Will rethinking operations improve hospital outcomes?

An article in the New York Times (February 2, 2016) titled “Hospitals Focus on Doing No Harm”, describes the dramatic impact of operational changes on outcomes, with an eye to reducing the 75,000 preventable deaths nationwide. Orlando Health reports reducing patient infection related deaths by 44% with better procedures.   Minnesota Hospital Association reports reduction of pressure ulcers in patients confined to beds by 40% due to better coordination of care. Orlando Health reports a 32% decrease in blood clots in  patients in its seven hospitals by starting treatment for it faster when detected.  Should hospitals be held responsible for outcomes greater than the national average ? Should hospitals be held responsible for implementing state of the art treatment regimens ? In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

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23 Responses to Will rethinking operations improve hospital outcomes?

  1. Patrick Lee says:

    I worked in a hospital hematology laboratory. I observed many of my colleagues delaying sample processing–because only 1 or two samples existed on the table. Subject to this, I feel requiring better than national averages outcomes would force faster specimen processing and the generation of timely treatment decisions. Also, I agree that hospitals should be on the cutting edge of innovations–so hold them responsible for developing treatment regimens is worthwhile. Lastly, everyone responds to incentives–why wouldn’t a hospital not like being rewarded for sharing best practices ?

  2. Rodney Williams says:

    I believe the answer is yes to all three questions. It’s easy for employees to forget to wash their hands when there isn’t much emphasis being placed on it. However, when hospital staff know that cameras are installed that will ensure that proper hygiene measures are being taken and consequences for failure to comply, then I’m sure fewer people will forget to wash their hands. This is something that is completely within the power of hospital management to change also. I do think that it may be difficult for every hospital to identify steps in their processes that are in need of improvement and know how to implement necessary improvements, but if another hospital or organization, has already found success through a process change then it should be shared. This will allow other facilities to have a blueprint that may work for them also with few modifications. The overall goal is healthy patients leaving the hospital and not competition between hospitals. Keeping a successful processes secret will only led to unnecessary deaths that could have been prevented through information sharing. Hospitals that share info to help others should be rewarded because they are improving care beyond the walls of their facility.

    Lastly, hospitals should be held responsible for outcomes greater than the national average. In the article, it stated when surgeons were shown where they rank among others, they actually came forward requesting ideas for process improvements. I believe hospitals will behave in the same manner in which they would want to best the national average and would research and pursue processes that are likely to help them achieve that.

  3. Emily London says:

    *Should hospitals be held responsible for outcomes greater than the national average?

    Yes, hospitals that are not performing well should be known by the public. Their stats and reviews should be available online, like the way Yelp does for restaurants.

    *Should hospitals be held responsible for implementing state of the art treatment regimens?

    I think that depends on what they are trying to treat because regimens can change and I am sure it will be costly to implement a new regimen. For sure, any state of the art equipment or regimen that will aid in a life-threatening situation should be required by the hospital.

    *In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

    Yes, hospitals should be rewarded for having great operations. It would help with their reputation and they could gather more patients/customers from afar because of that. Whatever is working for their operations needs to be shared with others so each organization can learn from each other. The end result could be a larger percentage of lives saved.

  4. Frank Griffin says:

    Key points we should consider: 1) Institutions have been able to reduce health related deaths at hospital in the past. 2) Human life matters. 3) An institution of healing should not contribute to increased deaths. Car’s makers are held accountable for crash tests. Food and Drugs have to pass FDA approval. Why should hospitals be allowed to show increased hospital related deaths.
    Based on those points, I feel hospitals should be held responsible for implementing regimens that will reduce hospital related deaths. Possibly allow a timeframe for implementation. Also since the overall goal is to reduce deaths (since life matters), information sharing should be built into the process to expedite the implementation across the US.

  5. Paul C. Barron says:

    Q1: Should hospitals be held responsible for outcomes greater than the national average?
    I would offer that the national average is potentially too high. Instead hospitals should be differentiated by sufficiently funded and underfunded (an even split of the population). Then the standard of responsibility should be pegged at the outcome average of the underfunded hospitals nation-wide. Ultimately I do think hospitals should be held accountable, but not at the national average. I agree with Rodney regarding the sharing of best practices.

