How to Get an “A” for Patient Safety?
As the movement away from fee-for-service towards value-based care marches on, hospitals and health systems will continue to be at greater and greater risk for payments. As patients, employers and insurers continue to bear the ever-increasing burden of rising healthcare costs, they will begin to demand better value for their financial outlay. Simply put, value = quality/cost. But what is quality and how will it be measured? Quality is a combination of numerous factors or variables in the value equation: Patient Safety; Patient Outcomes; Patient Experience; and Patient Satisfaction. Each of these variables has numerous measures associated with them and they are measured or “scored” by different agencies. For example, the Center for Medicare and Medicaid Services (CMS) measure quality, largely a proxy for patient outcomes, utilizing their Star Rating System, with hospitals ranked from 1- 5 stars. Patient Experience is largely assessed by HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, collected from patients surveyed after discharged from the hospital. Patient Satisfaction is most often assessed by patient surveys (mailed, emailed or telephonic) following discharge, with the Press Ganey survey being the tool utilized most often in the U.S. While the survey contains many questions, the score most often used for comparison is the “likelihood to recommend” the hospital. Patients are given four options: very likely, somewhat likely, somewhat unlikely, or very unlikely. The so-called Top Box score of “very likely to recommend” is tightly clustered around the national average of 72% + 11%.
In my experience, changing and improving a hospital’s or health system’s quality and safety scores can be a daunting task. To create hard-wired improvements requires a sustained effort and may necessitate an organizational cultural transformation. As some of the publicly reported measures are dated and involve one or two-year rolling averages, improvements might not be readily apparent for more than a year. As consumers have largely ignored the available data, most health care executives do not make their quality and safety grades a high enough priority to warrant this sustained effort. Moreover, because of the lag time from meaningful change to reported results, leaders and staff can quickly become frustrated. Patient Satisfaction scores can be impacted in a shorter timeline, but there a few challenges: first, the data is reported as rolling one year averages so quarterly improvements are outweighed by the prior 9 months’ performance; second, and the data is moire than one year old when publicly reported; and third, improvements tend to be modest, despite significant efforts. For example, at Saint Francis Hospital, a 600 bed, Level 1 Trauma and full-service teaching hospital, we were able to move the “very likely to recommend” scores from the State and National Average of 72% to over 82%, but this was over five years!
Patient safety is assessed and scored by The Leapfrog Group, using an A to F grading system. The Leapfrog Group was formed by Fortune 100 companies and other payers twenty years ago, soon after the Institute of Healthcare Improvement (IHI) reported in “To Err is Human” that approximately 44,000 lives are lost in American hospitals each year due to preventable medical errors. While the number has been questioned, more recent analyses of the data suggest the number was closer to 100,000 and now might be close to 400,000 deaths each year, making preventable deaths in hospitals the tenth leading cause of death in the U.S. As with the other measures of quality, numerous measures--28 to be exact--go into the formula used by The Leapfrog Group and hospitals are “graded” twice per year, in the Spring and Fall. Only about 10-15% of hospitals earn an A rating, and fewer than 10% get an F. About half the hospitals earn a C or worse. I have had success in driving a hospitals safety score in two different health systems. In my most recent position as President of Saint Francis Hospital, we earned four consecutive A ratings in the past two years and seven A’s and one B in the last four years. Our closest and most similar competitor in the same market earned 8 C’s over that same period. Only a small percentage of hospitals in the U.S attain 4 straight A’s; indeed, not another single hospital in CT was able to do so during this same two-year period.
As the Hospital Patient Safety Grade from Leapfrog is the one grade that gets reported twice a year, it can be improved upon in a shorter time frame than some of the other measures in the value equation. Also, going from a “C” to an “A” can be very satisfying and to an executive team, the staff and the Board of Directors. So, I am frequently asked, how did you do it? There is no simple answer to this question, but upon reflection, there are ten key lessons I have learned during the quality and safety cultural transformation journeys.
1. Create the “burning platform”. Share your letter Grade with your senior leadership team. If your competitors have better grades, show their grades for comparison. Competition is a good thing.
2. Make it personal. If your grade is a C or worse, ask your team if they want to be part of a leadership team of a hospital with a mediocre safety record. Make it clear that this is important to you; if you are an effective and valued leader, your team will not want to let you down.
3. Go beyond the grade. Show how your organization is faring in each of the 28 measures that go into the overall grade. Celebrate any successes within; undoubtedly, there will be some. You can build upon these.
4. Make it real. Leaders tend to share the good letters they receive from grateful patients and send the bad letters off to the risk management or patient experience managers. Read aloud letters from patients with bad experiences and bad outcomes. A little shame and guilt can go a long way to motivate changes in behavior. To drive real change, you must make the stories real and paint the picture for your team. Who better to do this than the patients themselves?
5. Make it personal. Very often, quality and safety data are shown on tables and charts with numbers and red and green dots. Remind your leadership team, that behind every number or red dot are patients who have been hurt on your watch. Falls with injuries, hospital-acquired pressure injuries, significant medication errors, etc. Remind you leadership and management team that these patients who have been harmed are their neighbors and friends, or even members of their own families. They are someone’s brother or sister, mother or father, son or daughter.
6. Strive for attainable goals. Setting unrealistic, and sometimes mathematically unattainable goals, is a sure-fire way to frustrate and disappoint your staff. Your organization is unlikely to go from a D to an A in a single six-month period. Consider raising your safety scores more of a marathon than a sprint, particularly if you want the results to be hard-wired and sustainable. Hospitals frequently bounce back and forth between A’s and C’s, but achieving consistent A’s takes a sustained effort.
7. Learn from others, inside and outside of the healthcare industry. When we are experiencing unacceptably high rates of hospital-acquired pressure injuries—so-called HAPIs—we read all the success stories of other organizations. I appointed our CNO as the accountable executive and she took ownership of the issue. She spoke with her counterparts at other organizations that had successfully reduced their HAPI rate. You will find that even your competitors are very willing to share their safety best-practices.
8. Drive the change from the top. As a CEO or president, you must drive this change from the top. Be sure to assign one of your C-suite colleagues the primary responsibility for the measure you are focused on. You might have two or three executives working on different measures. For example, your CMO might be responsible for hospital-acquired infections, your CNO might have HAPIs and your COO might have the job of reducing medication-errors. Meet with them regularly and make the safety initiative the first item on the agenda to assure there is time to address it and to remind your team that this is a top priority item. Incentive compensation can be tied to the measure, but your message to your team should not be, “Improve the score or you’re fired”. The message should be, “This is important to me and the Board, and most importantly to our patients and their families who trust us to prevent harm.”
9. Celebrate your successes. Share any improvements with your management team as soon as a trend is established. Depending on the size of the organization, it might take some time to demonstrate meaningful progress, so resist showing improvement in short intervals of weeks or even 1-2 months, as improvement does not usually manifest as a smooth upward sloping line, but is more of a saw-tooth pattern with a regression line showing improvement over time. Month to month up and down variation might frustrate the team, while quarter over quarter changes are usually clearer evidence of improvement.
10. Do not try to fix everything at once. Think of this as trying to improve your college GPA. If you have 2 A’s, 2B’s, a C and a D, work on the C and D first. You are more likely to make substantial gains and then you can build upon these going forward. However, be sure to not allow your gains to regress over time. With each improvement, raise the target and challenge your team to beat it.
