Sunday, September 09, 2012

Stop setting the benchmark at the state average

Ashish Jha, of the Harvard School of Public Health, recently commented on a Massachusetts report about stroke treatment in the state's hospitals.  He explained:

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  
So what might state and federal policymakers do if they wanted to get serious about improving these rates?  There are lots of potential solutions, including greater training, more oversight, even robust pay-for-performance.  I have a simpler request:

Stop setting the benchmark at the state average.

Ashish is right on point.  In several earlier posts, I have talked about how the use of benchmarks can be inimical to clinical quality improvement, stating a preference instead for absolute targets, like zero or 100%. For some reason, many state and federal agencies persist in comparing hospitals to the norm.

Regardless of what the government agencies are doing, though, hospitals can do better.  The NHS' Jim Easton put the job on the leaders of hospitals:

[We] need to improve ourselves as leaders. [We need to] be intolerant of mediocrity, to hate it. [We must] 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.

I have told the story of being at a hospital where the CEO said directly to his senior management and clinical leaders that his goal was to be “just above average” when it came to quality and safety metrics. A CEO who has chosen not to do that has, in essence, said that the loss of hundreds of lives at his institution is acceptable.

In contrast, heed these words of Paul Wiles, former CEO of the Novant Health system, discussing preventable infants' deaths in one his hospitals:

My objective today is to confess.  I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties [by focusing instead on the traditional set of executive duties (financial, planning, and such)].

If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.


suiji said...

Nice article. I can relate to this one since I'm a nurse and at the same time, I've been a patient also. Accountability is very important in the medical practice. Though we are only humans, but errors in the medical field is never an option.

Anonymous said...

You have placed the responsibility for not killing people in hospitals squarely in the proper place - on the hospital CEO's shoulders. Would that so many hospital CEO's would realize that leading a hospital requires an entirely different mindset and commitment than leading any other government-regulated organization. The government is there to serve as a backstop of oversight for ensuring minimum performance - not to provide the aspirational goal. Anyone who sets their sights on meeting government standards only is cheating, and perhaps killing, their patients.
(ps, we have disagreed before on the responsibility of physicians for setting and meeting these goals. While I do not let the physicians off the hook, the movement toward hospital employment of physicians only enlarges the CEO's degree of responsibility.)

nonlocal MD

e-Patient Dave said...

As I just tweeted, this ethos of "Today's reality is the standard" is exactly what Detroit said many years ago just before it got creamed by Japan. US execs told Washington it's not possible to make a better car ("If there were, we'd know it - this is our industry.")

I'm sure, though, that those CEOs feel disempowered - like there's nothing they could do, within their reach, to fix it. Another example of what's become one of my top healthcare observations: information alone doesn't change behavior.

(Nonlocal: would it be on the CEO's and board's shoulders?)

e-Patient Dave said...

One more thing - I attended a retreat this summer where one speaker noted that it's now 25 years since a commercial airliner landed with its landing gear not lowered.

And in that culture, he said, they used to say "There are two kinds of pilots: those who've landed with the wheels up, and those who will someday." THAT's disempowered.:) But they fixed it - with 0 misses, not "pretty good."

Anonymous said...

Dave, IMO the subject of hospital boards is a large one unto itself, but my short answer is that, unless the hospital already has a program to educate board members (which would mean that it was already enlightened), it seems unlikely to me that a board would drive such an initiative rather than play a supporting role. Paul may have a more informed commentary from his direct experience.


Mark Graban said...

Great post and I really admire Wiles' position.

Paul O'Neill says that, back at Alcoa, the plant manager was responsible for everything that happened in that plant. As CEO, O'Neill was responsible for everything (every injury or worker death) that occurred under his watch.

Too many healthcare leaders are satisfied to publicly throw their employees under the bus after errors occur. Sad lack of leadership.

Jesse said...

Carol Haraden at IHI (whom I suspect you may know) uses a wonderful phrase for benchmarking against the average, a phrase which I now use frequently to help move people away from thinking this is an acceptable practice. She calls it trying to be the "cream of the crap."

Maura Davies, Saskatoon Health Region said...

As a CEO of a large health system in Canada I absolutely agree that I am ultimately accountable for the quality of care we provide. But we are working hard to develop a culture where everyone who works in my organization, including our physician colleagues, see that as part of their job, every day, with everything they do, regardless of whether they provide direct care or support those who do. A large part of the role of the CEO, senior team and board is to foster a culture that promotes quality and safety. In Saskatchewan, our new provincial healthcare management system is based on lean, with an aim to eliminate harm to patients across our entire system. My region is taking the lead in adopting a Stop The Line/Patient Safety Alert system as part of those changes. Stay tuned.