How Much Should We Measure in Hospital Quality?

Why some of the leading pundits have it all wrong

OMW! Here we go again. Yesterday in an editorial on psqh.com, Don Berwick is quoted as stating at the IHI National Forum in December 2015, that we should “cut in half all metrics currently being used and then cut them in half again.”

I wholeheartedly disagree. And here is why.

Clinical Dashboard – Hemorrhagic Stroke

Ischemic Stroke DB Pt 1

How You Can Create Your Own Total Knee Replacement Dashboard

It's Easier Than You Think

Creating a clinical dashboard is easier than you think – and with this template and tips you’ll be on your way to having a dashboard in no time.

Quick Tips to Get You Started

First, you need the design for the Total Knee Replacement (TKR) Dashboard. Download it here in excel format.

Second, you need to remember three “truths” about quality data.

Mandatory Bundled Payment Set for Total Joint Replacements

Bundled Payment Set for 67 Geographic Areas

The Associated Press reported recently that Medicare launched mandatory bundled payment for hip and knee replacements effective April 1. 67 metropolitan areas are on the list and more will likely follow, so preparing for bundled payment ASAP is the smart play.

What’s Your First Move?

How a Medication Error Killed My Grandpa

Would "No Interruption Zones" Prevent Such a Tragic Outcome?

My Grandpa was one of my heroes. He had survived WWI, the Great Depression, and WWII, and yet, he still wore a smile on his face everyday. And he loved his grandkids, and his great grandkids.

I was taking the second part of the boards one day when the dean came into the auditorium and pulled me outside.

She said, “your grandpa has been in an accident. He’s over at St. Mary’s. Go to him and we’ll worry about this test later.”

I had just finished a cardiology rotation at this hospital and one of my professors was Grandpa’s cardiologist. This gave me a sense of hope that Grandpa would be OK.

My professor said, “your Grandpa has a pneumothorax (a collapsed lung); they put in a chest tube to reinflate it; his heart failure is stable; we fully expect that he will make a full recovery.”

I was so grateful my Grandpa had a good prognosis.

The next several days went off without a hitch, but then … three days later my professor called me aside, and he had a grave look on his face.

How to Solve Our Healthcare Patient Safety Crisis

And a New Resource That Can Help

We have a healthcare crisis of epic proportions – a patient safety crisis. It only came to light in the 1990’s, but its likely existed in all of our healthcare organizations for our entire careers. But so far, we have only made a dent in the problem. Our patients know this and they are afraid, their families are afraid, and when we’re honest with ourselves, many of us worry about being hospitalized in our own organizations.

Here are the sobering statistics:

  • 210,000 to 440,000 people lose their lives each year to medical errors in hospitals, according to research conducted by J. James and published in the Journal of Patient Safety.
  • Medical errors may now rank as the third leading cause of death in the United States; only cardiovascular disease and cancer takes more lives each year.
  • Preventable Adverse Events (PAEs) account for “roughly one-sixth of all deaths that occur in the U.S. each year.
  • More than 1,000 people die every day from preventable accidents in hospitals.
  • Preventable medical errors, in the form of “oops”, errors of omission, complications, readmissions, and avoidable mortality cost the US economy untold billions each year.
  • The average hospitalized patient experiences 1.5 medication errors daily and medication errors are the most common form of error.
  • There are more than 6 million patient injuries per year due to errors.
  • 40 percent of hospitals received a C, D, or F on Leapfrog’s Safety Score.
  • According to the Leapfrog Group, “since Fall 2014, (hospital) performance on safety outcomes – including preventing errors, accidents, and infections – has not significantly improved.”

A Dashboard for Total Knee Replacement

The Key to Managing Clinical Outcomes

Here’s the first of more than a dozen clinical dashboards that I’ll share in the coming weeks. Why? Because the pressure on physicians and hospitals to manage clinical outcomes increased exponentially when ProPublica published surgeon complication rates on the web in July.

This dashboard is for total knee replacement (click here to download an excel file). It’s one of eight surgical procedures reported on the Surgeon Scorecard and is also a high volume procedure in many hospitals. It’s also included in your hospital’s Healthgrades ratings and Truven 100 Top Hospital profiles.

