Ask any hospital executive whether quality and safety are important, and you’re sure to get an “of course” look. After all—who would say no? But ask that same executive what their hospital is doing to reduce clinical variation, or what steps they’re taking to improve their publicly reported quality ratings, or how often quality and safety are on their board’s agenda, and you’ll likely get a range of responses.
Because while no one would dispute the foundational significance of quality and safety, the reality is that hospital leaders are managing competing priorities, and for many, financial solvency and staffing challenges are what’s keeping them up at night.
Add to that the complicated issue of hospital quality ratings. For consumers who are accustomed to seeking out online reviews of goods or services before they decide where to spend their money, publicly available rankings such as CMS Star Ratings, Leapfrog Grades, and U.S. News and World Report’s Best Hospital Rankings would appear to be a sensible way to determine what kind of experience they’ll have with a particular hospital or provider. But these rating systems measure hospital performance in very different ways, and the data behind the published rankings can be up to several years old. The results can be misleading for patients and frustrating for hospitals when scores don’t reflect current practice or actual clinical outcomes.
Tim Babineau, MD, a principal with ECG, has served as both a practicing surgeon and a health system executive for more than 30 years. Before coming to ECG, he was the CEO of Lifespan Health System in Rhode Island. Kim Adelman, PhD, FACHE, is a principal with ECG and a former health system executive. Both believe that quality outcomes and patient safety should be the top priority in every decision a hospital executive makes—not just because hospitals have an ethical obligation to provide the safest-possible care, but because doing so can also improve competitive position, reputation, and ultimately, the bottom line.
In a three-part Q&A series, Tim and Kim share their perspectives regarding quality and safety and what they often hear from hospital executives; the business case for improving quality and safety ratings; and why change needs to start at the top.
Where are we as a country when it comes to quality and safety in our healthcare system?
Tim: We’re coming up on the 25th anniversary of the seminal Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System,” which put an intense spotlight on quality and safety issues in healthcare. The stunning statistic from that book is back in 1999, there was an equivalent of a jet plane crashing every day in terms of the number of patients that were killed or harmed in hospitals every day. So for many years, quality and safety became a priority of both the C-suite and the governing boards, and progress was made.
However, it’s Kim’s and my perception that in the last three to five years, given the increasing financial headwinds of the healthcare industry and the pandemic, quality and safety is not a primary, culturally embedded focus, and governing boards and C-suites became intensely focused on the bottom line. And not inappropriately during the pandemic—keeping the lights on and the doors open was imperative. So quality and safety, regrettably, became kind of an afterthought.
We believe strongly that it’s time to redouble our efforts, and really bring it back to the fore in terms of a C-suite priority and the governing board priority. Really for two main reasons. One, we have a moral and ethical obligation to do that, as we always have. But increasingly, there’s a very compelling case to be made that when you focus on quality and safety and you improve both, the business gets better.
You mentioned the pandemic. How did COVID-19 affect hospitals’ focus on quality and safety?
Kim: The immediate priorities when the pandemic started were supply chain, bed and services availability, clinically figuring out how to keep people safe, adjusting to not having family in the hospitals, keeping as many patients as possible out of the hospital, and really just focusing on day-to-day operations. With that, most of the quality reporting requirements were temporarily suspended, so paying attention to specific quality measures was not really top of mind. Then you had the resource strains—staff, equipment, and space; deferring care that was not immediate and urgent; and shifting to telehealth and virtual care, which created additional challenges.
All of that created circumstances that impacted quality of care and clinical outcomes, particularly for those with chronic ailments or on the preventive screening side of things. But hospital leaders had to do what they had to do, just like Tim said, to keep the doors open, keep staff and patients safe, and learn. Remember, in the early stages of COVID, we didn’t even know if some of these treatments were working and what the outcomes were going to be. So that was just the immediate fire that had to be put out.
Tim: It’s probably inaccurate to say that quality and safety got pushed to the side during the pandemic. It didn’t. It’s just that the quality and safety priorities shifted. It was about getting enough PPE. It was about contact precautions. It was making sure we had enough ventilators. It was making sure we had enough medicine, enough beds. Now that the pandemic seems to be in the rearview mirror, we need to remember to bring back those quality and safety matters we were working so hard on prior to the pandemic—central line infections, readmissions, errors in diagnosis, care variation—and double our efforts.
With the growth of consumerism in healthcare, patients are increasingly trying to make better-informed decisions about which organizations and provider are best for them. To what degree can they rely on hospital ratings?
Kim: It’s hard to utilize hospital ranking data in an objective way, because all of the publicly reported data is lagging. So what you see out there can be 6, 9, 12 or more months old. People are making decisions based on data that isn’t timely. There can be a lot of change within one year within a hospital, good or bad, for a certain quality measure. And that’s separate from any debate we might have about the validity of some of the measurements.
Tim: As Kim mentioned, it’s hard for patients to really judge the quality of a hospital. There are many public rankings that are familiar to most people—CMS Star Ratings, Leapfrog Health Grades, U.S. News and World Report, Newsweek: they all measure something different. As Kim noted, many of the measurements lag. So for example, when CMS Star Ratings publish their findings, those findings are based on data that was submitted a year or more ago. Are they maybe a proxy for how a hospital performs? Sure. They give you a direction. Obviously, if you have a choice between going to a CMS 5-star hospital and a CMS 1-star hospital, you’d go to the 5-five star one. But they’re not a very timely and accurate measurement of what’s actually going on inside that hospital on the day you walk through that door.
COMING UP NEXT: In part two, Tim and Kim explore common breakdowns in clinical quality and explain what hospitals can do to establish a culture of safety.
Interviewer: Matt Maslin
