The man charged with shepherding in a new national era of healthcare quality called last week's release of hospital information by the Leapfrog Group the beginning of a revolution.
"This is the wave of the future; this is where it is going," said Kenneth Kizer, M.D., chief executive officer of the National Quality Forum, a private organization charged by the government with setting a national healthcare-quality agenda.
News of the Leapfrog Group's publicly accessible Web site showing where 241 hospitals stand in meeting three patient safety standards isn't all that earthshaking on its own. But "what it symbolizes is immense," Kizer said.
Leapfrog, led by a group of Fortune 500 companies, includes more that 90 private and public organizations buying healthcare benefits for 28 million people. Officials there said 48% of nearly 500 urban hospitals in six regions they examined around the country completed a survey about whether they are implementing Leapfrog standards. As the Leapfrog train pulled away from the station, there were those who managed to jump on the last car and those who chose to stay behind.
The Joint Commission on Accreditation of Healthcare Organizations, which in July 2001 introduced its own patient- safety standards for accreditation of hospitals, announced a formal partnership with Leapfrog one day before the release of the hospital information.
Meanwhile, two days before the release, the American Hospital Association, the Federation of American Hospitals and the Healthcare Leadership Council hastily arranged their own news conference to share criteria for hospitals and policymakers to use in evaluating patient-safety standards. The AHA downplayed Leapfrog's significance.
"I think their results provide important information, but they simply provide information on those three initiatives," said Carmela Coyle, the AHA's senior vice president. "It should not be used to assess the overall quality of a hospital."
The AHA and the federation hope Leapfrog and others putting out patient-safety standards will use criteria that Santa Barbara, Calif.-based consulting firm Protocare developed for the hospital groups. "We really need to avoid a flavor-of-the-month approach, which I think some groups may tend to take towards standards," said Charles "Chip" Kahn, president of the federation.
The irony wasn't lost on Kizer that two patients died because of hospital blunders in Connecticut on the same day Leapfrog reached a milestone in its 14-month effort to push hospitals to do something about the estimated 98,000 preventable deaths in their facilities each year.
Leapfrog's standards include having a computerized system for placing medication orders, using specially trained physicians to manage intensive-care units and meeting high-volume requirements for certain high-risk procedures, such as open-heart surgery. Of the respondents, 53% meet one or more of the Leapfrog standards.
Leapfrog's members and others have promised to put the hospital-specific information on their Web sites for employees and other beneficiaries. The Centers for Medicare and Medicaid Services said it will link its Web site to Leapfrog's and promote the data in brochures it sends to its 37 million beneficiaries. Consumer groups, such as the 30 million-member American Association of Retired Persons, will actively promote awareness and use of Leapfrog information among its members. Even Web-based health information vendors such as HealthGrades, to which Leapfrog is a competitive threat, said they now would carry the group's data on their sites.
Although the number of markets involved so far is modest, affecting less than 10% of the nation's hospitals, the Leapfrog initiative will move into 15 more urban markets this year, said Gregg Lehman, president of the National Business Coalition on Health, which represents regional healthcare business coalitions.
Coyle rebutted the suggestion that Leapfrog was filling a void in consumers' growing quest for information on hospital quality, saying that information on JCAHO accreditation and state hospital certification has been available publicly for years. "There are a lot of mechanisms that have been tried and tested to help address what is a very, very complex issue," Coyle said.
The pressure on various groups to address patient safety has built since the Institute of Medicine reported the number of Americans who die each year because of preventable hospital errors (See chart). Efforts to pass a federal mandatory or voluntary medical-error reporting law so far have stalled. But moving in to fill that void are private-sector efforts at self-policing. So far, however, separate groups have had a hard time joining forces, and it is unclear whether their initiatives will quell or renew calls for a single, federally mandated system.
