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What Could Don Do?

What is the important thing Don Berwick could do as head of CMS to improve quality and reduce the cost of health care?  Let’s face it, as head of a humongous agency, it is hard to make changes.  You have to pick your battles carefully, for every cause has a constituency and an opponent.  Gridlock is a fact of life in Washington, DC:  The system is designed for that result.

Let’s just say, though, that you had a chance to adopt one innovative regulation or proposal, one where even opponents would have little moral ground on which to get traction.

Here’s mine:

Announce that you are going to create a website in which each hospital is invited to input two or three real-time metrics with regard to reducing harm. Let’s start with central line infections.  There is a common definition provided by the CDC.  Many hospitals keep track of their rate of infection.

Provide a password-protected template and give each hospital CEO (yes,
CEO!) the opportunity to send in his or her hospital’s quarterly figure
for the world to see.  Set up the web page so the accumulated sequence
of numbers is translated in a trend line, so anyone can watch a given
hospital’s progress over time.

Why the CEO?  Well, as noted in a recent Washington Post story: “[Peter] Pronovost said part of the problem was that many hospital chief executives aren’t even aware of their institution’s bloodstream infection rates, let alone how easily they could bring them down.”

Here is an example, the web page used by our hospital.

Notice that I am not proposing any audit procedure.  I am not proposing any financial incentive or any reward or sanction for participating or not participating.

I am not proposing that numbers be adjusted by relative risk, size of hospital, geographic location, or anything like that.  The trend line is the key: Each hospital will be competing against its own record, not that of other hospitals

I am proposing a kind of transparency that will bring credit to the participants because it would indicate that they are willing to be held accountable to a high standard of clinical care.  This is what motivates doctors and nurses.  Not dollars.

Don has the bully pulpit.  He will only get a few chances to use it.  Power is Washington is ephemeral.  Don can use the power of his office to tap the real power — the good intentions of clinicians who have devoted their lives to alleviating human suffering caused by disease.  He can give them a forum to show their stuff.

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e-Patient DaveNatestop smoking helpMD as HELLGary Lampman Recent comment authors
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Nate
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Nate

I don’t remember the exact numbers from the Ohio study but they found a significant number of ELECTIVE premature births. Women would induce 2-3 weeks early to coinside with grandparents comming to help, leave from work, or other voluntary reasons. They found that any premature birth greatly increased the chance of complications. By convincing women to deliver to full term they reduced a number of complications saving X dollars and Y number of babies. Is it sexist to think women choosing to have a baby should do everything reasonably possible to insure it is born healthy? Liberal women do have… Read more »

Nate
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Nate

“Aside from that, thanks for that little sexist gem at the end. How very 18th Century of you.” Your either illiterate or display moments of idiotcy. In case you really don’t know, it is, as of yet, impossible for a man to have a baby, thus there is no need to incentivise men to wait until they are full term to deliver their baby. If you find that sexist then take it up with your god or evolution. What is it with liberal women and the sexist card, you go out of your way to find it, making yourselves look… Read more »

Dennis (Investigator/Negotiator) at Medical BillDog
Guest

Wow, Nate. My parents are in their early 70s and on Medicare. If my Dad heard you say that, he’d likely kick your ass. Thank you for that offering of pure ageist drivel. You seem to have forgotten that Medicare/Medicaid covers a lot of folks who are much younger but are disabled. I have a sixteen-year-old foster son on Medicaid. Also, with the Baby Boomers hitting retirement age, your calculation as to the mean age for Medicare is quickly shifting toward the earlier years. Aside from that, thanks for that little sexist gem at the end. How very 18th Century… Read more »

stop smoking help
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Dennis, I guess you made my point for me. The metric was wrong, you are absolutely right – that’s the problem. I believe Medicare was who we reported that metric to in hopes of getting better reimbursement. Our administrators never told us if they stratified the data into some usable form, we were just told to get the outcomes. There are just too many ill-fitting metrics for an accurate comprehensive comparison. Why can’t we cohort hospitals’ metrics and report the data that way? Well, lets carry this example out a little further. Lets say you publish, as you said, “stratified… Read more »

e-Patient Dave
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This issue seems so clear to me, from several perspectives: patient, “transformationist,” and guy with a long business career. It seems to me that professional management involves creating structures, policies and culture that lead to better performance. Posting a scorecard is a clear, simple, focused, relevant way to do that: “Hey, how are we doin’?” Doin’ on what? Well gosh, we’re a hospital, how about SAVING LIVES? And preventing “Oh crap we killed another one by accident”? Dennis, I don’t know how long you’ve followed Paul’s blog, but he’s been talking about transparency for years. (A Google search within his… Read more »

Dennis (Investigator/Negotiator) at Medical BillDog
Guest

Your problematic metric, stop smoking help, is actually pretty simple. You change the name of the metric to include the other variable. Instead of reporting the number of AMIs, you report the number of geriatric AMI. Too many hospitals make this same claim: “we accept the hard cases.” Those are just words. Prove it. Put your numbers where your mouth is. List the deaths and classify them by age and coronary disease history.

