Insights from the Armstrong Institute
Fifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and… Read More »Patient Safety at 15: How Much Have We Grown?
In this post, I present the case that U.S. News & World Report’s patient safety score, a component of its annual Best Hospitals rankings, has… Read More »Potential Bias in U.S. News Patient Safety Scores
Most of us would agree that there aren't enough valid and meaningful health care quality measures to guide patients' choices of hospitals and physicians. While… Read More »The Surgeon Scorecard and the Need for Measurement Standards
In the world of medicine, blood clots during hospitalization have become synonymous with imperfect care. As many as 600,000 patients per year experience a blood… Read More »Blood Clots Show Limits of Quality Care Penalties
For a moment, consider that you work at a primary care clinic, and your team needs to improve performance on annual foot exams on patients… Read More »What’s Your Theory? Bringing Rigor to Local Quality Improvement Projects
Imagine you were seeking major surgery, and the hospital's consent form contained this surprise statement, which you were asked to initial: "I understand that this… Read More »Can Hospitals Police Themselves to Avoid Too-Risky Surgeries?
When you stay at a five-star hotel — if you are so lucky — you might expect a bowl of fresh fruit in your room every morning,… Read More »Hospital Star Ratings Could Use an Asterisk
Some measures of health care quality and patient safety should be taken with a grain of salt. A few need a spoonful. In April, a… Read More »Why Health Care Performance Measures Need Their Own Grades
When you are a patient at a hospital, you want to know that the executives who run that facility put the safety and quality of care above all other concerns. Encouragingly, more of them are saying that safety is indeed their number-one priority—a fitting answer given that preventable patient harm may claim more than 400,000 lives a year in the United States.
Yet when you look at the way that most hospitals and corporate health systems are organized, weak infrastructure exists to support that priority. True, some hospital boards of trustees have made safety and quality their first order of business. At meetings, they might hear directly from a patient who suffered a medical error, sit through a case study of a unit that reduced complications, or get an overview of various efforts to boost the patient experience and improve outcomes.
Stories can inspire culture change. Sustained improvements, however, require health care organizations to institute top-to-bottom accountability for performance.
What would it look like if safety and quality truly were addressed this way? It might be something like how most hospitals’ finances are managed, from the board level to the smallest unit.
With amazing precision, the finance department in Johns Hopkins Medicine can track virtually every dollar that comes in and goes out. These data can be segmented, sifted and filtered into well-established reports, showing us how our clinics, departments and entire hospitals are performing.
This financial data is used across our organization, all the way up to our board, which reviews consolidated financial statements. If a clinical service line falls short of its financial goals, there is a robust management structure in place—from the hospital to unit and clinic level--to ensure that we investigate and seek solutions.
Quality and safety lack a parallel infrastructure. A health system typically has a chief quality officer, and so does a hospital. Yet the internal capacity within departments and clinics to contribute to improvement work is woefully deficient.Read More »To Make Hospital Quality a Priority, Take a Page from Finance
As standardized exam scores increasingly define success for students, teachers and schools, parents worry about the dangers of “teaching to the test”—and of their children being judged by tests with low or unknown validity. We want our children to perform well on tests, of course, yet only if they measure something that students, patients and teachers believe really matter. We also want the education system to inspire students develop into well-rounded people, not just skilled exam-takers.
In health care there is a similar danger of focusing on improving our “test scores” at the expense of real improvement in patient safety—and in this case, the exams have serious flaws. The federal government uses a composite measure of patient safety to help determine whether hospitals are penalized under two programs. One of those programs, the Hospital-Acquired Conditions Program, in December reduced Medicare reimbursements by 1 percent for 721 hospitals for their rates of preventable harms, such as serious blood clots, pressure ulcers, and accidental punctures and lacerations.
Serves them right, you might think. These hospitals are unnecessarily harming patients. That might be true if the test of their patient safety performance was scientifically sound. However, these programs have a serious methodological flaw: Many of their component measures are not based on reviews of the clinical record, but are rather derived from billing information, which produces a high rate of false positives. Indeed, for some of these measures, more than half of the incidents identified as preventable harm turn out to be false, once we review the clinical documentation. There can be many reasons for this. For instance, a patient may have had a pressure ulcer before admission that was not documented. Or a clot in a small vein might be mistakenly coded as a more serious clot known as a deep vein thrombosis.Read More »Health Care Shouldn’t Judge Itself by Flawed Tests