    Q2: Should hospitals be held responsible for implementing state of the art treatment regimens?
    Yes, if it is within their capacity and budget. Otherwise, to be held responsible would potentially force hospitals to expand their treatment offerings without expanding building capacity or their budgets. This would most likely result in a decrease in capacity for their current treatment offerings, a decrease in available funds for other treatments, and possibly a decrease in the “quality of service” the hospital provides to the patients it is already capable of treating.

    Q3: In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide?
    No, establishing a reward-based system for a hospital contributing to the best practices knowledge base could undermine the mindset that hospitals should share—that is caring for patients. It may seem unfair to expect hospitals to have such an elevated level of motivation and voluntarily contribute to the general welfare of patients nation-wide, but if a hospital community is unable to achieve this level of motivation (in the general sense), then that hospital has greater problems.

  6. Sooin Kim says:

    Reading the article, it seems that the basic Doing No Harm practices are not properly known to medical specialists. Surely, the best practices need to be shared so that these can be replicated many more with others.
    The trouble would be more on how to “implement” the best practices; whether a specific process need to be followed up via a detailed check list or not. Considering the importance of hospitals, one definitely needs to meet the minimum “absolute” criteria to be called a hospital. There are already multiple international and national regulations for these, and basic steps such as “Doing No Harm” should be part of these license conditions.
    However, I don’t think a hospital should be judged by the comparison with the national average. This relative evaluation may lead to distorted results than truly trying to focus on its chosen possible specialist areas, e.g. one may improve its evaluation rating by not taking difficult-to-cure disease- patients or terminal patients.

  7. Jimmy J. Guerrero says:

    I argue that using a national average as a measure of compliance, or success, for hospitals and medical institutions when providing healthcare services, does not necessarily encourages them to do “their best”. In fact, it may limit their ability to achieve their full potential by providing a “common” target level to aim at.
    Due to the fact that hospitals and medical institutions deal with human beings when at their most vulnerable state, I suggest that their focus should be, in addition to providing and maintaining state-of-the-art facilities and processes, knowing how to successfully deal with their patient’s emotional burden besides their physical ailments. It is a proven fact that highly capable and caring staff that can also deliver compassion and empathy, when needed, has a more powerful healing effect on patients than treatments alone.
    Should hospitals and medical institutions be held responsible for the outcome of their direct actions or activities? Absolutely! But at the same time, they should be supported, encouraged, and even incentivized, not just to reach a national average level, but to surpass it. If prospective rewards are linked to improvements in overall performance beyond the national average, when compared to previous evaluation(s), it may inspire continuous improvement efforts measured and judged mainly from a patient perspective.

  8. Akos Janza says:

    I am not 100% sure that rewarding everyone matching or exceeding the nation average will help, but choosing a benchmark and electing a goal is important. In his book The Checklist Manifesto Atul Gawande shows what the simple idea of the checklist reveals about the complexity of our lives and how we can deal with it. He brings up the example of hospitals and how checklist can help to reduce the number of preventable deaths. A simple surgical checklist introduced by the World Health Organization adopted in more than twenty countries as a standard for care and has been heralded as “the biggest clinical invention in thirty years” (The Independent). I argue that if such a simple checklist can save lives all around the world what could be implemented and how It could be enforced in the US.

  9. M. Moore says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Institutions should be required to measure and disclose their performance and be held responsible for their institutional outcomes via performance tiered reimbursement / Medicare /Medicaid payments.
    As part of competition and improving healthcare, Hospitals shall measure their performance based on a “Key Performance Indicators” and publish/display them. The public can make an informed decision when choosing their quality of care. In addition reimbursement levels the hospitals receive from the government should be tied to the institutional performance. If an institution performs well they would get a top tier reimbursement and if they do not perform the reimbursement levels would be at significantly reduced levels.
    This model has been successful with the implementation of “Door to Balloon time” for cardiology labs across the US to perform interventional procedures for a heart attack. As this measure became a standard KPI, the American Society of Cardiologist set targets for the time the patients entered the hospital to the time the intervention was performed (angioplasty balloon – arterial reperfusion) to continuously improve patient outcomes.

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    Hospitals utilize latest technology and state of the art treatment regimens to attract patients to their institutions via institutional marketing and physician referrals. Additionally these procedures and processes would directly influence their results to key performance indicators. Hospitals that compete and are successful will implement state of the art treatments.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide?
    Benchmarking and best practices should be proliferated and can be rewarded through publication rewards and/or mutual rewards via reimbursement levels.

