December 2004, In This Issue:

On behalf of HPCI, Happy Holidays to You and Your Family!

Bridging Health Care and the Customer.

Engaging LEAN enterprise in Iowas health care industry is a key priority of HPCI. A new project focus for 2005 is bridging health care and the customer. This references the external customer including the consumer/patient and employer/purchaser. Becoming customer focused is essential in applying LEAN. Becoming so focused is also a great benefit of the LEAN enterprise approach. It is a win-win-win for health care providers, consumers/patients and purchasers. Work is underway on this customer focus with linkages and benchmarks. LEAN tools including the Quality, Cost, Delivery and Safety (QCDS) metrics are being applied.


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New HPCI Website.

An improved and updated HPCI website can be found at www.hpci.org Check it out.


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Iowa Health Care Collaborative.

Recently the Iowa Health Care Collaborative, co-sponsored by the Iowa Medical Society and the Iowa Hospital Association, held its first annual conference on quality, patient safety and value. The conference was very well done with excellent attendance.

According to the co-sponsors it set the tone for a state-wide hospital-physician effort to create an Iowa health care culture of continuous performance improvement that will lead to improved quality, greater patient safety, and better health care value.

The keynote speaker, Jim Conway, Vice President and Chief Operating Officer at Boston's Dana-Farber Cancer Institute, shared 10 years worth of experience in pursuing a corporate culture focused on patient safety. He spoke passionately on the power of transparency as a catalyst for change and improvement in the delivery of institutionalized medicine.

Results were presented of a survey of all Iowa hospitals based upon the National Quality Forums (NQF) 30 Safe Health Care Practices. The survey included 103 Iowa hospitals in total (48 critical access hospitals, 27 rural hospitals, 7 rural referral hospitals, and 21 urban hospitals).

Summary results were represented for each of the 30 safe practices. For each the percentage of Iowa hospitals that have fully implemented the standard and the percentage who see it as a very high priority were shown. The "biggest gap" identified was creating health care culture of safety with 80% of the hospitals indicating it was a very high priority and 18% fully implemented. The "longest journey" was computerized prescriber order entry with 29% indicating it a very high priority and 6% fully implemented.

The researchers summarized what they learned as follows:

  1. We are making some progress in traditional areas of focus in patient safety;
  2. There are many new areas of focus providers are working hard to deploy;
  3. Culture is critical;
  4. We can learn much together.


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Consumer Purchaser Alliance.

The Consumer Purchaser Alliance is a group of leading employer, consumer, and labor organizations working toward a common goal to ensure that all Americans have access to publicly reported health care performance information by January 1, 2007. Their shared vision is that Americans will be able to select hospitals, physicians, and treatments based on nationally standardized measures for clinical quality, consumer experience, equity, and efficiency.

The group believes that improved transparency about performance will improve both quality and affordability. Driving this improvement will be 1) consumers using this valid performance information to choose providers and treatment, 2) purchasers building performance expectations into their contracts and benefit designs and 3) providers acting on their desire to improve, supported with better information.

Recognizing that measurement and public reporting of performance are powerful mechanisms to drive quality and efficiency improvement throughout the health care system, purchasers and consumers have embraced a vision of a transparent health care market, one in which decision making is supported by comparative information. This vision of a comparative "dashboard" of publicly disclosed performance information should apply to all levels of the health care system - hospitals, physicians, physician groups/integrated delivery systems, and treatments. Measures should address all six improvement areas sited in the Institute of Medicine's Crossing the Quality Chasm (safe, timely, effective, equitable, efficient and patient centered).
See below for a description of the six aims.

The Consumer Purchaser Alliances efforts and advocacy are focused on four priority areas:

  1. Encouraging development of quality measures relevant to consumers and purchasers;
  2. Promoting the endorsement of a robust set of performance measures through the National Quality Forum (NQF);
  3. Encouraging adoption and public reporting of NQF-endorsed measures supplemented by other qualified measures to fill gaps in NQF measurement sets; and
  4. Enhancing the availability of data to support public reporting.

