Nashville has always been vain about its status as a health care leader, but the truth is that the leadership has more to do with the business of health than the care. The challenge for local health institutions is to address the quality of care.
So far, a new survey indicates, the record is spotty. While Nashville has led the way in the development of corporate medicine through such companies as the industry-leading hospital franchise HCA, that hasn’t always translated into a systematic push for better care, with many providers still operating like mom and pop shops. And it should come as a disconcertingly small surprise locally that it’s the nonprofit hospitals that are leading the way on reforms ahead of their for-profit brethren.
What we’re talking about is patient safety. Hospital mistakes are estimated to kill as many as 100,000 patients nationally every year. These mistakes wouldn’t be tolerated in most businesses, but because medical slip-ups affect just one patient at a time, a pattern of incompetency doesn’t emerge. There is no big customer with deep enough pockets to yell “foul.” So hospitals go on prescribing the wrong drugs or failing to staff intensive care units (ICUs) with physicians who are adequately trained to care for the critically ill. (Critical care doctors can reduce deaths within ICUs by 10 percent, according to studies.)
But now there’s a self-proclaimed victimcorporate America, the folks who pay a big chunk of the national health care bill. The Business Roundtable, which promotes Big Business interests, has underwritten the nonprofit Leapfrog Group for Patient Safety. Leapfrog has identified three areas that hospitals need to address to improve patient safety immediately. Although the Leapfrog recommendations are highly detailed, they basically boil down to this:
having doctors enter prescriptions and test orders directly into the hospital’s computerized information system;
getting specially trained doctors to run the intensive care units;
making sure hospitals do enough high-risk procedures to be sure they know what they’re doing.
Leapfrog emphatically says that these procedures would save 60,000 lives and cut the number of prescription errors in half, to about 500,000 annually. To pressure hospitals to conform, Leapfrog is striving to publicize the results of its first hospital survey, released last week.
Nashville’s hospitals didn’t fare well, although no better or worse than most of the hospitals in the country. Only one Nashville hospital, Vanderbilt, fully met two of the three performance criteria. Other hospitals in town haven’t made quite as much progress.
Vanderbilt’s progress didn’t come easily. Doctors don’t change their habits easily. It took Vanderbilt three years to set up its first computerized prescription system for physicians in 1995, and although most of the hospital was using the system by late 1998, it wasn’t until this fall that the last ward went online. Is the system a success? Randy Miller, a Vanderbilt professor who helped design the system, known as WizOrder, says what is important to him is that the docs are avid users of the system. “Once you get them to use the system, you can introduce other patient safety systems.” (Quality control can be profitable too. Vanderbilt is licensing WizOrder for sale through a medical information systems vendor.)
Vanderbilt is fully compliant with the first two measures. But, on the third criterion, Vanderbilt met the volume targets for only three of the six procedures tracked in the survey. Two other high-volume hospitals, Centennial and St. Thomas, do more of these procedures (things like coronary artery bypass and abdominal aortic aneurysm repair), but don’t have many physicians filling out orders on computers or ICU specialists. Other smaller hospitals in town such as Summit, Southern Hills and Tennessee Christian don’t do nearly enough of this risky procedures to meet Leapfrog’s preferred standard, which reflects their roles of providing more general, less complex hospital care. Their limited progress on the drug controls and ICU are more problematic.
A special case is Metro General, currently managed by Vanderbilt as part of the alliance with Meharry Medical College. General has not begun to implement any of the recommended controls and does not have significant volumes on complicated procedures, reflecting its satellite role. It’s too bad that Meharry medical students don’t learn in an environment that reflects the latest thinking in patient safety, but Vanderbilt officials say that Meharry residents and students perform rotations at Vanderbilt, and are therefore exposed to both the computerized order system and high-risk procedures.
Baptist simply didn’t respond to the survey, although hospital representatives saywhat elsethat they believe that the hospital would stand up well to the Leapfrog standards. Baptist meets the volume requirements for five of the six procedures named.
“Everyone agrees we need to go to automatic order entry, but only 5 percent of the hospitals have it right now,” says Dr. Robert Hardin, Baptist’s medical director. “It’s going to be very expensive, and I just don’t know that we want to be the first to jump on.”
He adds that the hospital has made patient safety a major concern, moving from the old “gotcha” approach of catching people who made mistakes to systematically trying to improve practices.
Why should Nashvillians care? Most probably feel reasonably comfortable with their personal physicians, but they can’t very well make judgments about how good their care really is. Public information about patient safety at their hospitals is a means of self-protection.
And even if they don’t want to go that far for themselves, they can know that the big business interests are looking over the hospitals’ shoulders. Moreover, Leapfrog is pushing major corporations to decline business with health systems that don’t adopt these kinds of standardsso the enforcement may come through the marketplace. But that’s a few years away. In the meantime, it’s every patient for himself.
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