  10. Erik Strobel says:

    Should hospitals be held responsible for outcomes greater than the national average? Hospital information related to patient outcomes should be easily accessible. The problem is that even if the information is available patients may have no other option for care in the area. Should we remove a doctors license to practice medicine? Malpractice insurance and hospital insurance rates could be tied to outcomes but at some point when we expect perfection we will have no doctors to treat patients.

    Should hospitals be held responsible for implementing state of the art treatment regimens? Who would you like to pay for these improvements my healthcare costs are already enough.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide? Yes it’s called consulting or takeovers/absorption into a network of hospitals.

  11. Ryan Laskey says:

    Should hospitals be held responsible for outcomes greater than the national average? Yes, hospitals should be required to post / market their performance against other health care facilities. If there was a standardized scorecard that would provide open sharing of information with their customers, then the market would be able to drive the necessary operational improvements.
    Should hospitals be held responsible for implementing state of the art treatment regimens? If hospitals don’t upgrade their treatments and their processes to meet industry benchmarks then they will lose their customers.
    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes system wide? No, let the market drive their own improvements per the voice of the customer. There isn’t a need to regulate rewards. Communication can allow this to occur.

  12. LaBaron Hartfield says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Yes, hospitals should be held responsible for outcomes greater than the national average. This is an important measure seems to be indicative to the quality care patients receive throughout their hospitalization. Patients are likely to be attracted facilities that are known to offer better care.; Insurers are likely to be more willing to reimburse facilities that can reduce incidents outlined in the article at higher rate if they facilities can show the cost-savings in charges for customer care related to better treatment regimens..

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    My answer as potential patient in a hospital is yes. Everyone wants access to the best medical care and outcomes possible. However, I think healthcare providers should only be held to the requirements set forth by regulating agencies as the costs associated with implementing the most state of the art regimens could be cost-prohibitive for smaller or poor funded hospitals.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?
    There should not be a direct reward based on this measurement. Indirectly, hospitals can seek rewards by leveraging success to attract patients, recruit better medical staff and extract better reimbursement rates from insurers.

  13. Matthew Geddie says:

    Ryan Laskey makes a great point in a standardized system. Similar to national industries, allowing hospitals to “compete” against a standard that I believe should raise a certain rate every year would greatly benefit patients.

    Furthermore, perhaps implementing a federal reward system would motivate hospitals to compete on their treatment regimens, granting the top 10% additional funding towards research or other areas in which they seek funding.

  14. Peter says:

    In regards to the question “Should hospitals be held responsible for outcomes greater than the national average” I think the answer is yes, but I disagree with the group consensus on why and how. Standards set by medical professionals should placed on the hospital by States Boards of Health and vigorously enforced. All of the information disclosed in the reports should be public record and that will inevitably sway patient choice, creating a reward for well performing hospitals and an incentive for those who need improvement. This competition predominantly works in non-emergency cases and in a finite amount of distance (depending on the condition).
    I feel that setting up a Federally mandated reward system will create a moral hazard in the hospital enterprise. If a hospital is aiming for a certain score in a results based test, they could prefer to not take in certain patients. If a hospital system wants to have higher statistics, they may not offer services to impoverished or disenfranchised areas.
    While the desire for self-preservation will always insert monetary reward into health care (ie, people will give all of their money to make themselves, their loved one and sometimes even their pet, well) the institutionalization of mandated care, especially by non-medical professionals, far away from the location of care, creates competition to the creed of “Do no harm.”

  15. Michelle Hummel says:

    Should hospitals be held responsible for outcomes greater than the national average ?

    I believe hospitals should be held responsible for outcomes greater than average in their tier (not necessarily National average) and should be rewarded/recognized for these successes. Greater health outcomes can almost always be linked to more meticulous practice and better patient care. Hospitals should always be undergoing continuous improvement to achieve these goals, however, with a more standard approach to measuring these successes we can only assume better health outcomes overall.