Nate
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Nate

“Don has expressed an interest in patient-centeredness. I really expect his big gambit in CMS to be something in this direction. I think that’s a large part of why you’re getting so much feedback asking how the patients could use the comparative data you list.” Wow I hope your wrong on this Dennis. If Don’s plan is to take a population with an average age in the late 70s, large percent of which don’t control their mental faculities and make them the vanguard of a patient-centered movement he was a waste. For once CMS needs to stop trying to manipulate… Read more »

stop smoking help
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Spoken by someone who sees the forest, but not the trees. Hospitals are not homogenous. You cannot compare every single hospital to each other. For example, our hospital looks at various metrics, one of which is AMI (acute myocardial infarctions) outcomes. We admit thousands of geriatric patients with complicated cardiac histories. Our mortality rate is higher than national averages because of our beginning population demographics. Now compare us to a new community hospital which admits a younger, healthier demographic. Their rates will appear to be much better. Does that mean their hospital is better than ours? Certainly not. This is… Read more »

MD as HELL
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MD as HELL

CMS will not pay for central lines. If you have no veins you have been treated enough. Time to go.

Gary Lampman
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Gary Lampman

Dennis: I agree with Bev M. D.. Hospital administrators don’t give a damn. The investors and Loss prevention is his only Concern regarding curtialing loss of Money versus Lost of Life. From some of your comments;I would find your leanings to be focused on the Fiscal Profitabilty. It is all right (for some narricists) to be one of these statisticians that hide behind the scenes far from the realities of Health Uncaring and burry oneself in the business of maximizing Profits. The facts are that many Hospitals are ignoring their ethical and Moral responsibilities to serve the Greater Master.Filthy Lucher!Money… Read more »

Dennis (Investigator/Negotiator) at Medical BillDog
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Sorry, Bev, I just don’t see your reasoning. You claim that ” Only when [Administrators] are [willing to look up from their balance sheets and take pride in their clinical work and clinical staff] will the public eventually be able to trust the published numbers – and trust that the hospital really wants to take care of THEM, not their own public image.” I don’t see it. I’m a patient. I look at Paul’s CLI chart and see that BIDMC went from a rate of 1 infection per 1000 patient-days to a rate of 0.6 infections per 1000 patient-days. That’s… Read more »

bev M.D.
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bev M.D.

And Barry; As far as I know, central line infections are on the “never events” list which CMS will not pay for. Therefore the hospital will actually lose money for every infection. Besides, read Dr. Pronovost’s data – it costs 3K per infection to implement the checklist, and 30K or more per infection to treat it. The culture you speak of is important -but as I said in the previous comment, I believe Paul is attempting to change that very culture among his own colleagues. Good place to start, but you are right – doctors are the ones statistically least… Read more »

bev M.D.
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bev M.D.

I had to read this post 3 times before I understood the real innovation in Paul’s proposal. Other commenters may feel he missed the point – that this data is more important for consumers to know than for the hospitals to track their progress. But Paul “gets” the most damning fact: the CEO’s don’t CARE WHAT THEIR OWN NUMBERS ARE. If CMS addresses a hospital CEO with this attitude and announces they will publish his/her data for the public to see (which, btw, is already starting), what will they get? Gaming of the system to make their numbers look the… Read more »

Dennis (Investigator/Negotiator) at Medical BillDog
Guest

Okay, cheers and jeers. First the cheers: This is an intriguing–possibly brilliant–idea, Paul, and one I think you should champion. You’re already connected in some form or another with the IHI and ICSI, right? So, push it there. Independently, convince other admins to get onboard with this idea of posting self-improvement. You don’t need a government site. The IHI could set up a program. Or, you could set up your own independent wiki on a wiki farm without a hosting umbrella. Either way, you don’t need Don Berwick or the CMS to accomplish this. Jeers: This idea really sounds like,… Read more »

Barry Carol
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Barry Carol

Reducing patient harm is certainly a laudable goal and the staff can and should be justifiably proud as they achieve meaningful progress. Needless to say, it speaks well of the institution too. For patient (and employee) safety campaigns to be fully effective, however, requires a very strong commitment from senior management, especially the CEO. Delicate issues can arise including the following: 1. Under historical reimbursement protocols, the hospital can actually experience lower revenue as it reduces patient harm and associated medical care to address the harm. 2. It can be quite a challenge to create a work environment and culture… Read more »