Current members of the Consumer Purchaser Alliance:

3M Corporation
American Benefits Council
American Hospice Foundation
Bank of America
The Business Roundtable
Buyers Health Care Action Group
California HealthCare Foundation
California Health Decisions
Carlson Companies, Inc.
Center for Health Care Strategies, Inc.
Center for the Study of Services/Consumers' CHECKBOOK
Center for Medical Consumers
Consumer Coalition for Quality Health Care
E.I. duPont de Nemours & Co., Inc.
Eli Lilly And Company
Employer Health Care Alliance Cooperative
ERISA Industry Committee
Ford Motor Company
General Electric Company
General Motors Corporation
HR Policy Association
International Association of Machinists and Aerospace Workers
The Leapfrog Group
Maine Health Management Coalition
The Manufacturing Institute
March of Dimes
Massachusetts Healthcare Purchaser Group
Midwest Business Group on Health
Motorola, Inc.
National Association of Manufacturers
National Breast Cancer Coalition
National Business Coalition on Health
National Business Group on Health
National Citizens Coalition for Nursing Home Reform
National Coalition for Cancer Survivorship
National Partnership for Women & Families
National Small Business Association
Niagara Health Quality Coalition
Pacific Business Group on Health
The Robert Wood Johnson Foundation
South Central Michigan Health Alliance
U.S. Chamber of Commerce
Union Pacific Railroad
United States Office of Personnel Management
Verizon Communications

More information can be found at www.healthcaredisclosure.org.


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Six Aims for Improvement.

The Institute of Medicine defined six improvement aims to address key dimensions in which todays health care system functions at far lower levels than it can and should. The Consumer Purchaser Alliance has embraced these six aims as part of effort for disclosure:

Safe: Freedom from accidental injury. To improve patient safety, health care organization and professionals must establish and improve systems that minimize the likelihood of error, make visible those errors that do occur, and prevent or mitigate harm from errors that reach the patient.

Timely: The flow of care, free of undesired waits and delays for both those who receive care and those who give care. The process flows smoothly and waiting times are continually reduced for both patients and those who give care.

Effective: The disciplined use of systemically-acquired knowledge to provide services that are likely to benefit patients and refrain from providing services not likely to benefit patients.

Efficient: The continual reduction of waste in health care, especially waste stemming from errors and from overuse of ineffective tests, medications, procedures, technologies and other interventions. Waste includes any resource use that fails to help meet patients' needs, including materials, supplies, time, forms, measurements, reports, motion, duplicated efforts, ideas not used, and information that is lost.

Equitable: The care of populations and individuals. At a population level, the goal of a health care system is to improve health status for all Americans and to do so in a manner that reduces disparities among particular subgroups. For individuals, the provision of health care services should be based on individual needs and not on personal characteristics unrelated to their health condition. In particular, the quality of care should not differ solely because of such characteristics as gender, race, ethnicity, income, education, disability, sexual orientation, or location of residence.

Patient-Centered: Health care that respects and honors patients' individual wants, needs, and preferences, and that assures that individual patient's values guide all decisions.


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Comparative Public Reporting of Health Care Organization Performance.

HPCI is preparing an inventory or summary grid of the various efforts underway to produce public reporting of comparative information on quality, patient safety and value. Included is the initial initiative of the Centers for Medicare and Medicaid Services (CMS) 2003 Quality Indicators, the 2004 CMS "Starter Set," the Joint Commission on Accreditation of Health Care Organizations (JCHCO) and the Leapfrog Group Hospital Patient Safety Survey. Other information will be added as it is identified.


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U. S. Health System - #1 in Cost and 37th in Performance.

