Improving Quality and Customer Satisfaction in Our Hospitals: Medicare Style

Ever since the Institute of Medicine released the report To Err Is Human: Building a Safer Heath System and focused attention on the quality of healthcare in the United States, many have cited the need for the healthcare industry to emulate the airline industry’s safety practices and adopt similar standards. For example, regulations restrict airline pilots from flying too many consecutive hours to minimize the risk of fatigueassociated errors. Airline pilots go through a checklist before every takeoff and landing.

This systematic approach has resulted in an impressive track record of safety. Allow me to hop on the bandwagon and encourage our healthcare leaders to take a similar approach to improving quality in healthcare. As a hospitalist, I see tremendous opportunities to improve the care we provide our hospitalized patients. Unfortunately, I also see many other similarities between the healthcare and airline industries. Have you flown in a commercial airline lately? There are routinely long lines at the airport, the airplanes are rarely on time, and the customer service is often unsatisfactory. Unfortunately, our patients’ experience in our hospitals is not much diff erent. Our patients routinely spend many hours in the emergency department. They are lucky if their stretcher is in an actual room and not in the hallway. They have no control over when testing occurs or even what they eat—good luck trying to get something to eat in the hospital if you missed mealtime because you were at the CT scanner.

Does that remind you of fl ying today? When exactly is that airplane going to take off? Does anyone know when this patient will be admitted or discharged from the hospital? Hospitals never seem to have enough beds. When was the last time you saw empty seats on a plane? Flying may be unpleasant, but rarely is it a dangerous experience. Although there are thousands of flights daily, passengers are rarely injured. Unfortunately, the same cannot be said for hospital care. Despite the warnings in the Institute of Medicine report on safety, most hospitals still have insuffi cient processes in place to reduce preventable medical com-plications and errors. In fact, dangerous medical errors have become so commonplace that many healthcare providers have become inured to their presence. We should be outraged when our patients develop sepsis due to a vascular line infection or develop catheter-associated urinary tract infections. But these conditions occur so commonly in our hospitals that I worry we take them for granted. I am concerned that many providers actually believe these conditions are unpreventable.

As a doctor and a patient, I expect more from our healthcare system. We must change the attitude that medical complications are inevitable. I believe that Medicare, the biggest healthcare payer in this country, took a step in the right direction with the recent changes to its Inpatient Prospective Payment System (IPPS). In the 1980s, Medicare developed the Diagnostic Related Group (DRG) system as a core component of the IPPS. Under this system, Medicare pays hospitals a set fee based on the patient’s DRG. For example, if the hospital provides inpatient care for a Medicare benefi ciary with acute decompensated systolic heart failure, the Medicare payment for services is a set fee associated with that DRG, regardless of the hospital’s actual expenses. Whether the patient was hospitalized for one day or 10 days, Medicare pays the hospital the same amount. Under this compensation model, hospitals must manage their expenses in the delivery of care if they hope to achieve a positive margin on each case.

An exception to the rule is that payment for an individual case can be higher if the patient has a clinical co-morbidity (CC). For example, if that same patient with acute decompensated heart failure develops a decubitus ulcer during the hospital stay, the hospital can add a CC to the acute decompensated heart failure DRG and receive additional payment from Medicare. The rationale is that the additional payment off sets the incremental expense incurred by caring for the decubitus ulcer. This part

of the IPPS has never made sense to me. Medicare actually pays hospitals a higher amount if a patient develops a complication, unrelated to his or her primary diagnosis, during the hospital stay. Therein lies the problem.

What is the incentive for the hospital to actually prevent these complications from occurring in the first place? Why should hospitals set up systems to prevent these medical complications if they are going to get paid more when the complications occur? I liken this to taking my car into the garage for a new muffler, only to be charged extra for a new tail light because they accidentally broke the tail light while replacing the muffler. Wouldn’t you be outraged? Why shouldn’t we be outraged that Medicare pays for preventable complications in hospitalized patients? Well, effective October 2008, that will change. Th e latest changes to the Inpatient Prospective Payment System, mandated by Congress in the Defi cit Reduction Act of 2005, address this issue by creating a set of “Present on Admission” indicators:

• Object left in surgery
• Air embolism
• Blood incompatibility
• Catheter-associated urinary tract infections
• Pressure ulcers (decubitus ulcers)
• Vascular catheter-associated infection
• Mediastinitis after coronary artery bypass surgery
• Hospital-acquired injuries - fractures, dislocations, intracranial injury, crushing injury, burn, and other unspecifi ed effects of external causes

If any of these conditions are present on hospital admission, Medicare will continue to allow payment of the CC in addition to the DRG. But if any of these conditions develop during the hospital stay, Medicare will soon stop paying the incremental payment associated with the CC. For fiscal year 2008, which began October 1, 2007, Medicare requires hospitals to code the development of these events in hospitalized Medicare benefi ciaries. On October 1, 2008, Medicare will stop paying for these complications by dropping the CCs from the DRG payment. For fiscal year 2009, Medicare has proposed the addition of several other “Present on Admission” indicators, including ventilator-associated pneumonia, deep venous thrombosis, and pulmonary embolism.

