Grad­ing griev­ances

Leapfrog’s safety-score pro­gram still di­vi­sive

Modern Healthcare - - THE WEEK IN HEALTHCARE - Mau­reen Mckin­ney

It’s not per­fect but it’s as good as it can be, given avail­able data, and it’s cer­tain to im­prove over time. That’s how Dr. Robert Wachter de­scribes the Hos­pi­tal Safety Score pro­gram. Wachter is one of the ex­perts the Wash­ing­ton-based Leapfrog Group tapped two years ago to help craft the con­tro­ver­sial ini­tia­tive, which re­lies on pub­licly avail­able data to as­sign let­ter grades—A, B, C, D or F—to acute-care hos­pi­tals, based on their records of pa­tient safety.

Leapfrog, an em­ployer-backed not-for­profit group, launched the pro­gram a year ago, brand­ing it both as a tool con­sumers can use when choos­ing sites of care and as a mo­ti­va­tor to get hos­pi­tals to step up their im­prove­ment ef­forts.

The grades have drawn strong re­ac­tions from hos­pi­tals, with many of­fi­cials call­ing them un­fair char­ac­ter­i­za­tions of the safety of the care their or­ga­ni­za­tions de­liver.

Draw­ing from the CMS’ Hos­pi­tal Com­pare, the Leapfrog Group’s an­nual sur­vey and the Amer­i­can Hos­pi­tal As­so­ci­a­tion’s an­nual sur­vey, the grad­ing method­ol­ogy was de­vel­oped with the help of an eight-mem­ber ex­pert panel that in­cludes pa­tient-safety heavy hit­ters such as Wachter;

Dr. Peter Pronovost, head of the Arm­strong In­sti­tute for Pa­tient Safety and Qual­ity at Johns Hop­kins Medicine, Bal­ti­more; and Dr. Arnold Mil­stein, pro­fes­sor of medicine at Stan­ford Univer­sity, Palo Alto, Calif.

“We thought there was enough data out there in the pub­lic do­main to take our best shot, based on to­day’s un­der­stand­ing, with the recog­ni­tion that it would be in­com­plete and the mea­sures would get bet­ter,” Wachter, chief of the di­vi­sion of hos­pi­tal medicine at UCSF Med­i­cal Cen­ter, San Fran­cisco, said of the panel. “It is bet­ter to have some in­for­ma­tion out there rather than none.”

On May 8, Leapfrog re­leased its third round of safety grades, show­ing rel­a­tively lit­tle change since the last up­date in Novem­ber. Of the 2,514 hos­pi­tals cov­ered in the lat­est up­date, 780 re­ceived an A, 638 re­ceived a B, 932 re­ceived a C, 148 re­ceived a D and 16 re­ceived an F. Nearly three quar­ters of hos­pi­tals re­ceived the same let­ter grade as last time, while only 1.9% saw a big change—up or down two or more grades—in their scores, a Leapfrog of­fi­cial said dur­ing a con­fer­ence call.

Hos­pi­tal of­fi­cials’ re­sponse to the lat­est wave of grades was mixed.

Rox­anne Moster, a spokes­woman for 466bed Ron­ald Rea­gan UCLA Med­i­cal Cen­ter, Los An­ge­les, said in a state­ment that the hos­pi­tal was “dis­ap­pointed but not sur­prised” by its most re­cent grade: a D, up from the F it re­ceived in Novem­ber. She con­tended the low grade did “not re­flect in any way the qual­ity of care” the hos­pi­tal pro­vides, and said she ex­pects to see higher marks in the fu­ture.

Michael San­born, pres­i­dent of 115-bed Bay­lor Med­i­cal Cen­ter at Car­roll­ton (Texas), which saw its let­ter grade jump from a C to an A, cred­ited the im­prove­ment to ag­gres­sive qual­ity and pa­tient-safety ini­tia­tives, ef­forts that he said have in­creased since the hos­pi­tal was ac­quired by 11-hos­pi­tal Bay­lor Health Care Sys­tem, Dal­las, in 2009.

