Home Q&A Can one group’s recommendations create “leaps” in health care quality?

Can one group’s recommendations create “leaps” in health care quality?

January 2005

Published in the January 2005 issue of Today’s Hospitalist

When the Leapfrog Group released the results of its latest survey of hospitals late last year, the news was mixed.

For the last four years, the group has become well-known for recommending that hospitals use technology like computer physician order entry systems and staff their ICUs with intensivists. Last year, however, the group expanded its recommendations to include 27 new measures.

Those measures focus on fairly standard procedures, like requiring clinicians to wash up before and after treating patients. While those hygiene practices may be basic, Leapfrog’s most recent survey found that only 21 percent of hospitals said that they have policies to make sure that clinicians follow this and other recommendations. (See “How hospitals fared in the latest Leapfrog survey,” next page, for more results from the survey.)

Suzanne Delbanco, the group’s CEO, says that while she had hoped that more hospitals would already be complying with most of the new measures, she’s not entirely surprised.

“The 21 percent figure is low in the sense that most of the practices outlined in that list are things for which there has been evidence for a long time,” she says. “But given the problems that were detailed in the IOM report five years ago, it’s not surprising to discover that there are some gaps.”

That’s where Leapfrog comes in. The group hopes to help hospitals address gaps by changing how health care in this country is delivered and paid for. The group aims to trigger giant “leaps” forward in the safety, quality and affordability of health care.

Leapfrog’s recommendations “and its survey to measure hospitals’ progress “is a key part of that process. “It’s disappointing that these practices aren’t more prevalent,” Ms. Delbanco says, “but our hope is that the survey will provide a roadmap for hospitals about the things they should be working on.”

And while it’s true that Leapfrog is just one of several organizations trying to improve quality in American medicine, the group already has the attention of many hospitals. Because Leapfrog is a coalition of more than 160 Fortune 500 companies and other large employers, it represents some of the largest purchasers of health care in the country. The group, in fact, boasts that its membership represents more than 34 million patients.

To learn more about Leapfrog’s most recent survey and the group’s mission to reinvent U.S. health care, Today’s Hospitalist talked to Ms. Delbanco. She discusses Leapfrog’s plans for the future, and the group’s decision to focus on intensivists as part of that mission.

Since Leapfrog began surveying hospitals, where have you seen progress?

Before we started our survey, data estimated that about 2 percent of hospitals were using physician computer order entry systems. In the regions where we focus our analysis, about 6 percent of hospitals say they have adopted the technology. From a patient perspective, that may seem like a slow increase, but it’s in the right direction.

When it comes to ICUs, research initially showed that about 10 percent of hospitalists were using intensivists to staff these units. Now we’re seeing a figure that is closer to 20 percent. We feel pretty good about that, in part because it makes a huge difference in patient survival. We haven’t done the math to figure out exactly how many lives might have been saved because these hospitals are using intensivists in ICUs, but we think it’s pretty significant.

Why did Leapfrog recommend that hospitals staff their ICUs with intensivists?

When we got started, there was very little published research about hospitalists in ICUs, so we went with the evidence that was available. That research showed that if you have doctors with specialized training in critical care, you greatly improve patients’ odds of survival.

Are you planning to make any recommendations about hospitalists based on the growing body of research about their effectiveness in the wards?

Leapfrog initially created its own quality measures with the help of health services researchers and quality experts. Since then, we’ve been working with the National Quality Forum, which is producing consensus-based standards. (The 27 measures added to last year’s survey came from the National Quality Forum.)

Going forward, our goal is to use those consensus-based standards as much as possible. We won’t go directly to the research and try to create a recommendation on our own about hospitalists. Instead, if the National Quality Forum comes out with something about the role of hospitalists, we will consider adding that recommendation.

I should also point out that we are currently working with the Joint Commission on Accreditation of Healthcare Organizations to develop the first-ever risk-adjustment methodology and national reporting program on ICU outcomes. We’re going to start reporting risk-adjusted outcomes for ICUs, so it won’t matter who’s staffing those units. We’ll take the ICUs that have great outcomes and track backwards and ask why.

I expect the evidence to show that hospitalists are about as effective as intensivists. I think a lot of the benefit probably comes from having a doctor with a lot of experience looking over patients in a constant fashion. My guess is that when we start looking at outcomes, probably in 2006, we’ll see very good outcomes in hospitals that use hospitalists.

Leapfrog has used hospital volume as a proxy for quality, a measure that has been questioned by some researchers. Why did you decide to focus on volume as an indicator of overall hospital quality?

When Leapfrog got started, we hoped to help patients select hospitals based on beautifully risk-adjusted outcomes data that were publicly reported. When we looked to see what was available, however, we didn’t find much. Even today, there are only four states that publicly report outcomes on some procedures.

Because we didn’t have a way to compare risk-adjusted data from hospitals, we decided to start with a measure that was crude, which is volume. The evidence was strong enough that if patients chose a hospital with a higher volume for certain procedures, their outcomes were likely going to be better than if they chose a low-volume hospital. In other words, the odds of shooting in the dark were worse than going on volume.

Our hope in promoting volume as a basis for referral was that we would spur providers to share more information. We have tried to bolster what was really a proxy measure in the beginning, data on volume, with other kinds of data. We believe that by combining these various data, we’re creating an even stronger measure.

In your most recent survey, what results would be of particular interest to hospitalists?

One thing I found interesting was that seven in 10 hospitals don’t have an explicit protocol to make sure that patients understand the risks of procedures. That doesn’t mean that seven in 10 hospitals have no communication with patients, but it does mean there’s no concerted effort to come up with a protocol or plan that everyone is supposed to follow.

How are the employers that belong to Leapfrog using results from your surveys?

One major employer on the West Coast is creating incentives for its employees to choose hospitals. If employees choose hospitals that have the Leapfrog practices in place, their coinsurance is waived, and they don’t have to pay any part of their hospital stay. If they go to a hospital that hasn’t implemented the practices, however, they have to pay 5 percent of their stay. That’s one example of how employers have created incentives for patients.

In New York City, we’re in the third year of a program where hospitals are paid bonuses if they have implemented computer physician order entry and if they have intensivist staffing in place. The health plan is administering the bonus, but it’s a direct passthrough from the employers involved in the program.

How hospitals fared in the latest Leapfrog survey

The Leapfrog Group’s most recent survey polled more than 1,000 hospitals on measures to improve health care quality and reduce errors. Here’s a look at some of the survey’s highlights:

The good news

  • Eight in 10 hospitals have implemented procedures to avoid wrong-site surgeries.
  • Seven in 10 hospitals have pharmacists review all medication orders before medications are given to patients.

The not-so-good news

  • Seven in 10 hospitals don’t have an explicit procedure to make sure that they have adequate levels of nursing staff.
  • Seven in 10 don’t have any policy to make sure that patients understand the risks of procedures.
  • Six in 10 lack procedures to prevent malnutrition.
  • Five in 10 don’t have procedures to prevent bed sores.
  • Four in 10 hospitals don’t have policies requiring workers to wash their hands before and after seeing patients.

    At a glance

    Name: The Leapfrog Group
    Founded: 2000
    Mission: To trigger “leaps” in safety, quality and affordability of health care. Members: 160-plus Fortune 500 employers and other organizations that purchase health care.