Piedmont Healthcare, a four-hospital system in Atlanta, stepped up its efforts to improve patient safety long before Health & Human Services launched its Partnership for Patients program in May. Still, the organization signed a pledge to support the safety program, along with more than 1,500 other hospitals nationwide.
Chief Medical Officer Leigh Hamby, M.D., says Piedmont made the commitment partly because it views the Partnership as an extension of the safety campaigns of the Institute for Healthcare Improvement. "I'm a big fan of [former Institute for Healthcare Improvement President] Don Berwick, and I was pretty excited when he took over Medicare," says Hamby. "The Partnership for Patients is reminiscent of the things we did for IHI's 100,000 Lives and 5 Million Lives campaigns, and it's aligned with what we've been working on."
Piedmont already is addressing most of the health care-acquired conditions that the Partnership asks providers to focus on. It's starting to make real progress in reducing the incidence of central-line infections and ventilator-associated pneumonia, and it has reduced mortality from sepsis by 20 percent.
"As it stands now, I don't see anything we'd have to do differently as a result of the Partnership," Hamby says. However, he hopes the second goal of the campaign—to improve transitions of care and reduce readmissions—will identify ways hospitals can work more closely with other providers to improve care after a patient is discharged.
Piedmont doesn't expect to receive any of the $1 billion in government funds allocated to the Partnership. Although the organization might apply for a transitions-of-care grant, Hamby says, "We're operating as if we had to do this out of our current operational budget."
However, The Centers for Medicare and Medicaid Services' value-based purchasing program has influenced Piedmont's thinking. Under VBP, which starts in October 2012, 1 percent of a hospital's Medicare payments is withheld and only can be restored if the hospital meets specified quality and patient-satisfaction goals. In the following year, the criteria will add eight health care-acquired conditions. "So, working on these [safety goals] will allow us to not have as big a withhold as we would otherwise have," Hamby notes.
Most health care observers say that the Partnership's overall goals—a 40 percent reduction in health care-acquired conditions and a 20 percent reduction in readmissions by the end of 2013—are ambitious, but feasible. Along with parallel campaigns by the Joint Commission, VHA, the Premier Healthcare Alliance, IHI and others, it even could represent a turning point in patient safety, increasing awareness and creating a bandwagon effect.
The American Hospital Association strongly supports the CMS initiative. The Partnership for Patients is a "unique opportunity" for health care organizations to improve transitions of care and prevent serious adverse events in the hospital, says Nancy Foster, the AHA's vice president for quality and patient safety policy. Some hospitals, she adds, are interested in obtaining government grants to improve post-discharge care in tandem with community organizations.
A Financial Imperative
Unless hospitals work harder on safety than they have in the past, there could be serious financial repercussions. These will come not only from the VBP program, but also from CMS rules that penalize hospitals for certain health care-acquired conditions, "never events" and, starting in 2012, preventable readmissions.
"With Don Berwick moving into his position at CMS, hospitals have realized that the never-events, readmissions and hospital-acquired conditions not only harm patients but, in the future, also will cost hospitals a lot of money," says Berc Gawne, M.D., vice president and chief medical officer of the Christ Hospital in Cincinnati. "They do already, but in the future, you won't be reimbursed. So, having a conversation with your CFO about quality has gotten a whole lot easier."
Bassett Healthcare Network in Coopers-town, N.Y., a leader in the patient-safety movement, is paying close attention to VBP. The board of directors has asked to see a quarterly report on all the measures targeted under the program, comparing Bassett's performance with state and national averages, notes Ronette Wiley, Bassett's vice president of performance improvement and care coordination.
"This is an extreme game, and everyone is vying to be in the top 10 percent of hospitals on these measures," she points out. "It's going to be very difficult, because everyone is striving for perfection."
Doing the hard, sustained work required to improve safety requires an "incremental investment" by hospitals in staff or new technology, or both, points out Nicole Latimer, executive director, business intelligence, for The Advisory Board, a consulting firm in Washington, D.C. "It's going to seem like an up-front cost, and they may not see a return on that for a while."