Daviess Com­mu­nity Hos­pi­tal, a 48-bed fa­cil­ity in Wash­ing­ton, Ind., went from an F to a C, a two-grade bump that David Bixler, the hos­pi­tal’s CEO, said re­flects close work with Leapfrog to im­prove ad­her­ence to best prac­tices.

Of­fi­cials at 146-bed Larkin Com­mu­nity Hos­pi­tal, South Mi­ami, Fla., at­trib­uted their D grade in Novem­ber to is­sues re­lated to their sub­mis­sion of data for Leapfrog’s an­nual sur­vey. The hos­pi­tal worked with Leapfrog to cor­rect those prob­lems, said CEO Sandy Sosa-Guer­rero, and re­ceived an A this time around. “We al­ways felt that we were an A hos­pi­tal,” she said.

But while she called the grades valu­able, she also ac­knowl­edged that they could be mis­in­ter­preted by pa­tients. “It looks at a cer­tain amount of very limited qual­ity in­di­ca­tors,” Sosa-Guer­rero said. “It’s a good start but it needs to be more inclusive.”

Jonathan Aquino, chief qual­ity of­fi­cer of 172bed Kern Med­i­cal Cen­ter, Bak­ers­field, Calif., whose grade slipped from a D to an F in the lat­est rat­ings, said Leapfrog’s score did not align with the hos­pi­tal’s per­for­mance in statewide im­prove­ment ini­tia­tives. “We truly don’t be­lieve we merit the grade that we got,” he said.

He cited method­olog­i­cal con­cerns that many other hos­pi­tals have pointed to, in­clud­ing Leapfrog’s re­liance on older data. The most re­cent grades used data from 2010 and 2011.

Leah Bin­der, Leapfrog’s pres­i­dent and CEO, said the group uses the most up-to-date pub­licly avail­able data, adding that “Leapfrog would be happy to work with hos­pi­tals to ad­vo­cate for CMS to put data out faster.”

She also cited a re­cently re­leased peer­re­viewed ar­ti­cle in the Jour­nal of Pa­tient Safety, co-au­thored by many of the mem­bers of Leapfrog’s ex­pert panel that re­views in de­tail the de­vel­op­ment of the group’s safety-score method­ol­ogy.

The pro­gram bases grades on hos­pi­tals’ per­for­mance on 26 safety mea­sures, in­clud­ing 15 process and struc­tural mea­sures, such as an­tibi­otics within one hour of surgery, and 11 out­comes mea­sures, such as air em­bolisms and late-stage pres­sure ul­cers.

This lat­est round of scores re­flects re­cent changes to the group’s grade-set­ting method­ol­ogy, in­clud­ing an ef­fort to bet­ter align re­port­ing re­quire­ments among dif­fer­ent sources. Leapfrog also put safe­guards in place to en­sure no sin­gle mea­sure dom­i­nated hos­pi­tals’ safety scores, Missy Dan­forth, se­nior di­rec­tor of hos­pi­tal rat­ings, said dur­ing the con­fer­ence call.

Some of the mea­sures, such as use of com­put­er­ized physi­cian-or­der en­try, can be de­ter­mined only if a hos­pi­tal sub­mits data to Leapfrog, lead­ing some hos­pi­tals to ar­gue that the grades are skewed in fa­vor of those who com­plete the sur­vey.

Wachter, how­ever, said the ex­pert panel worked hard to make the grad­ing sys­tem “ag­nos­tic about whether hos­pi­tals sub­mit­ted data to Leapfrog.” He also said the newly pub­lished study il­lus­trates the lengths the panel went to in or­der to choose the right mea­sures and give them ap­pro­pri­ate weight.

“This is just one tool pa­tients can use to get a pic­ture of safety and qual­ity, but it is a method­ol­ogy that quite a few cred­i­ble ex­perts in the field said is as good as it can pos­si­bly be,” he said.

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