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Sunday, October 26, 2014

Hospital Safety In Light of Ebola Scare

Hospital Safety In Light of the Ebola Scare

Due to public hysteria and resulting quarantine for Ebola patients, family members, and anyone who may have come in contact with any of these unfortunate individuals, this is a good time for consumers to re-acquaint themselves with patient safety standards through publicly available sources. First a primer on the main causes of adverse patient safety events in hospitals in the United States. In patient safety lexicon when something goes wrong in health care treatment while in a hospital setting, this is referred to as an adverse event. There are a number of health care organizations within the nation that track patient safety information including: the Centers for Disease Control, Joint Commission for Hospital Accreditation, the National Quality Forum and several nonprofit entities. Of the nonprofit leaders, The Leapfrog Group® is known for its annual hospital quality and patient safety survey, of which over 5,000 hospitals participate. In addition to this, the Commonwealth Fund[1] has also published patient safety and health care outcome information, including the average number of safety events by category and by county.

A detailed analysis of patient safety tracking entities is provided in Unraveling U.S. Healthcare-A Personal Guide[2] and no less than three chapters detail hospital quality and patient safety, by facility and by state. However, since this is a monthly health care column and not a book, I am using Hospital Safety ScoreSM, The Leapfrog Group® annual hospital quality survey to highlight how hospitals rank which are handling Ebola patients[3]. This is meant to provide consumer information on basic patient safety rankings, so that the informed patient will use sound information and not hysteria when making health care decisions. To that end, here are the rankings, starting with Dallas Presbyterian Hospital:

Dallas Presbyterian Hospital Survey Results as of August 2013[4]
Infection rates observed in patients versus the expected rate are listed below for two common metrics
Central Line Infection Rate is .56, which nearly matches the national average of .55, which is a solid performance.
Catheter Infection Rate is .19, which is far better than the average rating of .71 for the survey respondents.
Patient Safety Processes
Computerized Order Entry-100 (out of 100)
Physician Staffing in Intensive Care Unit-100 is a perfect score
Identification and Mitigation of Risks-120 (out of a possible 120)
Hand Hygiene-30 (out of a possible 30)
Nursing Workforce-100 (out of 100)

By all measures Dallas Presbyterian Hospital is a top-notch facility in terms of patient safety, but the Ebola patient who died was treated too late, and time-to-treatment is a key statistic for improving patient survival in many clinical interventions. Additionally, the man was autoimmune suppressed and taking medication for HIV. The laboratory delay was not the fault of the hospital, which used normal protocol, but reflected the dearth of resourcing from a disease prevention level at the Centers for Disease Control and Prevention.
Only the best hospitals are now accepting Ebola patients, those trained for the most acute care, including the venerable Bellevue Hospital in New York City, Harborview Medical Center in Seattle and Emory Health Care in Atlanta. Focusing on the patient safety processes of the Leapfrog survey, here are the scores for these facilities as well:

Note: The [Leapfrog] Hospital Safety Score grades hospitals on data related to how safe they are for patients. For more information, visit”

Leapfrog Group Criteria for Emory Health Care-Atlanta[5]
Central Line Infection Rate-.522 (better than average)
Catheter Infection Rate-1.60 (much worse than the average reported of .71)
Computerized Order Entry-65 out of 100
Physician Staffing in ICU-65 out of 100
Identification and Mitigation of Risks-Did not report
Hand Hygiene-Did not report
Nursing Work force-Did not report

Leapfrog Group Criteria for Bellevue Hospital-New York City[6]
Central Line Infection Rate-.645 (worse than average)
Catheter Infection Rate-.682 (better than average)
Computerized Order Entry-65 out of 100
Physician Staffing in ICU-Categorized a 5 or the lowest score in this criteria, the average facility had a score of 31 and the top hospitals scored 100.
Identification and Mitigation of Risks-Did not report
Hand Hygiene-Did not report
Nursing Work force-Did not report

