The Business of Health Care

A (Real) Tragedy at the CDC

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the Virgina Mason Medical Center expert on Lean process improvement, noted,  “I’d rather have no board rather than an out-of-date board.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.

Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.

9 replies »

  1. I believe its time to reframe the public discussion about Healthcare Acquired Infections (HAI) and other medical errors in our hospitals. Citizens4health reframes the challenge from HAI’s as an unavoidable result of sophisticated, necessary medical care in a complex environment to one that is an unacceptable preventable occurrence.

    We believe that the only acceptable goal is that all hospitals are “top hospitals”, and the only questions for public discussion are: What are the barriers to achieving zero preventable medical errors? What is the treatment plan to achieve it? How do we collect and monitor the results?
    We believe that as individuals we assume a number of roles in interacting with the healthcare system. As patients we need to achieve the best outcome for our care. As consumers we have to select the safest hospitals. As citizens we have to assure that our taxes are spent most effectively.

    Citizens4health has developed a civic engagement strategy that includes an action plan for individuals, in all their roles, to work together with stakeholders to achieve zero hospital errors.

    To learn more about our initiative check out our website at
    Shimon Waldfogel

  2. Dr. Mike, assuming you are not being sarcastic above, I congratulate you for your intellectual honesty. Most commenters on this blog stick stubbornly to their opinions no matter what.

    I, too, was astounded when hospitals, including Mr. Levy’s former hospital, achieved this goal. It truly makes one revise one’s mindset as to what is possible in this field, as I noted in my comment above.

    You might want to read his blog post of some years ago on this subject. Pretty stunning:

  3. I apologize – I stand corrected. My comments were way off mark. I did not think this possible but it has indeed happened. The stuff from Carroll Hospital Center is impressive. Their charting templates would be useful to share with other hospitals.

  4. The main problem with your comment, Dr. Mike, is that zero is possible and has been proven to be so in several settings. Where not zero, it was incredibly close to zero, but the target was always zero. It was accomplished without incentives and without penalties or punishment in those hospitals that decided to exercise the leadership to do it. Indeed, I would argue that incentives and penalties are inimical to progress in this arena.

  5. Oh enough already with the airline analogies. This would be more akin to asking the airlines to make sure they never kill an ant as they take off and land – theoretically possible but, um, really? You place a tube of plastic that originates somewhere around your very unsterile head and neck and termnates somewhere very close to your heart and you expect that you can have an infection rate of zero? If you believe that, please go get a job at McDonalds or something because you obviously have no business in healthcare.
    And yes, if someone is punished (and they will be) for not meeting this goal, then they lose. And the opposite of losing is winning. That is not to say there are not ways to encourage behaviors that get us as close as possible to a zero infection rate without penalities, but examples of such incentive programs are few and far between.

  6. Win?! Dr. Mike, this has nothing to do with winning. This is about avoiding preventable deaths. There is no intellectually defensible goal other than zero when we are talking about preventable harm.

    By the way, speaking of quality, my apologies to readers of this reprint of my blog post. For some reason, whoever copied it did not include the italicized format of the quotes. You can pretty much figure out what they are, but the original post is much more clear about what are my words and what are quotes from others.

  7. Dr. Mike, how do the airlines do it? They have targets of 0 fatal accidents and 100% protocol compliance (unless anyone knows of policies that state otherwise). These have been highly constructive and effective targets.

    You “win” when you get to keep your job, which presumably is rewarding and remunerative. You “lose” when you are reprimanded for doing something you know you aren’t supposed to do, and which you have the power to do otherwise.

    If the institution supports you doing the right thing in terms of policies, staff support, workflow, etc., then perfection targets do not create conflicts or resentment. If the institution does not support you doing the right thing (by rushing you and putting pressure to take shortcuts) then this creates problems and will fail in multiple ways.

  8. Yes, but…

    How can you set any benchmark without intending to in some way punish those who fail to meet that benchmark? For otherwise your benchmark is pointless in terms of promoting change.

    And how can you expect to succeed when you create an environment in which there are no winners, only losers? For when the benchmark is zero or 100, no one can win.

  9. We have gotten so used to incrementalism in medicine that we forget how truly transformative thinking can – well, transform, practice.