Additional indicators under consideration include C. diffi cile-associated disease and Methicillin-resistant S. aureus infection. Not only will hospitals not receive Medicare payment for these preventable events, but they are also not allowed to pass on the cost to patients. Payers and quality organizations, for the most part, have supported these Medicare measures. Some organizations, including the Leapfrog Group, have called for Medicare to further expand the list of conditions to include those described by the National Quality Forum as “Never Events.” This is a list of 28 adverse events that the National Quality Forum believes should never occur in hospitalized patients. Some examples of “Never Events” include surgery on wrong side of body and discharge of infants to the wrong person.

Since Medicare announced the “Present on Admission” indicators in the Federal Register in August 2007, hospitals around the country have been scrambling to implement processes to prevent these events. Many looked to Minnesota, where HealthPartners (a large healthcare payer) has, since 2005, stopped paying affi liated hospitals for charges associated with “Never Events.”

The program has been described as a national model for other hospitals and payers. Medicare’s focus on quality in the hospital has not been limited to error prevention. Since 2006, Medicare has also been measuring patients’ satisfaction with their inpatient care in acute care hospitals. The Consumer Assessment of Healthcare Providers and System (CAHPS) Survey provides a standardized survey instrument to measure patients’ perspectives on hospital care. The subjects in the survey include a random sample of patients 18 years or older who had an overnight stay in an acute care hospital for a non-psychiatric diagnosis. Surveyors gather data by mail or telephone. The survey has 27 questions that encompass seven topic areas:

1. Communication with doctors
2. Communication with nurses
3. Hospital staff responsiveness
4. Pain management
5. Communication about medicines
6. Hospital environment
7. Discharge information

Three specific questions from the survey address physician communication:

• How often did the doctors treat you with courtesy and respect?
• How often did doctors listen carefully to you?
• How often did doctors explain things in a way you could understand?

Medicare expects the survey to produce data that will allow comparisons of hospitals, create incentives for hospitals to improve the quality of care, and enhance accountability by increasing transparency. In March 2008, Medicare will report the initial survey data for the period from October 2006 to June 2007 on the Hospital Compare website.

Time will tell whether these Medicare actions will have a measurable impact on improving the quality of care and customer satisfaction in our acute care hospitals. Nobody knows yet the right process to motivate healthcare providers to improve quality and customer satisfaction. Over the past decade, the quality movement has seen its ups and downs but continues to roll full steam ahead. We have seen quality reporting lead to unintended consequences. When New York state began reporting complication rates associated with coronary bypass surgery for individual surgeons, there was data to suggest some surgeons began to avoid off ering surgery to higher risk patients.

On the other hand, we have also seen some hospitals (for example, Cedars-Sinai Medical Center in Los Angeles, Dartmouth-Hitchcock in Lebanon, NH, and Beth Israel Deaconess Medical Center in Boston) take the lead in increasing transparency by posting all quality performance measures on their hospital websites. Go online and you can fi nd out the hand hygiene rates of providers at Beth Israel Deaconess Medical Center or the rates of ventilator-associated pneumonia at Cedars-Sinai. These are among the vanguard medical centers in the country trying to move the profession forward and improve healthcare quality. But look at their data online, and you will see that it is far from perfect.

The question remains: if these large medical centers are struggling to meet quality mandates, will the majority of the more than 5,000 hospitals in this country—many of which are small community hospitals—ever come close to meeting these mandates? Whether you believe the mandates are achievable or not, I don’t believe we can aff ord to think of improving healthcare quality as merely an option. It is a necessity; we must train all hospital personnel to incorporate healthcare quality as part of their job expectations. I believe that hospitalists are well suited to take a leadership position in addressing healthcare quality and customer satisfaction in our hospitals.

Joseph Ming Wah Li, MD, is Director of the Hospital Medicine Program at Beth Israel Deaconess Medical Center, Boston, MA, and assistant professor of Medicine, Harvard Medical School, Boston, MA.