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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21 replies »

  1. 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 your own perverse way of placing your rights and needs above all others. Maybe I should start wearing sexist as a badge of honor, if wanting to see babies born healthy makes me sexist then sexist I am. You win Maggie I am misogynist.

  2. “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 pretty foolish in the process only supporting the argument of those that do find you inferior. This country needs more conservative women.
    “Seems like you’re out of the topic at that point.”
    Maybe you haven’t put two and two together. The Don he refers to in the title is Don Berwick, he was recess appointed to head CMS, CMS runs Medicare. How is discussing poorly ran Medicare and the new individual that will be running it out of topic?
    “It’s also a load of hooey.”
    So Medicare doesn’t have a fraud rate around 10%? 4-5 times that of private insurance. Medicare doesn’t shift cost to private insurance by changing eligibility criteria? I could go on but you obviously don’t have the slightest idea what I am talking about.
    “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.”
    Do you need me to define the word average and large percent? That means some people are over 70 and some are under. A large percent means many but not all. While daddy is of sound mind and body why don’t you have him work on your words with you. A basic comprehension of the english language would answer most of the questions in your post.

  3. 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 of you.
    Nate, you say Medicare is dragging the rest of the health care system down. Seems like you’re out of the topic at that point. It’s also a load of hooey. I’d love to hear a coherent analysis of how thinking like mine got the system where it is, but I know that won’t be coming, either. Greed is bring the system down. Opacity is bringing the system down. The positive side of Paul’s idea is that it works against both opacity and greed.
    Dave, thanks for jumping into the fray. I’m confused by your response to Barry, though. You seem to be saying the same thing he said: we want to see the current performance, not the trend.
    I agree, however, that the overall point is the importance of transparency.
    Oh, and, Dave, if you’re interested in working on “preventing ‘Oh crap we killed another one by accident,'” join me at SXSW on my panel, “Life-Saving Errors: Health 2.0 Incident Reporting.” (Sorry, just had to try to sneak that in.)

  4. 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 data” on a website and let the consumer make the choice. Is the Medicare consumer savvy enough to pick out the best hospital for their situation? They’ll have their choice of a teaching facility, destination hospital with great geriatric AMI results (given the population) which is downtown; or the county hospital which treats trauma and the elderly indigent population, but also has good AMI outcomes, albeit, slightly different populations; or they’ll have their community hospital which doesn’t see as many patients but has well above average geriatric AMI outcomes, granted they only saw 35 patients all year, but hey, they’re ten minutes away and they were great outcomes! To compound this, our city has over 4 corporate hospital systems and 40 hospitals to choose from.
    I’m all for report cards, given the metric is sound (like handwashing rates and infection control figures). Even then, you have different definitions for some metrics, like VAP. Which definition are you using? Is every hospital measuring handwashing failures the same? Is it before they enter the patient zone, do they include physician interactions? Hell, we couldn’t even get our observers to agree on what constituted an error in hand hygiene, and there were very precise rules.
    I just wanted to point out the very realistic and difficult task associated with the information gathering and then in getting that information to our patients in a way that is easily digested and understood by those patients.
    Everybody who reads these articles and posts know how to interpret the numbers and what questions to ask. Do your patients? It’s okay to have good ideas that never get into practice. It doesn’t mean we can’t use them as jumping off points for improvement.

  5. 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 blog shows hundreds of hits.) And I don’t just mean he’s posting numbers on their site – I mean discussing why it works, the challenges of changing the culture, citing the results, discussing what other hospitals are doing, and much more.
    CLIs (or CLABSI’s – yuck) are close to my heart (literally, heh). Paul posted about them in December 06, before I got diagnosed. (What a time capsule that post is – I commented as “Patient Dave” (my pre-e persona), and Don Berwick dropped in too!)
    The next month I got diagnosed. In February I read Paul’s updated stats “We saved one person’s life” (zero for January!) That was really good news for me, because then I learned I was gonna have 28 patient-days of central lines during my treatment. (4 insertions, 7 days each, to deliver the Interleukin.)
    And when my time came, I chatted with each of the surgeons about the uniform process they were all now required to use. It was funky AND EMPOWERING to be able to discuss, knowledgeably, what they were doing to me. Can anyone think of a non-arrogance-based reason not to enable this kind of patient awareness?
    It’s WONDERFUL. Patients, families, providers, working together (participatory medicine!) to improve healthcare.
    Barry, it seems clear to me that an informed and empowered patient would consider today’s performance, not the trendline. (If car brand x has improved in Consumer Reports from Much Worse Than Average to Average, I’ll still prefer one that’s been steadily Better Than Average.)
    Bev MD, correction if I may: a “converted” CEO will protect his nurses, staff AND PATIENTS from these docs.
    Paul linked to his April Ohio post about how hospitals there are sharing methods, saying “we compete on everything, but we don’t compete on safety.” I said something similar about personal health data: “Save lives first, *then* compete.”
    I understand business but I just don’t see any defense for “leadership” decisions that de-prioritize reducing fatal errors. Can you imagine realizing that your hospitalized mother’s being cared for by cover-up artists who are in denial about it? Ew.
    Hey, you other Boston hospital execs – how do you sleep at night? What the hell are you doing? Really.

  6. 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.