According to the World Health Organization, the U.S. health systems spend a higher portion of its gross domestic product (GDP) than any other country and ranks 37th out of 191 countries in health system performance. The United Kingdom which spends just 6% of its GDP on health services ranks 18th. Other countries: France, #1 in health system performance, spends 10% of its GDP; Italy, #2 in performance, spends 9% of its GDP; Spain, 7th in performance, spends 8% of GDP; and Canada, 30th in performance, spends 9% of its GDP. The U.S. spends 14% of its GDP on health expenditures. The World Health Organization Indexes are from the most recent estimates for 1997.


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Iowa Employers, Unions Want to Buy Better Health.

A guest column entitled "Iowa Employers, Unions Want to Buy Better Health" appeared in the November 14, 2004 Cedar Rapids Gazette. It was written by the co-chairs of the Iowa Health Buyers Alliance, Garth Bowen, Pace Iowa, and Gloria McMahan, City of Cedar Rapids. HPCI is an Alliance co-sponsor. The article is available through HPCI.


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Survey Finds Nearly Half of all Consumers are Concerned About Safety of Health Care.

A new survey found that five years after a groundbreaking Institute of Medicine report focused attention on medical errors in hospitals, Americans say they do not believe that the nations quality of care has improved.

Four in ten (40%) of people say the quality of health care has gotten worse in the past five years while one in six (17%) say the quality of care has gotten better and nearly four in ten (38%) say it has stayed the same, according to the new survey by the Henry J. Kaiser, Family Foundation, the U.S. Agency for Healthcare Research and Quality (AHRQ) and the Harvard School of Public Health.

The survey also finds that nearly half (48%) of U.S. residents say they are concerned about the safety of the medical care that they and their families receive, and more than half (55%) say they are dissatisfied with the quality of health care in this country - up from 44% who reported the same in a similar survey conducted four years ago. These perceptions exist despite the efforts by hospitals, doctors, health plans and purchasers to reduce medical errors and improve the quality of care in the wake of the 1999 Institute of Medicine report, "To Err is Human: Building a Safer Health System."

About one in three people (34%) say that they or a family member had experienced a medical error at some point in their life. People with chronic health conditions are considerably more likely than other consumers to express concerns about their quality of care and report having personal experiences with medical errors.

More than nine in 10 Americans (92%) say that reporting of serious medical errors should be required, and most (63%) want this information released publicly. Almost nine in 10 (88%) say that physicians should be required to tell a patient if a preventable medical error resulted in serious harm in the patients own care.

The complete survey results are available at:



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Leapfrog in Iowa: What did the University of Iowa Study Conclude?

HPCIs focus is on supporting improvement in health care quality, patient safety and value. Public reporting of performance by health care organizations to standardized comparable measures is increasing across the U.S. While we understand there are unique situations, HPCI believes the National Quality Forums 30 Safe Practices and the Leapfrog Group initiative are two important efforts.

The University of Iowa Department of Health Management and Policy within the College of Medicine conducted a study on the initial three Leapfrog Group leaps. They issued their report to the Iowa Department of Public Health in 2003. HPCI spent considerable time reviewing the study and discussing it with the lead researchers.

HPCI concluded there is nothing in this study that indicated that the initial three leaps of the Leapfrog Group did not or should not apply to most large Iowa hospitals. The Leapfrog Group consistently indicated that these initial three leaps were intended for larger or metropolitan hospitals across the US.

Also in 2003, the National Quality Forum (NQF) released its consensus report entitled "Safe Practices for Better Health Care." The report endorsed 30 practices that can have a major impact on the safety of patients in health care settings. Included in the 30 practices are the original three leapfrog leaps (CPOE, ICU Staffing and evidence based hospital referral for certain high risk procedures). The remaining NQF 27 safe practices are now contained in a new fourth Leapfrog leap, the NQF Safe Practices Leap.

Leapfrogs initial three leaps targeted urban hospitals. Non-urban hospitals across the U.S. are now invited on a voluntary basis to complete the hospital survey for the NQF safe practices leap. They may also choose to complete the survey for the first three leaps as well. Early indications are the hospital representatives are finding the NQF report very useful as a check list or audit for improving the organizations safe practices.

