Thursday, December 21, 2006

First, kill as few patients as possible

That was the name of a humorous book by Oscar London, but there is a serious side to the concept:

For years, Don Berwick and his colleagues at the Institute for Healthcare Improvement have been proselytizing and working to improve care in the nations' hospitals. They conduct important research and offer training programs for all types of hospitals, medical staff, and administrators. Recently, they have offered a metric that is the grandaddy of all metrics, the
hospital standardized mortality ratio. This is a disease and procedure based, risk-adjusted single number that tells you how you are doing in term of deaths compared to the average and compared to other hospitals. According to IHI, "the HSMR, appropriately adjusted for multiple variables such as population characteristics and diagnoses, provides an essential starting point in improving care and reducing mortality. "

In shorthand, for us lay people, the metric gives a sense of your likelihood to die at a specific hospital compared to other hospitals. If your hospital has a value of 1.0, it is average. If you have below 1.0, it is better than average. If you have above 1.0, it is worse than average. [Note: See correction to this statement in my comment below.] As with all metrics, you can quibble with the components and argue with the calculations, but it is as powerful a tool as I have seen. It is rapidly becoming the touchstone for many hospitals as they review their safety and quality programs.

IHI offers this tool to help people do better. It is not meant for advertising purposes or punitive purposes. As they note: "Many hospital deaths could be prevented if all the factors that contribute to them were better understood. Each hospital death provides an opportunity for learning -- by understanding and addressing local conditions that contribute to mortality."

We recently asked a group of outside experts from places with the strongest national programs to review BIDMC's progress in patient safety and quality. We received a good grade, but we also received a number of thoughtful and helpful suggestions for improvement. We have high aspirations. Our goal is to set audacious targets for improvement in overuse, underuse, misuse, and waste in the care of patients -- to set plans and milestones for doing so -- and to manage towards those targets.

Academic medical centers have a special responsibility in this regard, to create within the safety and quality program an academically rigorous examination of what works and what does not in various health care settings. I have given you a few examples in the postings below, entitled "What Works". But no single hospital has a monopoly on ideas when it comes to this field, and the first step is for all of us to disclose publicly how we are doing.

This HSMR number is not published anywhere unmasked by name, but if you contact IHI they will give you your own data, which is what we did. To relieve your suspense, 0urs is 0.71, which just puts us in the top ten percent in the nation. (Frankly, if a Harvard-affiliated academic medical center were not better than average, everyone would have a reason to wonder why.)

I wonder if my academic medical center colleagues in Boston and around the country would similarly be willing to post their HSMR number publicly on their own and to authorize IHI to maintain a publicly available list on their website. With a national debate swirling about the cost of care and value of academic medical centers, what would be more powerful than a grand display of openness about our progress in trying to kill fewer people?


Anonymous said...

I hope you would have posted your HSMR, or progress on HAI, even if BIDMC's numbers didn't look so good. We need an independent entity--and not one that relies on substantial funding from hospitals--to have this disclosure responsibility so that we ensure that we patients get the good and not so good information.

In that spirit, anything you're not so proud of at BIDMC that you'd care to share?

john trenouth said...

This sounds similar to efforts in the airline industry years ago to improve safety through more transparent reporting of performance. They did this by removing many punitive actions against employee error. This freed employees from fear of reporting thier errors, encouraging better reporting which then allowed the entire industry to learn collectively and avoid repeating errors.

I hope this happens in healthcare as well.

Paul Levy said...

Dear anonymous,
Yes, I would have posted our number, regardless. Why don't you now ask that question and the others of other hospital administrators?

Patient Dave said...

> efforts in the airline industry
> a few years ago ... to report
> on-time performance

Here here! A month or two back I remarked on exactly that analogy. It's apt. Not much different from Consumer Reports "frequency of repair" records for cars.

20 years ago I traveled a lot between BOS and Detroit, a market that Northwest pretty much dominated. In those days you could give your ticket to another airline and they'd accept it, and they'd bill the original airline for the ticket revenue. (There was some condition that it only worked if there was no alternative flight on the original airline. I don't remember the details.)

I went through MONTHS of those Northwest SOB's delaying flights, hour by hour, until just after the only competing flight (United) had left, at which point NWA would cancel the earlier flight, combining two flights into one. It was a horrid experience.

The airlines fought tooth and nail against being required to report their on-time performance. But as soon as the requirement started, consumers voted with their feet based on the data. Flights that had 30% cancellation or 50% late were avoided. And guess what? Performance changed.

And re the Consumer Reports analogy - I heard on NPR today that Toyota may be about to pass Ford as the #2 car seller in the US.