The AHA doesn't have any plans to publicly release quality data on specific hospitals, Coyle said. And though the JCAHO will begin collecting hospital clinical outcome data later this year, it has no timetable for making data available to the public, said Paul Schyve, M.D., the JCAHO's senior vice president.
In September 2001, CMS Administrator Thomas Scully challenged the NQF, of which AHA and other hospital groups are members, to provide hospital-quality data soon or the government would be forced to do it.
"Hospitals feel Leapfrog is starting to move them onboard a little bit, and I think it is terrific," Scully said. "Most hospitals I know, know this needs to be done."
One influential consumer advocacy group made clear that the Leapfrog data would serve as a proxy for quality. "Do not send your parent to a hospital that is refusing to give this kind of information," said John Rother, the AARP's director of policy and strategy. He called choosing hospitals "life-and-death decisions" and said his organization would "do everything we can to make sure that people know that this information is available."
Verizon Communications, a regional telecommunications company that buys health benefits for 1 million people, plans to make Leapfrog's data available on its employee Web site and will use internal newsletters to direct people to the site. "Verizon is not going to dictate physician choices or hospital choices, but I think the marketplace will help make the changes that are necessary," said Verizon Chief Executive Officer Charles Lee.
"I think this is a very tangible manifestation of the new era of consumerism and the new role that purchasers are playing in healthcare," Kizer said.
Empire Blue and Cross Blue Shield, a New York health insurer for more than 4 million people, awards hospitals a financial incentive for meeting Leapfrog's standards. Beginning Jan. 1, hospitals using computerized medication-ordering systems and intensivists to manage their ICUs were to have gotten a bonus worth 4% of their payments from Empire. The bonus will drop to 3% in 2003 and 2% in 2004.
Among the 241 hospitals that responded to Leapfrog's online survey, only 3% said they had instituted computerized medication-ordering and 30% said they planned to do so by 2004. Some 10% of hospitals had intensivists overseeing care in the ICU at least eight hours a day; an additional 18% planned to use intensivists by 2004.
Hospital compliance with volume requirements for six high-risk treatments fell across a range. Thirty-one percent of the hospitals met the standard of performing 400 or more coronary angioplasties, but only 15% did seven or more esophageal cancer surgeries.
Whether Leapfrog is pushing hospitals to adopt the patient- safety standards isn't clear. Cedars-Sinai Medical Center, an 849-bed hospital in Los Angeles that completed the Leapfrog survey, was implementing all the standards as part of its own quality improvement plans, not because of Leapfrog's prompting. "We have been performing in these areas well before Leapfrog was a thought," said Michael Langberg, M.D., Cedars-Sinai's chief medical officer and the lone hospital representative at the Leapfrog news conference last week. Regardless, Langberg said Cedars-Sinai was supportive of Leapfrog's endeavor to make hospitals accountable to their communities.
Leapfrog Executive Director Suzanne Delbanco told of "anecdotal" evidence that the group has changed behavior. Delbanco received word from one hospital's director of pharmacy who said the Leapfrog movement was just what was needed "to push the board (of trustees) over the edge" in making changes at the hospital.
The AHA and some state hospital associations have been critical of the particular standards Leapfrog picked, saying it isn't feasible for all hospitals to install high-cost computerized medication-ordering system and that there aren't enough intensivists in the country to fill demand if every hospital tries to hire a team to manage its ICU.
Earlier this year, the Agency for Healthcare Research and Quality found that the three Leapfrog standards lacked enough clinical evidence for the group to recommend immediate implementation in hospitals.
The concern over the standards led to wide variation in the hospital response rate to Leapfrog's survey from region to region. Although 92% of invited hospitals completed the survey in both the eastern Tennessee region and the Seattle-Tacoma-Everett (Wash.) region, only 3%-one hospital-participated in the St. Louis region. The other regions were Atlanta, California and Minnesota.
The Missouri Hospital Association told its members it had "concerns about limitations in the survey," said Mary Jenkins, the association's director of communications.