Over 1,000 hospitals are reporting to the Leapfrog Group including 100% of the hospitals in the state of Minnesota.

The following is a summary of the findings by the University of Iowa on the initial three Leapfrog leaps and their application to Iowa hospitals:

  1. Computerized physician order entry (CPOE). The University of Iowa study concluded that relatively modest savings in patient care costs would be sufficient to offset CPOE costs for urban and rural referral hospitals in Iowa. According to the study, several of these hospitals already have or are currently implementing CPOE systems. However, the report states, more substantial cost savings would be required for CPOE to reduce costs enough to make implementation financially feasible for rural or critical access hospitals. Thus, it is likely that subsidies for initial and ongoing CPOE costs in these hospitals will be required to make CPOE financially feasible. (Note: HPCIs request is for the 26 urban and rural referral hospitals report to Leapfrog.)
  2. ICU physical staffing. The University of Iowa study considered potential applicability of the ICU standard in a rural state (Iowa). That study included 81 Iowa acute care hospitals reporting one or more staffed ICU beds. They also reviewed intensivist physician supply.

    The University of Iowa study found that there appears to be marked variation in the use of ICU beds by types of patients among the four hospital categories. The lower mortality rates and shorter average length of stay suggests that less ill patients may be admitted to Critical Access and Rural hospital ICUs. The higher rates of transfer to other hospitals from smaller hospitals lend support to the notion that these hospitals tend to focus on stabilizing and transferring the more complex and ill patients for whom they are unable to provide the definitive care.

    The University of Iowa study suggested that the ICU physician staffing standard should be prioritized to those settings in which significant quality and safety gains can be made. It also recommends that modifications of the intensivists only staffing requirement for smaller ICUs caring for less complex and ill patients might focus on creating timely telemedicine consultation services.

    The Leapfrog Group focuses regarding the staffing of ICUs is on larger hospitals only. These are almost certainly the ones receiving the transfers noted in the University of Iowa study.

    The Leapfrog Group recognizes that changing ICU staffing poses challenges and is committed to helping hospitals make progress in this area. Hospitals will receive partial recognition that operate adult or pediatric ICUs where intensivists lead daily, multi-disciplinary teams around or make admissions and discharge decision on weekdays. In addition, hospitals that use teleintensivist coverage on a partial basis can receive partial recognition.
  3. Evidence based hospital referral (EBHR). The University of Iowa study focused on the volume criteria which is part of the Leapfrog Groups EBHR safety standard which includes a combination of outcome, process and volume criteria. Based upon discharges for a single year, the University of Iowa study concluded they could not detect differences in mortality rates between Iowa hospitals meeting or not meeting the Leapfrog volume criteria.

    The University of Iowa study used all discharges in the state of Iowa for a single year, which in many cases, resulted in small sample size in terms of in-hospital mortality. Results were risk-adjusted using age, gender and severity of co-morbidities, but due to the small sample size the effect of volume on in-hospital mortality could not be fully tested. The University of Iowa researchers indicated caution must be taken in generalizing the results from this one year analysis of Iowa hospitalizations.

    On the other hand, more than 100 U. S. studies have demonstrated better results at high-volume hospitals with cardiovascular surgery, major cancer resections and other high-risk procedures.

    Hospitals fulfilling the Leapfrog EBHR Safety Standard will meet a combination of outcome, process and volume criteria. Hospitals will receive partial credit toward fulfilling the EBHR Safety Standard for favorable characteristics or performance on a subset of these measures.

    In its latest version, Leapfrog places primary emphasis on direct outcome measures (i.e. risk-adjusted mortality) for coronary artery bypass graft and percutaneous coronary interventions, using robust and approved measurement systems for the EBHR Safety Standards. While the standards also include specific process measures for coronary artery bypass graft, percutaneous coronary interventions, abdominal aortic aneurysm repair and certain high-risk deliveries, there is somewhat less emphasis on these measures.


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