How do struggling hospitals recover from a very public 'F' grade on patient safety?
When Leapfrog released its Spring 2016 patient safety grades recently, 15 hospitals got slapped with a very public 'F' grade casting a spotlight on them that no institution wants. But with more patients weighing public hospital grades, experts, as well as a few hospitals that have faced down bad grades, say denial is the last thing a poorly marked hospital should do.
Despite varied methodology among ratings programs, consumers are using these rankings to judge the institutions charged with healing them when they are at their most vulnerable, said Rita Numerof, president of healthcare strategy consulting firm Numerof & Associates. Consumers are also paying far closer attention to these types of rankings because they are shouldering increasingly larger portions of their healthcare costs, and are far more scrutinizing about where they spend those dollars, she said.
"As organizations have moved to high deductible health plans and payers have incentivized consumers to go to organizations or have a benefits package that shifts choice to higher value organizations, consumers follow the money, she added. "They've never had this kind of information readily available to them before, and the bottom line is when the consumer is forced to spend more of his or her own money this choice matters."
That's great news for those who scored well, but those who didn't make the grade must confront the fallout while fixing the issues that ail them.
[See also: Leapfrog out with troubling hospital safety numbers.]
Stony Brook University Hospital, located in Stony Brook, N.Y., was one of 15 hospitals to receive a failing grade from Leapfrog, capping what has been a years-long slide in the rankings. From the fall of 2013 through spring 2015 Stony Brook earned four B's in a row. This past fall it slipped to a C, and then bottomed out in the most recent rankings. The hospital profile on Medicare.gov shows data to support Stony Brook has issues with patient safety. It has been penalized for the past two years by Medicare for patient safety incidents, and ranked "worse than the national average" on Medicare's Hospital Compare for serious surgical complications, healthcare associated infections, including catheter associated UTI's, and intestinal infections, and several readmission categories as well.
According to its website, the New York State Department of Health lists the hospital as high quality performers when it comes to hospital mortality for common conditions and average performers for its rates of hospital-acquired bloodstream and surgical site infections, and timely and effective care. The state lists its patient satisfaction rating as 68.44 percent. However, it was rated as poorly perforning when it came to common patient safety problems, emergency department timeliness, and 30-day hospital-wide unplanned readmissions.
Why did Stony Brook perform poorly? Officials responded it was due to errors and misinterpretations on the voluntary portion of the Leapfrog survey, which the hospital took for the first time this year.
"Due to a misunderstanding of the Leapfrog survey questions and electronic query processes, several operational and systems measures were given ratings that do not accurately reflect our current practices. This had a significant negative impact on our overall grade," Stony Brook officials said in a statement. "The areas where there was confusion included questions about operational, processes and reporting, not in the clinical outcomes. When the errors in interpretation were discovered and brought to the attention of Leapfrog, they advised that the review period had closed and the data could not be corrected and grade could not be changed,"
They did not address other questions with regard to some of the publicly available data that support's Leapfrog's grade, or whether they thought the alleged survey errors were the only reason for the poor grade. They also did not specify any measures currently underway to improve patient safety.
Leapfrog said that while they had been in contact with Stony Brook over the survey issues, there may have been other issues at play. According to Missy Danforth, vice president of hospital ratings for Leapfrog, Stony Brook reviewed its survey results and the CEO explained there were practices the hospital is compliant with that his staff didn't know about and did not report on. Leapfrog said they encouraged them to take a different approach to completing the survey "as it is really a gap if there are policies and practices the CEO knows about that the front-line staff and senior managers are not aware of, particularly if they are related to patient safety." Leapfrog said Stony Brook informed them they are committed to improving this process for next year and that they are "working hard on many fronts related to patient safety."
However, Leapfrog also asserted that the errors could have been avoided if their review process had been followed appropriately. They explained that Leapfrog gives hospitals technical support through a help desk and hospitals have opportunities to review their submitted responses and make corrections while the survey is open. The survey is open from April 1 - January 31 of each year. After the survey closes, no changes can be made.
"We publicize our deadlines and make clear how our measures are scored. We also have a CEO attestation of accuracy that every CEO must sign off on, or designate a delegate to sign off on, for each submitted section of the Leapfrog survey. This hospital submitted their 2015 survey on December 22nd, and their results were publicly reported on our website on January 5th. We encourage all hospitals to review their publicly reported results to check for data inaccuracies. If the hospital had noticed discrepancies in reviewing their publicly reported results, they could have updated their survey at any point throughout the month of January prior to the survey closing."
