Not long ago, a few colleagues and I were discussing the challenges of improving health care quality and patient safety. We debated the merits of clinical benchmarks that payers and regulatory groups now require, crude proxies of quality care like giving antibiotics at certain times, ordering specific tests at set intervals or permitting our results to be reported publicly.
One colleague, a devoted and highly respected clinician in his department, admitted that he found this growing list of directives from others exasperating. “I’m all for taking great care of patients,” he said, the muscles along his jaw tightening. “But how can some insurance bureaucrat or policy wonk who’s not in the clinical trenches know more about taking good care of real patients than someone like me?”
Since 1999, when a national panel of experts released a landmark report on the high number of medical errors, insurers, policy makers and regulatory groups have been piling onto the quality-improvement wagon with ever increasing gusto. As a result of their enthusiastic efforts, hospital accreditation procedures and standards have become more rigorous, physician duty hours have been trimmed, hand-sanitizing gel dispensers in hospitals have multiplied and physician reimbursement has been linked increasingly with quality goals and less with the number of CT scans ordered.
But few of these quality enthusiasts are actually caring for patients. And when a study in The New England Journal of Medicine last fall reported thatdespite all the efforts and new financial incentives, there was no significant decrease in patient injuries, these same enthusiasts were quick to point to the inertia and intractable attitudes of the medical “culture.” They noted that less than 2 percent of hospitals had installed comprehensive electronic medical records systems, doctors and nurses were routinely working in excess of limits on duty hours and few were paying attention to even simple hand-washing recommendations. It would take nothing short of an all-out legislative, financial and regulatory assault to change the system, many of them concluded.
But what these “experts” failed to take into account was the same thing that has led to the downfall of countless other groups’ efforts to create sustainable change: They ignored the contributions of the people within the system.
Based on an initiative in the 1990s that sharply decreased surgical complication rates in the Veterans Health Administration, the program was offered to all hospitals beginning in 2004 and is now used by surgeons at more than 400 institutions. Unlike most other quality programs, which gather data from insurance claims and coding data, it relies on information from patients’ hospital charts and follows patients for 30 days. A detailed analysis, along with statistics comparing results with those of all other participating hospitals, is then sent back to participating hospitals.
“When you feed back data that clinicians can believe and tell them that there is room to improve, most will work to get better,” said Dr. Clifford Y. Ko, who has directed the program for the last five years.
Surgeons and hospitals that discover, for example, that their rate of wound infections after surgery is higher than other participating hospitals have convened forums to discuss the issue, established electronic checklists to remind staff to administer timely prophylactic antibiotics and instituted mandatory training courses to improve how doctors and nurses care for patients’ incision sites before, during and after an operation.
“If a surgeon is doing several hundred operations a year and the department is doing several thousand, it’s difficult to keep track of all the urinary tract infections that patients might be having,” said Dr. Fabrizio Michelassi, surgeon in chief at NewYork-Presbyterian Hospital, which has been a part of the surgical improvement program for several years. “NSQIP has the power to let us examine complications and outcomes on a large scale, drill down and make systemwide changes, then see their effects.”
The program has also slowly transformed the traditional hierarchy of surgery. Nurses are crucial members of the surgical quality improvement team at each site, and employees from administration, pharmacy and central processing and sterilization are sometimes included on review teams. “There isn’t anyone who isn’t a part of this process,” said Jennifer Ritz, a nurse who has helped to run NSQIP at Henry Ford Hospital since 2006.
But not all hospitals have adopted the program. Many are already overwhelmed with the administrative demands of existing quality improvement programs, and the cost — a yearly fee of $10,000 to $24,000, plus the training and support of at least one full-time nurse — can be prohibitive. There’s also no immediate return on investment. “If you buy some high-tech surgical robot, more patients and surgeons are going to come to your hospital,” said Dr. Dennis Begos, chairman of surgery at Winchester Hospital, a 250-bed community hospital north of Boston that participates in the program.
The American College of Surgeons hopes eventually to collaborate with regulatory and federal agencies so that more hospitals, and patients, might be able to benefit. And it’s working with participating hospitals to further refine the program. “We all know that it’s hard to move the quality improvement dial,” Dr. Ko said. “But NSQIP has shown us that it is really possible to change care and give our patients better outcomes.
“And that quality improvement is local.”