By Raj Behal, MD, MPH
Senior patient safety officer and associate chief medical officer
Publicly reported measures of quality — like those included in our section "Rush's Quality Measurements" — typically focus on whether a hospital "does the right things" for the patient. These right things are decided based on studies that show certain treatments (e.g., certain antibiotics for pneumonia) are better than others. Many of the "core measures" focus on doing the right thing, and not necessarily on whether the patient gets better. But it takes a lot more than the right antibiotics and similar "process measures" to ensure the patient actually gets better and returns home.
For patients to have the best possible recovery from the illness that brought them to the hospital and not suffer from inadvertent harm during their stay a lot of things have to go right. Despite hospitals' best efforts, we know this is not always the case. Humans make errors, so the system of care we put together must be able to "trap" these errors so they don't cause harm to the patient. For instance, a common practice is to double check the patient's name and drug information before a high-hazard medication (potentially hazardous to the wrong person) like chemotherapy or a blood thinner is given to patients.
These double checks pick up many of the errors, but not all of them because the second person who performs the double check has similar fallibilities as the first person. A safer hospital — and one that places great importance on continuous quality improvement will recognize this, and not just tell the staff to be more careful, but actually design the process or equipment in a way that such errors are engineered out. In this case, the hospital will be looking at patient safety in terms of reliability.
Good is not good enough
When it comes to safety in health care, just like in air travel, good is not good enough. No health care system is perfectly safe or perfectly reliable. In this context, good is the enemy of perfect. High reliability requires a preoccupation with failures finding and analyzing defects and implementing safeguards.
A continual focus on improvement and learning is a key component of excellent teaching hospitals. What is the best way to treat a patient with lung cancer? How can we best restore function in patients undergoing hip replacement? What can we do differently to keep our patients safe from harm? Another aspect of this continual focus on quality improvement is discussing mistakes openly and without blame. High-quality hospitals do not sweep their mistakes under the rug, and further, should tell patients when errors occur. Many hospitals perform what we call a "root cause analysis" when a patient is harmed, followed by an action plan for improvement. According to research in safety, we know that simply re-educating staff and modifying policies often leads to the initial problem recurring.
Questions behind the numbers
You will see hospital readmission rates in the news or on the Internet. A patient who has to return to the hospital within 30 days of discharge is counted as a readmission. It is very important to take a closer look at this "quality measure" before concluding that it reflects poor quality. For instance, if a patient with diabetes is treated, recovers and then comes back for an elective knee replacement, is that counted as a readmission? Is that poor quality? No. If a patient with heart failure comes back with worsening of heart failure, is that poor hospital care? It is if the hospital sent the patient home prematurely or without the right medications or without proper follow-up with a doctor. It's not poor care if the patient has advancing disease that requires further diagnostic testing or more aggressive treatments or if the patient has little social or family support.
These are very complex issues. Nevertheless, your hospital should do its due diligence and examine its care when faced with high readmission rates (or any other indicator with low performance). Just saying the data are bad or the measures are poorly designed is not sufficient.
Look beyond the numbers
Those are some of the reasons why I recommend not just looking at the numbers. Ask questions. Try to assess a hospital's commitment to quality. See below for some ideas on how to do that. Also below: what you should know about academic medical centers before selecting a hospital.
Recognizing a hospital's commitment to quality of care may not be as difficult as it sounds. The following are some indications of that commitment that you can often find online.
Transparency of quality data: More and more hospitals are publishing their quality data online for the public to see. Notice whether a hospital only shares its positive numbers. If they publish survey results of their patients, do they present the full picture or only what is complimentary?
Hospitals most committed to quality share the bad data with the good because they expect to show improvements over time, and because transparency is what's fair to the health care consumers. They should also be able to tell you what they are doing to improve where their data show weaknesses.
Exceeding standards: Many hospitals meet national standards of care. Others exceed them and make continuous quality improvement part of their routines. There are several organizations that specialize in evaluating and monitoring health care quality who also recognize hospitals that excel in aspects of quality care. Organizations that use a rigorous evaluation process for their recognition programs include the following:
American Nurses Credentialing Center, a subsidiary of the American Nurses' Association, which designates Magnet Nursing Status to recognize excellence in nursing.
The Leapfrog Group, a national organization that promotes quality of health care, recognizes hospitals with its Top Hospital Award for Quality and Safety.
Premier, a health care alliance that promotes high quality, cost-effective health care, names a distinct group of hospitals to its Premier Award for Quality list.
The Joint Commission, which accredits hospitals, is another organization that recognizes hospitals for going above and beyond. In addition to overall hospital accreditation, which is considered necessary for Medicare reimbursements, the Joint Commission offers additional accreditations and certifications.
The University HealthSystem Consortium, an alliance of nearly all the U.S. academic medical centers, provides its member institutions with rankings from its annual quality and accountability performance study.
A number of very good hospitals are recognized by some of these organizations for some aspects of care. The best hospitals, those most committed to quality of care, tend to show up on most or all of these lists. Learn more
If you are researching hospitals specifically for cancer care or heart care, for example, see if the hospital has achieved recognition from organizations that evaluate quality of care in the specific line of service.
Academic medical centers care for patients with simple as well as complicated medical and surgical problems because they have both primary care doctors and highly specialized physicians. Patients are frequently transferred and referred to academic medical centers from other hospitals because of their experience with difficult conditions and the level of care they provide.
More than just teachings hospitals, academic medical centers also have their own medical schools. Some also have nursing schools and other clinical education programs. Academic medical centers also conduct research, including clinical trials that offer patients more options that are not widely available.
The opportunity to teach and to be involved in research attracts many of the brightest and best physicians to work at academic medical centers. Patients benefit from more treatment options and innovative thinking because academic medical centers often lead the way in developing and offering new treatments. And since academic medical centers teach the next generation of clinicians, there are always doctors in the house whether it is Monday morning or New Year's Eve.