Latimer cites the electronic surveillance software that 80 percent of hospitals use to reduce infection rates and report those rates to CMS and many states. "When you ask them what has been the return on that investment, they say, 'We've started to see some reduction in our infection rate,' and it's only two to four years later that they're getting the type of return that offsets the additional cost."
The Advisory Board says that software and other measures to reduce health care-acquired infections has demonstrated an return on investment of 2:1 to 2.5:1. Latimer says the ROI comes from avoiding the additional cost of treating complications for which CMS won't pay, and she predicts that the financial return will be even more significant when VBP and accountable care organizations arrive.
Kaiser Permanente already is a kind of ACO, and it benefits financially from avoiding complications and readmissions on commercial as well as Medicare patients. "That's the beauty of a system where you have aligned financial incentives. Our hospitals are viewed as a cost center, not a revenue center," notes Jed Weissberg, M.D., senior vice president, quality and care delivery excellence, for Kaiser, which pledged its support to the Partnership for Patients.
The 2-Part, $1 Billion Strategy
The Partnership, which involves providers, consumer groups, unions, employers, health plans and states, is divided into two parts, each of which will spend up to $500 million in federal funds.
To improve transitions of care, CMS will provide grants to community-based organizations allied with hospitals. While it's unclear what will comprise these CBOs, they must include patients and other local stakeholders. During the five-year care transitions demonstration project, which ends in 2016, "CBOs will be paid on a per eligible discharge basis for Medicare beneficiaries at high risk for readmission, including those with multiple chronic conditions, depression and cognitive impairments," according to the CMS website.
Many hospitals have increased their efforts to improve handoffs and reduce readmissions over the past couple of years. They're collaborating with physicians as well as post-acute care providers. For example, Bassett Healthcare Network formed a care transitions team that includes skilled-nursing facilities, home care agencies and durable medical-equipment vendors.
Health IT is a key tool in improving coordination of care. Latimer says a hospital might acquire an electronic health record and then extend the EHR not only to its employed physicians, but also to community primary care doctors, SNFs and long-term care facilities. It may even connect online with home-health agencies.
The Center for Medicare and Medicaid Innovation can spend up to $500 million "to test different models of improving patient care and patient engagement and collaboration in order to reduce hospital-acquired conditions and improve care transitions nationwide," the CMS fact sheet on the Partnership says.
Weissberg, says the Innovation Center staff is gathering best practices from around the country and will make them available to participating hospitals. "[They] will then try to build an evaluation framework to see whether the hospitals are delivering on the promise," he says. "They're also getting stories about who are the best performers—such as which hospitals go two years without a bloodstream infection in the ICU—so they can show others that it's possible."
Observers don't believe that hospitals will have to do any additional reporting beyond what they're already doing to document and code "present on admission" diagnoses and complications in the hospital.
One Solution Doesn't Fit All
The last few years have seen a sea change in thinking about how to improve safety in hospitals. The Joint Commission, for instance, long focused on a best-practices approach, along with goal-setting and sentinel alerts, says President Mark Chassin, M.D. But since founding the Center for Transforming Healthcare in 2009, the Joint Commission has been tackling such issues as hand hygiene, hand-off communications, surgical-site infections and wrong-site surgery based on individual hospitals' safety environment.
The center is using what Chassin calls "robust process-improvement tools," including Lean, Six Sigma and change-management techniques borrowed from other industries. "We're taking steps that we haven't taken before to understand why the process is failing," he says. "Under the old best-practice approach, you heard a story about a hospital that did a good job and [then you] tried to do it the same way. What we are finding is that the causes of these failures differ from one place to another. And each separate cause requires a different strategy to get rid of it."
Chassin emphasizes that the Joint Commission is working on the same safety problems as Partnership for Patients. "Each of the center's projects dovetails perfectly with one or more aims of the Partnership." But if the Innovation Center funnels some of its technical assistance funds through the Joint Commission—as Chassin hopes it will—hospitals will have a strong incentive to adopt its model for safety improvement.