I’ve used this dashboard for over 15 years. It has always been a critical part of my quality programs because it provides all of the important information needed to manage the quality of care for total knee replacement patients. Just as administrators use a monthly financial report to manage their budgets, the total knee replacement dashboard becomes the monthly report to manage quality and safety for these patients.

The Total Knee Dashboard contains several important sections:

  1. Process measures. These represent treatments recommended by evidence based medicine guidelines and order sets.
  2. Outcome measures. These are patient outcomes such as complications, readmission rates, mortality and LOS. In this example, only rates for “not present on admission” are included, because we only want to know what occurred during the hospital stay.
  3. Core measures.
  4. Comprehensive rates for Healthgrades complications and the HealthGrades star rating.
  5. Direct costs divided into the usual cost buckets. Implant costs could also be included here.
  6. Estimates for the cost of complications based on the complication rates reflected in the dashboard.

Where You Can Get The Data for The Dashboard

Most of the dashboard data comes directly out of your finance, coding, and/or cost accounting systems. This is one of the best kept secrets in healthcare. Frankly, there is enough data in these systems, (that can be converted into clinical dashboards), to keep you busy for the next 10 years. I’ve used this type of administrative data for the past 20 years and it’s been key to all of the 100 Top Hospital, 15 Top Health System, and Healthgrades designations.

I’ll post a second dashboard next week. Until then, if you have any questions about this dashboard feel free to email me at john@johnbyrnesmd.org and I’ll get back to you as quickly as possible.

PS: The data contained in the dashboard is for demonstration purposes only.

ProPublica’s Surgeon Scorecard Will Be Used for Recertification of Orthopaedic Surgeons

The American Board of Orthopaedic Surgery Announcement

In an article posted October 13, 2015, ProPublica announced that the American Board of Orthopaedic Surgery (ABOS ) will use ProPublica’s Surgeon Scorecard to help assess the competency of its surgeons.

According to ABOS Director Shepard Hurwitz, MD, “The American Board of Orthopaedic Surgery will incorporate (ProPublica) Scorecard’s ratings into its recertification process, in which surgeons are formally re-evaluated every 10 years.” He said, ‘Surgeons may also be put on a watch list based on their Scorecard rating.”

Dr. Hurwitz said the ABOS board of directors approved the decision on Oct. 5.

The ABOS is the first surgical board to formally use ProPublica’s Scorecard in it’s recertification process.

About 11,500 orthopedic surgeons are rated on the Surgeon Scorecard for complications following hip and knee replacements, two types of lumbar spinal fusion, and cervical fusion.

The Surgeon Scorecard has been controversial since it’s introduction in July, but publishing physician performance has been long overdue.  It’s a good first step in helping patients find surgeons based on the physician’s outcomes.

Dr. Hurwitz went on to say that the decision by the ABOS “… is controversial, but the fact that we’re doing it is in the spirit of transparency and holding people accountable for what’s already in the public domain.”

Like this story? Read my previous post, Surgeon Complication Rates Now Posted on the Internet where I share how I used this information when my sister underwent a knee replacement.

Surgeon Complication Rates Now Posted on the Internet

Information on Physician Performance is Here to Stay

Patient complication rates have been posted on the Internet for almost 17,000 surgeons. This landmark undertaking was achieved by ProPublica, an independent, non-profit newsroom[1].

ProPublica posted their “Surgeon Scorecard” in July. It compares the performance of surgeons for eight common elective procedures, including hip and knee replacements, spinal fusions, gallbladder removals, prostate resections, prostate removals, and cervical fusions.

The power of ProPublica’s site was demonstrated to me this morning when my brother sent me a text message that said, “Kathy (his wife) is having her knee replacement this morning.” I immediately asked for the surgeon’s name and then looked up his stats on ProPublica’s new site. In less than 5 minutes, I had information that would have previously taken hours, if not days, of phone calls to colleagues and professional acquaintances for recommendations and best guesses about who would be best for my sister-in-law to see.