Is quality improvement raising the liability risk of hospitals?

Is quality improvement raising the liability risk of hospitals?

February 2006
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Published in the February 2006 issue of Today’s Hospitalist

Just over a year ago, the Boston-based Institute for Healthcare Improvement (IHI) launched its 100,000 Lives campaign with great fanfare. The campaign advanced six quality initiatives “dubbed “planks” “that proponents claimed could save as many as 100,000 lives in U.S. hospitals in the following 18 months.

For hospitalists, the planks cover familiar ground, from instituting pre-operative glucose control to preventing central-line infections. (See “IHI’s quality ‘planks’: a new standard of care” on page 11.) While none of the initiatives requires major funding, all take an aggressive institutional commitment to making quality goals a reality.

Complete with a national bus tour and widespread press coverage, the campaign garnered virtually universal endorsements from quality and credentialing organizations “and from most American hospitals. More than 3,000 hospitals around the country have signed on.

In a provocative article in the November/December 2005 issue of Health Affairs, quality experts Alice Gosfield, JD, a Philadelphia-based health care attorney, and James Reinertsen, MD, a quality consultant and senior IHI fellow, map out the evolving intersection between hospital quality and liability they say the IHI campaign has created.

The two argue, for instance, that the campaign’s six planks effectively form the first set of national standards of care that will be invoked in malpractice cases involving hospital care in the near future. They further make the case that the campaign automatically raises the liability of hospitals, both those that have signed up to participate “and those that have not.

Today’s Hospitalist talked to both authors to discuss how the IHI campaign will affect not only hospitals, but hospital-based physicians like hospitalists.

You claim that hospitals that have signed on for the campaign have increased their liability. Why is that?

Ms. Gosfield: The issue for hospitals that signed up is this: Their names are now on a Web site, and they have held themselves out as taking on this initiative. Our argument is that these six planks now effectively constitute the standard of care. By taking on this initiative, hospitals are holding themselves out as meeting this standard of care.

We also take the position that hospitals that have signed up for the campaign have probably not increased their liability significantly more than hospitals that have not. That’s because the standard of care is the standard of care.

Have any hospitals been sued because they signed up to participate but failed to implement the initiatives?

Ms. Gosfield: No, and one of the reasons we wrote the article was to get people’s attention before that happens. The liability exists as of today, but I’m not sure many hospital boards have figured out the connection to their own institutional exposure. In the post-Enron era, that fiduciary responsibility is what it means to be a board member.

How aggressively are participating hospitals moving to implement these initiatives?

Dr. Reinertsen: I’d say about 20 percent are leading the way, another 60 percent are gearing up to implement, and another 20 percent are bringing up the rear and haven’t done much. What the standard of care argument brings out is that signing up and then meandering through these goals is not really an option. You have to get them done expeditiously and thoroughly. The good news is that the hospitals in the vanguard have shown that these initiatives really reduce mortality.

For hospitalists working in participating hospitals, might the IHI campaign increase their personal liability?

Dr. Reinertsen: I think it’s a hospital liability issue in the main, something that hospitals need to address. Running a hospital now without a rapid response team is pretty much like running it without sterilizing your instruments; it’s going to be an expected standard in the hospital business.

That said, hospitals have an obligation to implement their own policies, and to do what’s necessary to make sure doctors follow those policies. If physicians choose not to follow them, they put themselves at some risk of censure. The liability is that they won’t continue to have hospital privileges.

Ms. Gosfield: A hospitalist who is in an environment where the board has signed on for the program but there hasn’t been any follow-through could face some exposure, but probably not too much. The most personal exposure is going to come from the guys who dig in their heels and say, “We don’t want to do it that way.”

To limit their liability, should participating hospitals be reaching some minimum level of implementation?

Ms. Gosfield: The planks themselves are relatively binary: Do you have perioperative glucose control, yes or no? There may be disputes over whether you did it right, whether the control was sufficient, and whether you picked the right antibiotic; that’s what will go on in the courtroom. The planks don’t speak to the details of implementation, but the hospitals are going to have to speak to that.

Dr. Reinertsen: Hospitals need to prove they’ve vigorously implemented their own policies.

Say one element in a hospital’s central line infection prevention policy is to make sure any femoral line inserted in an emergency resuscitation is replaced with a cleaner site within eight hours. The question then becomes: How rigorously has that been implemented?

If that policy was in place but a femoral line was left in for three days and the patient got an infection, the hospital would be liable for not implementing its policy.

How might that play out as far as physician oversight?

Dr. Reinertsen: The standard will obviously evolve, but in the example I just gave, I know of one hospital where a nurse will call a physician and say, “You have to come in and replace that line.” And if the physician says, “I’ll come in on Monday to do it,” the next call the nurse makes is to the physician’s department chair.

Some medical staffs might call the hospitalist team that handles central line insertion and say, “Dr. X isn’t coming in to do this, we need to do this to protect the patient, so please come in and change the line.”

The IHI says that more than 70 percent of participating hospitals have already submitted at least one month of mortality data. Is this campaign going to accelerate how much care is being measured in hospitals?

Dr. Reinertsen: You’ll need to measure to make sure these things are happening. In hospitals that have implemented the ventilator bundle, which has five things that should be done for every patient on a vent, every day in the ICU “and in many cases, every shift “there is a new data point added to a chart on a wall to indicate adherence to that bundle.

You’re aiming for 100 percent, and if you reach 80 percent, the question is, “Why?” Someone will look into it and correct it. That’s the sort of daily operations management “and measurement ” that is necessary to make these things happen.

Is this campaign an opportunity for hospitalists to spearhead these initiatives?

Dr. Reinertsen: It is, because this is the kind of leadership hospitalists can show. They are often the most closely wired into the operations of the hospital, so they are probably as well-positioned as anyone in their organization.

And hospitalists probably see the full range of practice patterns, from excellent to not so excellent, so they would welcome some sort of standard, uniformly excellent approach. They also have some sort role in a number of these initiatives: the central line infection bundle, the rapid response teams, acute MI treatment and medication reconciliation.

Ms. Gosfield: It also depends on how hospitalists are viewed within the organization where they function. To the extent that it’s an organization that sees the advent of hospitalists as one prong in a multi-faceted effort to really ramp up their quality efforts, those hospitalists will have a relatively easier time of implementation.

But to the extent that the hospital has hired hospitalists just to save time for their referring physicians, hospitalists are going to face a tougher road because they’re not part of a broader quality improvement strategy.

IHI’s quality “planks”: a new standard of care for hospitals

In its 100,000 Lives campaign, the Institute for Healthcare Improvement identified six quality “planks” that the IHI claims could, if implemented, save 100,000 lives in American hospitals. Here is a brief look at those six lifesavers:

“¢ Deploy rapid response teams to identify failing patients outside the ICU before they code.

“¢ Implement evidence-based care for myocardial infarction, including appropriate beta-blocker, ACE inhibitor, aspirin administration, and timely reperfusion.

“¢ Avoid adverse drug events by reconciling medications at each care transition, from ward to ward, for instance, and at discharge.

“¢ Prevent central-line blood infections through a “bundle” of evidence-based services, including maximal barrier protections and appropriate catheter-site care.

“¢ Prevent ventilator-associated pneumonia through an evidence- based “bundle” that includes elevating the head of the bed 30 degrees and using daily sedation “vacations.”

“¢ Prevent surgical site infections through a service “bundle,” including clipping “not shaving “the site, appropriate use of antibiotics, and tight perioperative glucose control.

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