Leapfrog Group has a new partner on road to safety
The Leapfrog Group is moving forward with its efforts to improve patient safety with the results of its first major survey suggesting that providers have a long way to go in reaching some of the standards set by the group, particularly the implementation of computerized physician order entry (CPOE) and staffing of the intensive-care unit (ICU) with trained specialists known as intensivists.
At the same time, The Leapfrog Group is stepping up its plan to put pressure on health care providers to improve safety, mostly by amassing the clout of large employers. Now the group has another intimidating member in its ranks — the Oakbrook, IL-based Joint Commission on Accredi-tation of Healthcare Organizations (JCAHO).
JCAHO recently joined The Leapfrog Group as a formal partner, having previously worked with the group on an informal basis. The new arrangement means that The Leapfrog Group will seek JCAHO’s input on its patient safety initiatives.
The Leapfrog Group is a growing consortium of more than 90 Fortune 500 companies and other large private and public health care purchasers founded by The Business Roundtable. The group launched a national effort in November 2000 to educate employees, retirees, and their families about medical errors and the importance of hospital efforts to make advances in patient safety and to reward hospitals for their efforts in improving patient safety. Leapfrog purchasers provide health benefits to more than 26 million Americans and spend more than $46 billion on health care annually. The group was established in the wake of the 1999 Institute of Medicine report, To Err is Human, that makes the reduction of medical errors a top priority for health care providers.
In the first major collaboration effort between the two parties, the Joint Commission has begun work with Leapfrog leaders to pursue the identification of a specific set of ICU-related outcome and process measures. These measures may eventually be used to supplement or even replace the current Leapfrog measures that recommend that hospitals have board-certified or board-eligible intensivists.
Initial results from The Leapfrog Group’s patient safety survey suggest that there still is much work to do, reports Suzanne Delbanco, executive director of The Leapfrog Group. The survey is voluntary and ongoing, conducted among urban hospitals in six U.S. regions. Forty-eight percent of the hospitals contacted (241 out of 497) completed a survey on three pioneering practices proven to reduce preventable medical mistakes. Fifty-three percent of hospitals submitting responses meet at least one of the Leapfrog standards for specified safety practices. The survey asked urban hospitals whether they have implemented or plan to implement CPOE and staffing of the ICU with intensivists. For the third practice, evidence-based hospital referral, the survey queried hospitals about how many times a year they perform five high-risk surgeries, and asked those with neonatal ICUs (NICU) about how many infants they typically care for each day.
The Leapfrog practices are considered to be on the cutting edge of quality improvement, so it is no surprise that very few hospitals have implemented all of them. Leapfrog chose those practices not only because of their great potential to reduce preventable medical mistakes, but also because they are easily understood by consumers and feasible to implement in the near future.
These are some highlights from the survey:
• CPOE — 3.3% of the responding hospitals have instituted CPOE, but almost 10 times that many of responding hospitals — 30% — have indicated specific plans to implement such systems by 2004. Studies show that CPOE systems can be remarkably effective in reducing the rate of serious medication errors — at least 55%, according to The Leapfrog Group.
• ICU staffing — 10% of responding hospitals have intensivists overseeing care in the ICU at least eight hours a day. Another 18% of responding hospitals plan to enlist intensivists by 2004. Studies show that at least one in 10 patients who die every year in ICUs would have an increased survival chance if intensivists managed their care during their stay.
Herculean efforts’ needed to meet standards?
Not everyone agrees that The Leapfrog Group’s standards are reasonable. The Society of Critical Care Medicine questions the feasibility of implementing the ICU staffing standard recommended by Leapfrog. As the leading organization representing all four disciplines of critical care, the 10,000-member professional society is concerned that there may not be enough qualified critical-care specialists to comply with Leapfrog standards, says Ann E. Thompson, MD, FCCM, president of the society.
"While the society applauds the standard, it believes implementation will require Herculean efforts to accomplish this feat," Thompson says. "In the last decade, studies have clearly demonstrated the ability of intensivists to improve the survival of critically ill patients, maximize the efficient use of costly hospital resources, and decrease the cost of care. Failing to implement the standard will perpetuate the situation that exists in a majority of hospitals today. Our most critically ill patients do not receive optimal care, and many are dying unnecessarily."
Thompson says her organization has advocated for the use of trained ICU specialists for 30 years, but less than one-quarter of ICUs are currently staffed by physicians adequately trained in ICU management. And she expects the problem to significantly worsen.
The Society of Critical Care Medicine recently developed a position paper, The Aging of the U.S. Population and Increased Need for Critical Care Services, which indicates that there aren’t enough critical-care practitioners to provide adequate patient care for the demand expected from aging baby boomers. Even if a majority of hospitals want to comply with the Leapfrog standard, the current supply of qualified critical-care specialists is inadequate to meet those needs, the paper says. In fact, the shortfall is expected to increase significantly through the year 2030. The nursing shortage is even more severe. To increase the existing level of service, more physicians and nurses will be necessary than are currently being trained.
To counter the shortage, the Society of Critical Care Medicine suggests that providers improve the working conditions and compensation for nurses, educate the public about the need for intensivists, and urge the expansion of critical-care training programs.
The third practice measured by the Leapfrog survey, evidence-based hospital referral, indicates the likely success a hospital will have with a particular high-risk surgery or condition by how often the hospital performs or treats it. Measuring actual outcomes is the preferred way, but outcomes data are rarely available to the public. The next best method is level of experience. More than a hundred studies have shown a strong correlation between high annual volume and good outcomes.
The Leapfrog survey has good news on evidence-based hospital referral. Consumers in most urban areas have a choice of hospitals with extensive experience treating patients needing select high-risk surgeries or neonatal intensive care. The survey found the following percentages of participating hospitals meet Leapfrog’s recommended volume thresholds:
- coronary artery bypass — 12%;
- coronary angioplasty — 31%;
- abdominal aortic aneurysm repair — 21%;
- carotid endarterectomy — 20%;
- esophageal cancer surgery — 15%;
- additionally, 22% have NICUs that meet Leap-frog’s specifications for select high-risk deliveries.
"Consumers in these regions now have information on which hospitals are taking specific proven steps to reduce preventable medical mistakes, and which hospitals have a high level of experience with certain risky conditions and treatments," Delbanco says.
According to the Institute of Medicine, between 44,000 and 98,000 people die each year, and many more are injured from preventable mistakes made in hospitals. In addition, approximately 1 million medication errors occur in hospitals each year. Research shows that by implementing the Leapfrog practices, nearly 60,000 lives could be saved and more than 500,000 medication errors could be prevented annually.
Some Leapfrog members are beginning to offer financial incentives to hospitals that implement the recommended practices. For example, Empire Blue Cross and Blue Shield, IBM, Verizon Corp., Xerox, and PepsiCo will give hospitals with CPOE and intensivists a quarterly bonus payment.
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