Whether the survey errors were the major culprit or not, the fact that they offered no other explanation coupled with existing public data, which doesn't paint an entirely flattering picture of the institution, casts doubt on the true significance of the survey issue and moreover plants a seed of doubt in the public's eyes, said Numeroff.
"The worst approach is blame, denial or rationalizing away the numbers. Even if you don't like the measures, and there's lots of complexity behind the measures and they're far from perfect, knowing that you still have to perform against them. Taking this as a wake-up call and a lesson and recognizing that there is work to be done would be really helpful. You have to get your own house in order and to do that acknowledging mistakes is a starting point," Numerof said.
Other hospitals who received F's didn't delve into enormous detail, but were willing to admit there were things they needed to do better.
For Clarion Hospital, a small facility in Pennsylvania, this is the fourth failing grade they've gotten from Leapfrog, and they haven't scored better than a D since fall of 2013. They said there were not surprised that this spring brought their 4th 'F', but stress that they have been making improvements and are committed to patient safety.
"Patient Safety is very important to us here at Clarion Hospital. We are aware that our score is below average and have developed internal processes to make the necessary improvements. It is our mission to improve our Leapfrog grade within the next quarter," said CEO Byron Quinton.
They said their rates of hospital-acquired infections, patient harm incidents and avoidable deaths are all in line with state averages, and cited outdated data as a potential contributor to their poor grade.
"We are small community hospital and have lower numbers in comparison to many hospitals. The timeframe for the data, in some cases is greater than 3 years old and has not been updated, which reflects poorly on us even as improvements have been made," Clarion said in a statement.
Saint Michael's Medical Center in Newark, New Jersey also doesn't have a history of high scores to refute their current 'F'. Four straight D's in a row starting in fall of 2013 were followed by a peak C in Fall of 2015. Then came the bottom this spring. They did not participate in the actual survey portion and said based on public data their performance is on par with state averages, so the failing grade was a surprise.
According to Medicare.gov, St. Michael's is rated as a two-star hospital and is on par with national benchmark's when it comes to complications, and most readmissions/deaths categories except for unplanned readmissions for heart failure patients, where it was scored worse than the national average.
While St. Michael's Chief Medical Officer Claudia Komer also pointed in part to outdated data as having influenced their grade, it was not a flat-out denial, and stressed that the issues they do have are being addressed.
"The publicly reported data for two key areas used in the Leapfrog report, central line-associated bloodstream infection and catheter-associated urinary tract infections does show higher than average rates for the reporting period from April 2014 to March 2015. The hospital, however, having already identified the issue, developed a corrective plan of action to reduce both types of infections. We are happy to report that in the first quarter of 2016, we had zero CLABSI and CAUTI infections."
She said they have also addressed another shortcoming, the lack of a computerized physician order entry system. They said they received a zero in this category, but have since implemented such a new system. Finally, Komer said the hospital is under new ownership, having been acquired by Prime Healthcare in early May. She said the new parent company will open doors to better patient care for their hospital, and in the future they will definitely participate in the Leapfrog survey.
"Prime brings extensive resources to Saint Michael's that the hospital just didn't have before, including the sharing of best practices with other Prime hospitals nationally. Prime also has a stringent internal quality reporting process and each hospital is held accountable to those standards. Saint Michael's will have the resources to achieve an entirely new level of intense focus on patient quality and safety. It's what our patients deserve."
[Also: Leapfrog: 798 hospitals earn A scores for patient safety; See the list]
For Van Wert County Hospital in Van Wert, Ohio, the fall of 2014 and the spring of 2015 were bad months. The 70 bed nonprofit in northwestern Ohio received two failing grades in a row from the Leapfrog Group for patient safety, and staff there felt like they had been blindsided, having been under the impression that they provided safe and quality care. It was a bad assumption, Interim president and CEO Mike Holliday said, that had bred a culture of disconnect.
"We really didn't have that top-down focus because everyone assumed that we didn't have those kinds of issues. Once the information came out from Leapfrog, that hit us in the face and made us stand up and take notice," Holliday said.