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    My answer to this is only if applicable/available. Not every hospital has the funding/resources to be able to do this. If they are held responsible for such actions, the likelihood of short cuts and or short comings is high. Hospitals should have a standard approach to equipment functionality as well as treatment regimes, however, the specialist at particular locations are specialist for a reason. There are pros and cons to specialists vs. generalist as we discussed in class, and implementing state of the art treatment regimes at all hospitals would dramatically increase the cost of healthcare nationwide. While Hospital Administration and the State Department of Health and Human Services must implement a standard level of care, Hospitals should always be seeking continuous improvement to supersede these levels. I believe the responsibility lies within the Hospital tier itself and not necessarily within a National protocol.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

    More successful hospitals should share their successes with others *to help attempt to* improve outcomes system-wide; especially if these successes can be done with little to no cost. Obviously more expensive projects might not necessarily be able to be implemented and lower-funded facilities. Take the Hospital in the North East who decreased ER wait times significantly. Without remembering the specific facts, I believe the ER wait time went from 4 excessive hours to less than 30 minutes. With these vastly improve times not only did patient satisfaction increase but it attracted more “business.” Patients were more likely to chose this hospital due to their successes over others. These types of improvements, which may not be able to be heavily researched or re-engineered at other, lower-funded Hospitals, could be shared for the cost of nothing. I would be curious why anyone would say no?

  16. Mike Flatt says:

    Should hospitals be held responsible for outcomes greater than the national average ?

    I believe that yes they should be but there should be some established norms or industry agreed guidelines to adhere to as well. Although unlikely, there could be the potential for hospitals to collude and sand bag outcomes to make averages easier to achieve. Hospitals should be like most other businesses that are punished for poor performance.

    Should hospitals be held responsible for implementing state of the art treatment regimens?

    I feel that they should only be held responsible for this type of implementation when it is proven that these regimens will drive results to improve patient care. Terming a regimen as state of the art does not indicate whether it is useful or adds value. A small, rural hospital does not have the available resources to implement state of the art regimens that don’t drive results.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?

    Hospitals should be rewarded for sharing best practices that decrease patient harm that they cause. They are businesses that need to earn a profit but I feel that they have an additional calling to serve the greater good of society. Serving the health needs of a population in the most efficient manner using best practices developed by others and spreading the wealth of knowledge is something that should be encouraged and rewarded. The more difficult question that I’m not sure I have an answer to is how to fund this and how to allocate those rewards.

  17. Hospitals should be responsible say when the outcomes are greater than ~5% (for urban) to ~10% (for rural) of national average. It may pose a financial challenge and need for training staff for hospitals to implement state of the art treatment regimens. So I think they should be given a specific time frame within which they need to have the state of art facilities and then have them held responsible. For mutual benefit, it is important for hospitals to share their success, otherwise they may find themselves not being successful in other operations.

  18. Dan Skinner says:

    Should hospitals be held responsible for outcomes greater than the national average? No. You cannot penalize every hospital that is below who has outcomes below the mean and expect to improve outcomes. You could set a target that hospitals have to meet, but if the target is moving as the average moves, you can only improve your outcomes so far. Once you reach that level you encourage cheating, similar to the cheating (by teachers) you see on standardized tests. You can specify that hospitals improve to reach a certain target, but the target has to be realistic, attainable, and not floating to be effective in the long run.

    Should hospitals be held responsible for implementing state of the art treatment regimens? Hospitals should be required to have limited equipment. Beyond what every hospital needs hospitals should be allowed to use their budgets to specialize. Would you require every hospital to have advanced equipment, even if they do not have the expertise on staff to use it? What kind of equipment is necessary? What best practices are necessary? Where is the line drawn, and who draws it?
    I think hospitals should be rewarded to encourage them to share their best practices with their neighbors, but you cannot force the neighbors to adapt the best practices. I think the most effective rewards system would be the advertisement of outcomes like those above, and comparing them to their direct competition.

  19. Courtney Metzger says:

    Should hospitals be held responsible for outcomes greater than the national average?

    Yes, I believe they should be held accountable for outcomes greater than the national average. There should be strong metrics in place and they should be transparent to the public. This would allow for better information and ultimately better decisions for the patient. High performing hospitals would benefit and low performers would be forced to improve.

    Should hospitals be held responsible for implementing state of the art treatment regimens?

    As a whole, yes I believe they should. However, there must be some consideration for how this is regulated. All hospitals should not require all treatment types. Diversification should be allowed as it will benefit the patient and the hospital.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide?

    In keeping with the spirit of allowing the market to provide reward, I have to say no. However, I do see value in providing a program or platform to encourage knowledge share.

