Require them to post their goal and their progress.  Let them add editorial comments about why they chose the metric they did.  What we want to see is that they improve and that they maintain and sustain their improvement. Comparability with other hospitals simply does not matter.