His plan: fess up. There was no blaming their grades on survey errors or old data, Holliday said. They simply owned up to their problems.
"We took it at face value that it is what it is. It's not a very pleasant situation to find ourselves in. We had some work to do and we were going to roll up our sleeves and address those issues," he said.
Holliday said they got senior leadership involved from the start, and over time, invested in several programs that would help them discover where the issues were. They also instituted measures that brought staff closer together and opened the lines of communication wider than they had ever been. He said they sought education opportunities on how to improve their culture of patient safety, and put time and financial resources into the National Database on Nursing Quality Indicators program. The program's survey was provided to staff on a quarterly basis and the results helped steer their course in making needed improvements.
Holliday said they fostered teamwork and communication through the implementation of daily patient safety huddles, where every morning staff got together to review safety protocols and identify opportunities for improvement. These huddles happened at the management and executive levels as well, with senior leadership meeting daily to review the past 24 hours of activity for needed improvements and look ahead to what might come up in the next 24 hours.
"We can't fix issues if we don't know about them. So it gives staff an opportunity to raise those issues, raise those concerns and red flags and then give management the opportunity to address them in a positive educational learning process. It also helps make staff more comfortable with reporting those issues and then we can show that there's no negative culture about it."
Finally, to fix safety issues related to medications, pharmacists became part of rounding. They went with physicians, nurses and other staff as they met with patients to allow the pharmacist to communicate with the patient about their medication and also follow up with nurses and physicians on any issues.
Holliday said the turnaround happened faster than expected, and the 'A' they earned this spring was a much appreciated validation of all their effort. But it wouldn't have been possible if they had instead chosen to close ranks, deny they had issues, and opt for tight-lipped damage control to the public and the media.
"The benefit was to show the community we serve that we're transparent, that we're very serious about these issues, and that we know that they're depending on us as they're giving themselves up to us to help them through their medical conditions. It gave us the opportunity to re-earn their trust. Had we approached it differently we would have been subject to a lot of skepticism within the community and the potential of more negative press."
Wayne Memorial Hospital in rural Jesup, Georgia, also earned an F in fall 2014 rankings from Leapfrog, and it hit staff hard.
"We were devastated and our first focus was to find out where we could do better," said Kathy Buchannan, chief nursing officer.
The small 84-bed nonprofit facility had just lost two long-time trusted surgeons, and had been going through a difficult transition as replacements who Buchannan said lacked a focus on patient safety came and went.
"We felt like that was our weak link at the time," she said.
She also explained staff communication was a problem. But since they had close relationships with the members of their small rural community, denial wasn't an option for them either.
"It was in the newspaper. I remember when we got the F. We get a lot of the same patients because it is a small community. Some people didn't believe the F. But we told people we are better than that. We are working on it. So community members were aware of of it but were understanding," Buchannan said.
Buchannan and Lisa Boatright, Wayne's director of quality management, both said that many problems were solved once the revolving door of surgeons stopped turning and they were able to finally put in place a team that was the right fit and had the right focus, patient safety.
They also took communication and accountability to a much higher level. Boatright said physicians started bridging the gap between them and nurses by having educational conversations about procedures with them. Boatright said this improved the rapport between the two groups and made everyone more comfortable, especially new nurses who Buchannan said can often be timid about reaching out to doctors when they need help.
They also instituted an open door, anonymous reporting system whereby staff could contact supervisors or hospital leadership through a variety of channels to report concerns or problems.
"If people saw something they thought was unsafe they could report it anonymously. They could come into my office, call or just write it down. Names wouldn't be mentioned so they felt comfortable voicing concerns," Boatright said.
Finally, they brought patients into the process by interviewing everyone that came in for treatment about their experience. Boatright and Buchannan said they would generally wait until the second or third day of their stay, but everyone was given the opportunity to provide feedback and voice issues they had with their care before they left the hospital.
Even though these may not seem like huge steps to take, for a small rural hospital they made all the difference. In fact, earning an 'A' from Leapfrog this Spring wasn't even the biggest pay-off. In 2015, Wayne Memorial Hospital won the Small Hospital of the Year award from the Georgia Hospital Association. No small feat for a small facility that just a year prior was in turmoil. Buchannan said collaboration and commitment to change from all levels was key.
"It just let us know what kind of ownership our staff had of our facility. It made us happy to know that and also that so many people wanted to help make it better."