Leapfrog Group Criteria for Harborview Medical Center-Seattle[7]
Central Line Infection Rate-.46 (better than average)
Catheter Infection Rate-.71 (average)
Computerized Order Entry-50 out of 100
Physician Staffing in ICU-100 out of 100
Identification and Mitigation of Risks-120 out of 120
Hand Hygiene-30 out of 30
Nursing Work force-100 out of 100

Now that the CDC has stepped up its monitoring and support for Ebola, with airport screenings (not sure how effective this will be) and rapid lab responses for blood screenings, it is a good time to review how we resource disease surveillance in the nation. In the case of hospitals, with the exception of the Veteran’s Administration and university hospitals, most are private facilities. This means Texas Health Presbyterian Hospital in Dallas had to shell out the money for extra hazard gear, extra cleaning costs, and extra staffing for Ebola. If we are going to expect a private facility to provide this type of intensive support for prevention of highly contagious and highly fatal diseases, we need to look at how we fund these services. Certainly syphoning new Ebola patients to trauma centers is wise, but that in and of itself is not a cure, more like a Band-Aid.
Regarding the other facilities targeted for Ebola triage, of concern is the poor intensive care staffing score for Bellevue Hospital in New York City, sounds like this place could use an infusion of capital from the big apple. And it should be unacceptable for any publicly funded facility to refuse to provide patient safety reporting information on basic stuff like hand washing, identification and mitigation of safety risks, and their nursing staff standards & staffing (Bellevue and Emory). Finally, thank you to Texas Health Dallas Presbyterian for going first in this fiasco because the nation learned a lot at your expense. Clearly you run a first rate facility, based on your reported patient safety data, so maybe you can petition our federal government’s Health and Human Services for some disaster relief money.

And this is the healthpolicymaven signing off encouraging all readers to share this article virally, but with appropriate attribution for  the author of course. For more information on patient safety, read


Thursday, October 2, 2014

Taming the Willd West of Hospital Overcharging

Washington’s Winner-take-all Hospital Billing Environment
Why do we tolerate a 300% difference in treatment for the same procedures among our hospitals? Washington Health Alliance, a nonprofit consortium of healthcare organizations has just published the results of a statewide survey of hospital billing for treatment of stroke and a variety of other conditions.[1] The data for the analysis was extracted from Medicare records through 2012. While I worked for a hospital network I was involved in a value proposition to increase recovery efficacy for stroke patients by getting them into treatment quicker, which was funded with a $6,250 per patient Medicare incentive. This article reviews the high and low price points for stroke treatment by facility and explains the reason for this phenomena and what we can do to fix it.
I.  Price
Tacoma is the Most Expensive Place for Stroke Patients in Washington
Washington Health Alliance reviewed diagnostic related code information for treatment of stroke across the state of Washington and the nation, looking for variations in price for the same services.  In Washington, the nonprofit Multicare-Tacoma General Hospital, was found to have the most expensive stroke treatment with an average Medicare billing of $37,066 and a reimbursement of $5,001. The second most expensive facility for treatment of stroke was also in Tacoma, the nonprofit, St Joseph’s Hospital with a Medicare billing of $33,948 and a reimbursement of $4,227. How can two facilities in the same city have a $700 price variation for the same procedure and why is Tacoma the most expensive place for stroke treatment? These are the kinds of questions consumers and health policy analysts need to be asking. FYI, the third most expensive place for treatment of stroke was also a Multicare facility, Good Samaritan Hospital, with $33,581 in billable charges and a reimbursement of $3,703 in reimbursement.

The Least Expensive Places for Stroke Patients are Rural Hospitals
In this same study, Washington Health Alliance found that the least expensive facility for treatment of stroke was Olympic Medical Center in Port Angeles, gateway to our jewel Olympic National Park, with $10,835 in charges and $4,119 in reimbursement. Olympic Medical Center is a community hospital and not part of any hospital chain. The second least expensive facility for stroke treatment was Yakima Valley Memorial Hospital with $12,946 in charges and $4,778 in reimbursement. In third place for the most frugal was Central Washington Hospital with $13,811 in charges and $4,408 in Medicare reimbursement. Lest you think only rural hospitals are inexpensive, non-other-than Virginia Mason Medical Center in Seattle was the 4th most economical place for treatment of stroke, with $16,965 in charges and $5,563 in Medicare reimbursements. This is quite amazing since wages alone are much higher in the Seattle area than in rural Washington Communities.

