The Leapfrog Group, an employer coalition known for turning the screws on hospitals to improve patient safety, has added a pair of very unlikely new members to its ranks: two large hospitals systems.
As first reported in Modern Healthcare's Daily Dose electronic newsletter last month, national hospital company HCA, Nashville, and Promina Health System, Atlanta, became the first hospital systems in the nation to join Leapfrog, a group of more than 100 mostly Fortune 500 companies formed in November 2000 to address growing public concern over medical errors.
Washington-based Leapfrog has gained considerable traction among employers, consumers and government agencies over the past year since it began pressing hospitals to meet three standards, which research suggests can greatly improve patient safety. They are: having a computerized system for ordering medication, using specially trained physicians to manage intensive-care units and meeting minimum volume requirements for certain high-risk procedures, such as open-heart surgery.
While a handful of large health insurers-including Aetna and Empire Blue Cross and Blue Shield-have long been Leapfrog members, the hospital industry has generally remained wary of the coalition's aggressive patient-safety initiative, which involves publishing how well individual hospitals are meeting the standards and then steering employees to those in compliance.
But the addition of 200-hospital HCA and eight-hospital Promina, large employers in their own right, is a major validation of Leapfrog's effort and could signal a shift in the hospital industry's thinking to a more participatory approach, said Leapfrog Executive Director Suzanne Delbanco.
"We see it as a sign that our relationship with the hospital community is strengthening and becoming increasingly collaborative," Delbanco said. Until now, "many hospitals haven't even thought about joining. They've looked at Leapfrog as an employer initiative that's directed at them, rather than something they can actually participate in."
Indeed, Leapfrog is no stranger to dissent. Only 53% of hospitals in six urban regions agreed to take part in a survey the coalition issued last year to assess adherence to its standards. Many of the 485 hospitals queried refused to respond, arguing that the standards were biased against them and didn't take into account the broad array of safety-improvement efforts they were making.
The American Hospital Association has taken issue with the particular criteria Leapfrog has chosen to advance. The AHA has argued that it isn't financially feasible for all facilities to install costly electronic ordering systems, that there aren't enough intensivists to fill demand if every hospital tried to hire a team to manage its ICU, and that patients could end up with fewer choices if hospitals had to close programs that don't meet volume thresholds.
Officials at for-profit HCA and not-for-profit Promina, however, said joining Leapfrog made good sense from both a provider and an employer standpoint. The companies-which employ 168,000 and 13,000 people, respectively-each have been working to address mounting public concern over patient safety since the Institute of Medicine reported in 1999 that up to 98,000 Americans die each year because of preventable medical errors.
"We embraced Leapfrog's standards from the get-go and opened up a dialogue with them very early on," said Promina Chief Medical Officer Robert Ryan, M.D.
"It seemed only natural for us (to become a member), since we're both a large employer in Atlanta and one of the region's main provider systems," he added. "It sends a very strong message to our employees and patients that we're stepping up to the plate and that we mean business when it comes to quality and safety."
Promina has vowed to implement all of Leapfrog's standards within three years. The company is investing $41 million to build an electronic ordering system across its entire network. It will become the first hospital chain in Georgia to have such a system when it rolls out the technology at the first two of its facilities, 452-bed Piedmont Hospital and 100-bed Fayette Community Hospital, next spring.
HCA also has taken on the enormous task of implementing an electronic ordering system across all 200 of its hospitals. But the company still "has some issues" with Leapfrog's other two criteria, particularly the minimum volume requirements for certain procedures, said HCA Chief Medical Officer Frank Houser, M.D.
"That's one of the major advantages (of joining Leapfrog). We decided we would rather be part of the discussions than be confronted with policies that someone else has decided for us," Houser said. "If we believe, for example, that there aren't enough intensivists to go around-which there aren't-we want to be able to have some input on the matter."
Conflict of interest?
But just how much sway Leapfrog's new members will actually have over policymaking is something that should be watched, cautioned Gregg Lehman, president and chief executive officer of the National Business Coalition on Health, a Washington-based organization of 90 regional employer groups.
Though commending HCA and Promina for "putting their money where their mouth is" by joining Leapfrog, Lehman said hospital involvement in employer groups always raises some concern over potential conflicts of interest. Member health systems, for instance, could try to block more stringent policies aimed at hospitals, or could try to force employees to use only their own facilities.
"It's something employers will want to monitor to ensure that (the hospitals) don't exert undue influence," Lehman said, adding that 85% to 90% of the NBCH's member coalitions prohibit hospital membership precisely to avoid such conflicts of interest.
Delbanco, however, said Leapfrog has taken significant steps to ensure that such dilemmas don't arise. Companies that are primarily in the business of healthcare, she said, are not allowed to sit on the coalition's board, head up steering committees or lead regional rollouts of the initiative. (Leapfrog is introducing its compliance surveys to hospitals in 12 additional urban regions.)
But hospital involvement in Leapfrog makes good sense, Delbanco added, because in many areas, hospitals are among the main employers. Statistics show that in the nation's 40 largest markets, hospitals are among the top 10 employers, she pointed out.
Becky Cherney, president of the Central Florida Healthcare Coalition, agreed, calling hospital participation in business groups "progressive" and "essential." Her Orlando, Fla.-based organization represents 128 large employers, of which 22 are hospital systems.
"It's about moving the healthcare agenda forward, and that can't be an exclusionary effort," Cherney said. "Employers aren't going to do it alone. Hospitals aren't going to do it alone. It's going to take all constituencies putting their heads together."
Still, Promina and HCA's espousal of the Leapfrog initiative could be seen as a subtle blow to the AHA and the Federation of American Hospitals, which have been promoting a broader set of patient-safety standards. Last year, the two organizations hastily arranged a joint press conference-two days before Leapfrog released its standards-to unveil their initiative, which focuses on educating hospitals about safer medication practices and creating an overall "culture of safety" (Jan. 21, p. 4).
The Washington-based federation, whose largest member is HCA, downplayed the significance of the systems' decision to join Leapfrog.
"I really don't see this as a big deal," said federation President Chip Kahn, adding that hospitals all around the country have been joining various quality-related organizations, such as the National Quality Forum. Both the federation and the AHA are members of the Washington-based forum, which is working to develop industry standards for measuring and reporting healthcare quality.
"The issue of eliminating medical errors is a high priority for all our members; different (companies) are just choosing different ways to go about it. This is HCA's way," Kahn said.
Carmela Coyle, senior vice president of policy at the AHA, asserted that "Leapfrog's three safety-improvement steps are just three among many" and should not be considered the best or only factors in determining overall hospital quality. She pointed to a recent report released by the federal government's Agency for Healthcare Research and Quality that lists 81 steps for improving safety at hospitals. The Leapfrog standards did not make the top 11 safety practices in an AHRQ study released last year (July 23, 2001, p. 4).
"(Promina and HCA's) decision to join Leapfrog simply indicates that their approach lines up with the Leapfrog initiative," Coyle said. "But it's important to note that that's just one approach, not the only approach."
Indeed, both HCA and Promina remain AHA members. But joining Leapfrog, HCA's Houser added, seemed inevitable given the coalition's growing influence nationwide. "We couldn't afford not to (join)," he said.
According to research by Dartmouth Medical School, electronic ordering systems can cut serious prescribing errors by more than 50%, volume thresholds can reduce a patient's risk of dying by more than 30% and intensivists can reduce ICU deaths by more than 10%. If adopted by the nation's 2,800 urban acute-care hospitals, the standards could save up to 58,300 lives and eliminate 522,000 medical errors annually.
Coyle said that subsequent research by the AHRQ found that these results may be overstated.