  20. Sandra Aldana says:

    I am coming from a country that provides universal health, so I am a bit terrified to think of a hospital as a business and not a place that restores people’s health. That said, while hospitals should attempt to reach the maximum quality possible, I am not sure whether it is possible and how much that tracking and enforcing would cost that could be invested back in better care.

    Hospitals should be encouraged to share best practices with one another. We need to remember that a patient does not always have the choice to go to a hospital. In many cases it is chosen for them (like in a car accident). ANYBODY could end up in one, and it is a pity that someone dies or simply because a hospital did not share information with another. If a business like Patagonia shares its best practices with its main competitors and still be profitable, why should hospital be different? What better reward than saving a life or giving someone back their health?

  21. Oswin Joseph says:

    I think the question is how can we reward hospitals that have outcomes better than the National Average. In order to do that, there has to be common scorecard as Ryan Laskey mentioned to measure a whole range of metrics including preventable deaths, patient infections, blood clots, pressure ulcers etc. Hospitals can be graded on a scale like restaurants or universities. If a hospital is lower on the scale, they will lose customers and revenue which will force them to improve by implementing state of the art technology, driving efficiencies etc. Yes successful hospitals should be incentivized to improve other systems – though the question is how to reward good hospitals.

  22. C. Thomas says:

    Should hospitals be held responsible for outcomes greater than the national average?
    Many have already commented on the fact that a scorecard should exist that measures hospital performance. Some may not know that this actually already exists on many different levels. For example, the Joint Commission (organization that provides accreditation for U.S. hospitals) publishes national hospital inpatient quality measures (http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx). The problem with this is that healthcare literacy is extremely low in the U.S. While many patients may not know such measures exist, even more will not understand them or know how to use them to their benefit, and many more will not have access to them due to low socioeconomic status. I think the real question should be something like, “how can we make care in U.S. hospitals more transparent and more user-friendly to the average American that does not have formal training in healthcare.” Ultimately, yes, I believe that hospitals should be held accountable for certain preventable outcomes, but not ANY outcome greater than the national average. Many outcomes such as deep venous thrombosis after surgery, central line infections, and pressure ulcers are 100% preventable. It takes a leadership team to realize that focusing on their staff as a priority is the key to making this happen.

    Should hospitals be held responsible for implementing state of the art treatment regimens?
    I think this is a loaded question and ultimately my answer is no. State of the art does not always mean it will provide the best possible care for the best value. Many times providers order unneeded medications, tests, and procedures that are “state of the art” just because they can rather than if they should. This culture of the practice of medicine in the U.S. is a big reason why our healthcare system is in such disarray. I believe that institutions should not only be implementing state of the art treatment regimens (not required to do so though) while at the same time focusing on providing the best possible care for the lowest cost. It is often the case that more expensive, state of the art treatment regimens will only result in a marginal improvement and often times no improvement at all in the quality of care. U.S. institutions should be spending their healthcare dollars more wisely, because often the easiest thing to do to improve hospital outcomes is as simple, and as inexpensive, as washing your hands.

    In addition, should more successful hospital operations be rewarded for sharing their successes with others, to improve outcomes systemwide ?
    Absolutely! But I think this actually already happens to a certain extent when innovators publish their results in medical journals. This brings prestige to the author(s) and to the institution which also brings them financial benefits as well. I actually think that more emphasis should be placed on publishing negative results of research as well, which has been revolutionized by The Journal of Negative Results in Biomedicine. Negative results in research are far too difficult to get published and ultimately result in inefficiency of research in the entire field of medicine.

  23. Meera Gursahaney says:

    Public hospitals should be held to standard practice. Ideally, competition between private hospitals is continuously driving innovation to increase the standard of all hospitals. the same goes for the implementation of state of the art treatments; it seems unreasonable to expect public hospitals to be on the cutting edge, but as what was once “cutting edge” becomes the standard, it is the responsibility of all hospitals to ensure they do not fall behind. I really liked Emily’s idea of the “Yelp for hospitals”, this ensures patients/consumers are able to to make decisions that drive competition, advancement and innovation in the medical field. there should certainly be incentives for hospitals to share proprietary information in the name of saving lives. By sharing that information a hospital is losing out on the value of being the sole proprietors of that technology which would decrease the incentive of a hospital to sink money into R&D if there was not a financial benefit. A reward for sharing such information would allow for an increase in the greater public health as well as provide and incentive for hospitals to continue doing the expensive research necessary for such innovation.

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