"I think our approach is going to demonstrate that the old standby of borrowing best practices is not going to lead to the major improvements that lots of stakeholders, including CMS, are demanding of the delivery system," he says. "A few percentage points of improvement, year after year, are not going to get us there. The old approach of throwing the kitchen sink at a problem is not sustainable. It's not a prescription for major, durable improvement."
Meanwhile, the central region of group purchasing organization VHA has launched a Target Zero safety campaign that uses the "high-reliability" systems approach of Healthcare Performance Improvement LLC, a consulting firm in Virginia Beach, Va. Encompassing 12 hospitals in Indiana, Kentucky, Michigan and Ohio that volunteered for Target Zero, the initiative is designed to improve safety across the entire health care organization, not just in specific areas like the intensive care unit or the operating room.
Christine Hoffman, senior director of performance improvement for VHA Central, notes that safety efforts tend to operate in silos within hospitals. "You're trying to reduce pressure ulcers or patient falls. And there's an underlying foundation you need to have that has to do with being a high-reliability organization." Among other things, VHA looks at how hospital leaders create expectations and hold their staffs accountable.
The high-reliability approach, borrowed from industries like aviation and nuclear power, is the logical next step for hospital-safety initiatives, says Jeff Selberg, chief operating officer of IHI. "We need to apply improvement science to all-source harm and build a high-reliability organization in each hospital that can prevent any source of harm, regardless of what it is," he says.
Up to now, he notes, most safety efforts have targeted such specific areas of harm as central-line infections and ventilator-associated pneumonia. "In areas where we've had a specific focus, there are hospitals that have done exceptionally well. The issue is that those treatment bundles only represent a small percentage of all safety events that occur in a hospital."
Selberg believes a 40 percent reduction in health care-acquired conditions is feasible in only nine of the 10 categories specified by the Partnership for Patients. The 10th category, all-source harm, will require a different kind of assault—one that CMS itself is now investigating, he says, with help from "vanguard hospitals" and the Agency for Healthcare Research and Quality.
Doc, You're Part of a Team Now
Ultimately, success depends on the willingness of caregivers to make patient safety their top priority. Noting that health care has changed from an "individual sport" to a "team sport," Piedmont's Hamby says most physicians have not been "socialized" that way. "We haven't learned how to provide health care as a team rather than as a collection of stellar individuals. [Piedmont staff] had to learn how to do that, so if a unit secretary raises a question about a particular aspect of care, the physician will be open to that cross-check, just like the navigator of an airplane can raise a question to the pilot in the cockpit."
The Partnership for Patients tactics aren't sufficient, Hamby says. "We have to focus on how to get our culture into a team-based care model and focus on things that are not just inside the hospital. To me, that's what it's going to take to move the needle on safety in a substantive way."
Kaiser's Weissberg agrees. "The lack of teamwork is a pervasive issue in physician culture, and we at Kaiser are acknowledging that very directly and are taking it on and working on it actively. We consciously implement team care and train our physicians to understand they're members of the team. They rely on their team to ensure the best patient outcomes."
The Christ Hospital also emphasizes the cultural aspect of safety. While physicians and nurses agree on the importance of safety, CMO Gawne notes, "physicians have been trained to be captains of the ship. So they initially push back against standardization and teamwork. Hospitals have struggled with things like the universal protocol and time-outs. It's definitely an issue of culture. Culture takes work, and it takes time."
The Executive Factor
The Christ Hospital is using a variety of methods to imbed safety awareness into its culture. Those include having a "safety minute" at the beginning of every major meeting in the hospital, in which somebody tells a story about a clinician who advanced safety.
At monthly management meetings, a nurse or other caregiver who made a good "catch" or discovered something new about safety is celebrated. And, perhaps most importantly, part of executive compensation is tied to achieving safety goals.
Gawne believes that the VHA program and the Partnership will help improve patient safety. But will those and other national safety initiatives be able to help hospitals reach the goals that have eluded them for so long?
"All of these initiatives encourage hospital executives to be aware of what's happening with patient safety," says VHA Central's Hoffman. "And yes, that awareness is going to move the needle. But it takes a lot of work over a long period of time to impact it. It's not something that happens overnight."
Ken Terry is a freelance writer in Sheffield, Mass.