  7. “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 the entire US healthcare system and fix their house. His population are on the downside of the hill, now is not the time to teach them new tricks.
    The rest of the healthcare system us not pulling Medicare down, Medicare is pulling the rest. It’s thinking like what you speculated that got it there. Our crisis is hospital driven. If we don’t control that cost nothing will change. We can either reduce what we pay hospitals for legit care and avoidable cost or address the avoidable and pay more for the legit. Until we identify and fix issues like infections there is no more money to be spent.
    It’s impossible to tell what a market would do with data, good or bad, the key is to get the data out there. If I found out that Paul’s hopital had 1/4th the infections as the one across the street I as the plan administrator would push business over there. While Paul’s original idea didn’t have a reward aspect to it that doesn’t mean one won’t follow. I don’t think Paul would be the best one to determine how plans use these facts, he should honestly report them then let others do their job.
    I read a very interesting story in the Plain Dealer yesterday about Ohio hospitals joining together to reduce elective premature birth. They collected the data now its on me to implement changes to take advantage of it. We shouldn’t expect hospitals to solve any more then the treatment they are hired to deliver.
    If anyone has any ideas on legal ways to suquester women until they are full term let me know.

  8. 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 the problem with healthcare administrators, both in the board room and in Washington DC. They want metrics, they want information, but they don’t want common sense measurables or accurate cohorts from which to make educated decisions. Why? Couldn’t begin to tell you, although I have my suspicions.
    Healthcare used to be fun, yes I said it, “fun”. Now it’s just full of beaurocrats wanting information for information’s sake; or wanting information to make headlines, where they’re counting on the naivity of the consumer.

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

  10. 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 the root of all evil!
    MRSA or MERSA is a staph infection that accounts for 65% of all Hospital Staph Infections. These Infections are Preventable with proper ADI measures. However, Hospitals largely ignore the proper precautions.Also, for the record;Patient records are often tampered with and tabulated (in favor) of the Hospitals to maintain a fantisized grandiose image of confidence and integrity.
    Many Hospitals and Professionals have fought Public Infection Rate Transparency with more excuses than a habitual Lier. The Public doesn’t understand what it means when infection rates rise. Are patients too stupid to know that it increase the risk of Complications and even Death? Here is another Fact,Hospitals are NOt doing their Jobs to reduce infectious rates. Wow ! How is that for not having the Brain Matter to Understand!
    The Infectious Rates of many Hospitals are incredibly alarming and many professionals are Carriers that also infect Compromised Patients. Patients have a right to know the risk of Infections and it is about time the Hospitals Publicly list their infectious rates.

  11. 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 great. I suppose. I don’t know. Maybe that’s really lousy (I doubt it). I don’t have a point of reference.
    Besides, say the effort is spectacular. How does the CEO’s pride in his improvement on a handful of metrics demonstrate patient-centeredness? I’m a patient. I don’t care what numbers you’re willing to tell me that have improved. I’m pretty sure you won’t be posting numbers that are going the wrong way.
    You want to demonstrate patient-centeredness? Don’t make expensive decisions for the patient without consultation. Don’t tell a patient–EVER–that she has only one recourse, that she has to do exactly what you say without a full and clear explanation, or that a diagnosis is a death sentence. You want to give the CEOs something useful to do with their internal data? Post every infection and every iatrogenic death on a website followed by an explanation of what caused it (as far as you can determine) and what you’re doing to ensure it doesn’t happen again. Then, follow through.

  12. 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 likely to follow policies and rules. A “converted” CEO will strongly protect his nurses and staff from these docs. The era of throwing one’s weight around due to high patient volume is coming to an end, finally.

  13. 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 best, of course. (A similar motivation is in play in CMS’s plan to not pay for “never” events.)
    Paul is trying to play like a grownup and encourage the CEO’s to look up from their balance sheets and take pride in their clinical work and clinical staff. Only when they are doing that 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.
    In other words, Paul wants the CEO’s to become more patient-centered – precisely synchronous with Dr. Berwick’s aims. Very insightful, given my experience with most hospital administrators.

  14. 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.
    This idea really sounds like, “What Don Would Do If He Were Paul.” Yours just isn’t a Don Berwick idea. 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. As Barry notes, this data would be largely misleading to patients in that a big improvement doesn’t prove that a hospital is better than one that shows little or no improvement.

  15. 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 that would allow a nurse or tech to speak up with confidence if they notice a senior physician making a mistake or not following procedures like hand washing. Suppose the doctor reacts badly and suppose the doctor generates a large amount of business for the hospital and threatens to take his services elsewhere if the nurse or tech is not fired for challenging him.
    Safety campaigns are obviously well intentioned and a lot of good can come from them, but their effective execution can be fraught with challenges. That said, the psychic rewards from success are considerable.

  16. I don’t know, Vikas. It has worked well here. No one else in Boston is posting these numbers. We measure progress by competing against our own history, and people take great pleasure and pride in the success.

  17. Paul,
    Physicians (and everybody else) have an impulse to improve much of the time. But in my experience, it is modest —- the thing that fires the afterburners is comparison to the guy sitting next to me. And without risk adjustment, that gets bogged down in the usual argument.

  18. Hospitals are too far removed from the people they serve- real people-not professionals need to be on the board. Professionals are too conceited and stuck on reinforcing their own beliefs and way of doing things. Hoospitals need the fresh input that real people can provide. Quality should not be defined by hospitalists but by the people they serve. Unless this happens hospitals will forever be stuck in a reinforcement loop and there wont be any real progress.

  19. Sure, but this is not about consumers making choices so much as it is about providing the impetus for the clinicians to make gains or keep them. In your example above, the world is better in both hospitals because the staff is focusing on the issue.
    Maybe someday transparency will help consumers make choices, but I think that is a way off. If we focus on that aspect now, we will get into all kinds of debates about data and we will lose the value that can occur by focusing on self-improvement.

  20. Paul,
    Suppose Hospital A has a CLI rate 4 times the national average today and, over the next two years, cuts that rate in half to 2 times the national average. Hospital B has a starting CLI rate of close to zero and over the next two years makes no improvement. Other things equal, I would rather be a patient at Hospital B despite its flat CLI trend.