At the recent Health Care Quality Summit in Saskatoon, Sarah Patterson, the Virgina Mason Medical Center expert on Lean process improvement, noted, "I'd rather have no board rather than an out-of-date board. They have to be real." She was referring to the PeopleLink Board that is placed is key locations in her hospital to provide real-time visual cues to front-line staff as to how they are doing in meeting quality, safety, work flow, and other metrics in the hospital.
Now comes the CDC, announcing in April 2012, that 21 states had significant decreases in central line-associated bloodstream infections between 2009 and 2010.
CDC Director Thomas R. Frieden, said “CDC’s National Healthcare Safety Network is a critical tool for states to do prevention work. Once a state knows where problems lie, it can better assist facilities in correcting the issue and protecting patients.”
I am trying to be positive when progress is made, and I am also trying to be respectful of our public officials -- whom I know to be dedicated and well-intentioned -- but does Dr. Frieden really believe that posting data from 2009 and 2010 has a whit of value in helping hospitals reduce their rate of infections?
Try to imagine how you as a clinical leader, a hospital administrator, a nurse, a doctor, a resident, or a member of the board of trustees would use such data. Answer: You cannot because there is not use whatsoever.
I am also perturbed by the CDC's insistence on using a "standardized infection ratio" as opposed to a simple count of infections or rate of infections per thousand patient days.
Here's what the agency's metric means:
The SIRs represent comparisons of observed HAI occurrence during each distinct reporting period with the predicted occurrence based on the rates of infections among all facilities adjusting for key covariates (referent population).
The referent period remained January 2006 through December 2008, as in previous SIR reports.
The CLABSI and CAUTI SIRs are adjusted for patient mix by type of patient care location, hospital affiliation with a medical school, and bed size of the patient care location.
Affiliation with a medical school! Wait, do you get a bye from this statistic if you are not affiliated with a medical school . . . or if you are? Why on earth should that matter when the issue is the use of a well established protocol to avoid central line infections?
So, the bad news is that CDC data from 2009 and 2010 is too old to be useful. The good news is that the methodology chosen for reporting the data is meaningless. The "predicted occurrence" is basically a benchmark based on a period of time in which central line infections were an epidemic in the country.
Jim Easton, from the NHS, put it well at the Saskatoon conference:
We need to improve ourselves as leaders: Be intolerant of mediocrity, to hate it. Reject normative levels of harm. It is not OK to be in the middle of the distribution of the number of people we are killing.
A friend of mine, working in a Midwest ICU, read Jim's comment and said,
It's not morally ok. But it is, unfortunately, accepted as "reasonable."
Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System, put it this way a few weeks ago on a safety and quality litserv:
When the goal is zero – as in zero hospital-acquired infections, or falls – why seek a benchmark? A benchmark would then send the message - that in comparison to X, our current performance level is okay, which is a false message when the goal of harm is zero.
Jim Easton reinforces Sarah Patterson's point by saying:
It is shameful not to share clinical quality information. We have ethical obligation to share information about how well the health care system is performing.
Maura Davies, the CEO of the Saskatoon Health Region (seen here with the province's Minister of Health Don McMorris), summarized this for her staff in an email after the summit:
As we embrace Lean as the foundation of our management system, we are learning that when it comes to safety, there are only two numbers that matter: zero and one hundred. We should settle for nothing less than zero harm to patients or staff. We should expect 100 per cent compliance with the standards and evidence based practices we have adopted, such as the surgical checklist, hand hygiene and falls prevention. Are we up to these challenges?
I wonder if Dr. Frieden understands that his agency's policy with regard to this kind of information is, fundamentally, unethical and, indeed, shameful.