I suspect that when we as consumers have the same kind of information, the same will happen in our choice of health care providers. Who would knowingly choose a hospital with a 50% higher death rate for a given procedure? Not I.

Let's see who, if anyone, fights tooth and nail against THIS idea.

Anonymous said...

Great idea to ask the other hospitals. Health Care for All, you represent consumers and we know you read Paul's blog: take up Paul's challenge and ask other hospitals to report their HSMRs, HAI rates and anything else you think we consumer need to know!

Paul, you didn't answer my question in the second paragraph....

Paul Levy said...

Stay tuned for more in the future, but I have already published some not so good stuff -- e.g., if you look at some of the monthly figures in What Works -- Part 4.

BTW, while you are asking for public disclosure, why do you hide behind "anonymous" on this topic? Is there something you fear in letting the world know who you are?

I know anonymity is often part of blog communications, but it does not seem right for you to ask me to be open when you are not. It's ok to just post an opinion that way -- but you might get a more focused answer to a question if you revealed your name and affiliation.

Bwana said...


You and your readers might be interested in the ASRS (Aviation Safety Reporting System - ah what would life be without acronyms?).

Here are two links:
asrs dot arc dot nasa dot gov/briefing/br_1 dot htm

asrs dot arc dot nasa dot gov/callback_issues/cb_317 dot htm

I had to replace the . with "dot" in the above as the comment system does not accept HTML tags.

The thrust is that the system of reporting is voluntary, confidential and non-punitive. I believe there are benefits to self-reporting, such as avoiding a punitive action by the FAA if they subsequently decide to charge you with a violation of the FARs (Federal Aviation Regulations).

I am sure that you are aware of the trend towards voluntary and self-initiated disclosure of medical errors to patients and their families. This concept has problems since the current approaches appear to be based on a "mea culpa" system which would result in an explosion of lawsuits with alleged "admissions" of liability.

But I digress...

It seems to me that revealing information about mortality, etc. -- presumably in an effort to gain the confidence of patients who would gravitate to the hospitals with better records is potentially a trouble area. If a hospital with a good rating has an unfortunate incident or rash of incidents, it might then lose business.

If the purpose is to kill fewer people then the ASRS model may be useful as it would allow independent, confidential reporting and allow appropriate adjustments to be made.

After all, the point should be to make ALL hospitals safer, not just for one to have bragging rights for a length of time -- sort of like a Nielsen TV ratings moment. After all, you don't want BIDMC to become the Katy Kouric of the medical community!

One other thought -- if we are dealing with quality of doctors, rather than quality of systems and procedures, could we seriously expect to see a change in medical personnel at a given hospital?

On a concluding political note, it is heartening to think that the idea of killing fewer people retains currency in some areas.


Paul Levy said...

The real hope is not to use this and other metric for advertising purposes but to gradually move all hospitals to better and better performance.

That being said, if one place really has better results than another, why shouldn't the public know about that? Insurance companies tell me that they hope over time to use this information to encourage patients to those institutions -- and to pay hospitals based on performance rather than on market power.

Patient Dave said...

> while you are asking for public disclosure,
> why do you hide behind "anonymous"
> on this topic?
> Is there something you fear in
> letting the world know who you are?

Okay, I'm the one who wrote about airlines and cars. I really don't know why I went anon on this topic. Except I don't like to own up to being angry.

Honestly, I think it's disgusting if someone doesn't want us to know this info. Truth is, I think it's filthy that the info would be given to providers but kept from the public's view. And I get angry.

And not so patient.

Paul Levy said...

I just received this clarification from Sir Brian Jarmin in a copy of a note he sent to his colleagues from IHI. While this point doesn't change the general conclusion I set forth, I apologize for the error.

"Paul Levy doesn't mention that it's the regression-adjusted-HSMR that he is referring to for the BI/Deaconess (they had a value of 71.7 for 2004), nor that the comparison should be with the value for the USA as a whole, which was 86 for 2004. This makes quite a difference because people reading his blog might assume that the USA HSMR value is 100 for 2004 (and he himself may think that's the case). They are 14 points below the national value, not 28 points.

"In making these comments I am assuming that he is referring to the HSMRs that I calculate, though he doesn't mention that and it's not mentioned on the IHI web link that he gives.

"I think we should be careful to make sure that people don't misunderstand HSMRs: a couple of references wouldn't go amiss near the front of the IHI website where HSMRs are first discussed - this would help to avoid any confusion between HSMRs and regression-adjusted-HSMRs. It would also make clear that the comparison which I give is with the USA value for the year in question (in this instance a USA HSMR value of 86 for the year 2004) and not with a value of 100. The USA HSMR value is, of course, 100 for the year 2000, by definition, because I use the USA year 2000 as the reference norm."