Comparing Comprehensive Hospital Billing Data
Washington Health Alliance also compared multiple hospitalization codes across all state hospitals to develop a profile and what emerges is not a shock, in areas where there is only one hospital, the hospital becomes the economic price maker, which means it gets away with charging more. Here are examples of this phenomena:
Harrison Medical Center-Charges above average prices for a plethora of treatments including: pneumonia, COPD, UTI’s, back fusion surgery, and not a surprise, orthopedic surgery (someone has to pay for their deluxe new facility). Of note, their award winning cardiac program does not charge above average prices for treatment of cardiac conditions.
Skagit Valley Hospital charges were above average for treatment of: heart failure, dehydration/nutritional disorders (?), and Urinary Tract Infections.
Providence Hospital in Centralia posted above statewide averages for these conditions: dehydration/nutrition, UTI’s, and Anemia. Providence also posted an unusual outlier; even though there are multiple hospitals in the state capitol of Olympia, Providence had the most expensive charges in nearly every category: COPD, dehydration/nutrition, anemia, unblocking a heart artery, back surgeries, and orthopedic surgeries. They were more expensive than Capital Medical Center for all criteria in the Washington Health Alliance report except for treatment of heart failure. Capital Medical Center is part of a national group called Capella Health, which specializes in operating smaller hospitals.[2] Providence, of course, is one of the largest nonprofit hospital groups in the state.

II. Quality
Comparing Quality and Price
The highest safety scoring hospital mentioned was Virginia Mason Medical Center, which consistently scores as a top hospital by the nonprofit patient safety advocacy group, and is also a good price performer. This is an indication of health care efficacy, which means value created through clinical outcomes and efficiency of operations. In the latest survey, Virginia Mason scored 100% in the main patient safety criteria and 75% in the newest metric, safety focused scheduling.  
Here are the hospital rankings for the other facilities highlighted in this article based on the Leapfrog Group’s patient safety survey.[3]

Tacoma Hospitals
Multicare Medical Center-Good Samaritan Hospital received perfect scores for the four patient safety metrics, preventing medication errors, appropriate ICU staffing, steps to avoid harm, and managing serious errors, in the 2013 Leapfrog Hospital Survey. Tacoma General, another Multicare facility, which was the most expensive for stroke treatment in the state, did not do as well in the survey, with only a 75% score for the steps-to-avoid-harm criteria. It should be noted this information is current as of August 2014 and was voluntarily submitted by the hospital, so any hospital which participates in the Leapfroggroup Hospital Survey is committed to vigorous peer review and improvement of patient safety.[4] In the same survey, St. Joseph’s Hospital in Tacoma did poorly in appropriate ICU staffing, with only a 25th percentile score (yikes). Certainly something to consider for stroke treatment, where speed is of the essence.

Rural Hospitals With Low Prices
So, how did the rural hospitals score in the annual Leapfroggroup Patient Safety Survey?  None of the rural hospitals submitted a response to the patient safety survey, which means there is no consumer friendly way to compare their efficacy for safety and price.

National Outlook
In March 2014, I wrote an article on hospital price transparency,[5] which is practiced in Maryland and other states are adopting this practice. Maryland also happens to have a hospital pricing policy that limits the spread between what may be charged and what the actual reimbursement is for hospitals.[6] This has resulted in lower charges for Maryland hospital patients and ultimately impacts what employers and everyday consumers pay for health treatment. Twenty-seven states have enacted hospital pricing transparency laws.[7] The Obama Administration has an initiative to spread the adoption of the Maryland hospital pricing across the nation, which could just save us all money.[8]

This article was written by Roberta E. Winter, MHA, MPA, a health care policy analyst and advocate and author of

Feel free to share this article virally, but do provide appropriate author attribution if quoting, and this is the healthpolicymaven signing off.