A prominent survey of how California patients feel about their hospital care is steadily gaining support, though half of the state's hospitals remain reluctant to participate.
The voluntary survey, known as the Patients' Evaluation of Performance in California, or PEP-C, rates hospitals based on the reported experiences of their patients who were admitted for at least one night. Scores are made public to help consumers and to encourage underperforming hospitals to improve.
The results of the second annual PEP-C survey will be released Wednesday by the California Institute for Health Systems Performance and the California HealthCare Foundation, which jointly launched the effort in 2001. Yet changes in participation over the past two years alone say much about the growing willingness of hospitals to share quality information-as well as the limitations of a voluntary reporting system where those likely to perform poorly can choose not to be counted.
A full 181 hospitals took part in the most recent survey, which was conducted last year, representing 47% of the state's 383 hospitals and 51% of all licensed beds. That's up markedly from the initial 2001 survey, which was released in 2002, when 113 hospitals, or 30%, participated, representing 42% of licensed beds. Some 35,000 patients were surveyed in 2002, up from 21,150 the year before.
Still, there are areas of concern. Participation has remained surprisingly low in some key regions, including Los Angeles and San Diego. A number of major hospital chains have refused to volunteer. And while 83 hospitals joined for the first time last year, 15 of those that participated in 2001 subsequently dropped out.
"We would have liked the numbers to be higher," said Marsha Nelson, vice president of the Sacramento-based institute. "We realize that projects like these take time to pick up speed, and we're pleased by the increased participation. It's promising ... but obviously, we have a way to go yet."
PEP-C differs from other performance surveys in that it asks patients to objectively report their hospital experiences rather than subjectively rate their satisfaction with care, Nelson said.
Based on National Research Corp.'s "Picker approach," it grades hospitals on seven quality indicators: respect for patients' preferences, coordination of care, information, education, physical comfort, emotional support, involvement of family and friends, and transition to home. Hospitals receive one, two or three stars-for below average, average and above average-on each measure, as well as an overall score.
Hospitals have faced mounting pressure to join PEP-C from both consumers and employers demanding greater information by which to compare providers. Health plans also are increasingly using PEP-C measures in their contract negotiations. In October 2002, Blue Shield of California incorporated PEP-C results into its hospital tiering program, which divides facilities into two categories based on relative cost and quality. PacifiCare Health Systems and Health Net also grade hospitals in their networks, based partly on PEP-C.
Yet the fact that half of hospitals statewide declined to participate underscores the inherent limitations of a voluntary disclosure system, said Mark Smith, president and chief executive officer of the California HealthCare Foundation, an Oakland-based philanthropic organization. "There is no such thing as a voluntary, universal anything," he said. "People will always have reasons, some of them legitimate, for why not to participate."
Smith and others argue that full accountability-and major improvements in quality and safety-will be achieved only if performance reporting ultimately is made mandatory, as it is with the auto and airline industries.
"If it's voluntary, hospitals will self-select," said Earl Lui, staff attorney for Consumers Union in San Francisco. "You'll always get a skewed picture because the hospitals that think they have something to hide or know they aren't going to score well probably won't cooperate."
This self-selection phenomenon was underscored in a study about health plans published in September 2002 in the Journal of the American Medical Association. According to the study's authors, HMOs that received poor grades from the National Committee for Quality Assurance were almost six times more likely to refuse to provide data the following year, making the rankings "increasingly unreliable or even meaningless."
Lisa McGiffert, senior health policy analyst with Consumers Union in Austin, Texas, said mandatory reporting spurs far more rapid improvements in quality by creating healthy competition among hospitals. In 1995, for example, Texas passed a law requiring all of the state's hospitals to submit data on 25 quality indicators to be compiled into an annual report available to the public. Since the first results were released in November 2002, "hospitals have been scrambling to see why they scored lower on certain measures than others or why their mortality rates were higher than their competitors," McGiffert said. "We've seen a lot of improvement. But you're only going to get that if you name names."
Several states, including Connecticut, Maryland, New York and Rhode Island, have enacted laws that mandate hospitals to publicly report data on several quality and patient-satisfaction measures. Illinois' General Assembly passed a bill last month that would require all of the state's hospitals to participate in a report card that scores them on staffing levels and worker turnover as well as infection and mortality rates.
Hospitals, however, emphasize the importance of preserving the voluntary nature of report cards. "Anytime you say something is mandatory you immediately turn off the interest of those whom you need to be engaged," said Carmela Coyle, senior vice president of policy at the American Hospital Association. "You lose the spirit of collaboration and consensus building that's so important to the process. In some cases, it even creates an adversarial environment."
Coyle points to the Quality Initiative, a voluntary 10-measure report card rolled out last month by the AHA, the Association of American Medical Colleges and the Federation of American Hospitals. Already, 1,014 of the nation's hospitals, or about 20%, have enrolled and several other systems have pledged to participate, Coyle said. "The response we've had to date says there's a lot to be gained by asking rather than telling hospitals to cooperate," she said.
Indeed, several large hospital chains, including Sutter Health and Kaiser Permanente, have supported PEP-C from its inception, enrolling almost all of their hospitals.
Oakland-based Kaiser has shown particular commitment to public disclosure: It re-enrolled all 27 of its California hospitals in 2002, even though 15 of the facilities scored "below average" and only one scored "above average" in the first year. Of all the PEP-C participants, 23 hospitals scored "below average," 65 "average" and 25 "above average" in the initial survey.
Many other chains, including HCA and Catholic Healthcare West, made a strong showing in 2002 after taking a wait-and-see approach. "We've always supported industry efforts to establish quality standards that everyone can accept," said Jeff Prescott, spokesman for Nashville-based HCA, all six of whose California hospitals took part in PEP-C for the first time last year. "It's about being part of it, being a player."
"Our hospitals saw the usefulness in giving patients the ability to compare them to others in the state," said Jerri Randrup, spokeswoman for San Francisco-based Catholic Healthcare West, which had 20 of its 29 California hospitals volunteer for the latest survey, up from just one in 2001. Each hospital decided independently whether to take part, she said.
Industry observers, however, speculate many others opted out of PEP-C because of a reluctance to subject themselves to public scrutiny. All but two of the 15 hospitals that dropped out of the survey in 2002 had scored "average" or "below average" the year before. "Those that had low performance scores may be thinking, `Why expose ourselves even more?' " Nelson said.
Others suggested that taking part in PEP-C may have been considered too big of a gamble for some hospitals in highly competitive markets. Indeed, four of San Diego County's five major health systems-Palomar Pomerado Health, Scripps Health, Sharp HealthCare and UCSD Healthcare-declined to participate. As a result, only three of the county's 22 hospitals, or 14%, will have scores this year.
"If you're subjecting yourself to scrutiny and your competitors aren't, that could serve you well or that could serve you poorly," said Jan Emerson, spokeswoman for the California Healthcare Association. "It's a big risk."
The CHA endorses PEP-C but emphasizes that participation should remain voluntary. "Requiring hospitals to (take part) doesn't necessarily influence change," Emerson said. "When it's voluntary, you're making a commitment. You're buying into it, and that's what really drives improvement."
Despite efforts by PEP-C organizers to make the latest survey easier and more affordable-including offering 50% to 100% subsidies to hospitals that requested financial help-many smaller facilities said they were still prohibited by the money and time it takes to generate lists of hundreds of patients for surveyors to contact.
Weaverville, Calif.-based Trinity Hospital-which scored "above average" on the 2001 survey-dropped out this year after major layoffs thinned its administrative staff. "We just didn't have anybody to take the lead on the project," said Robert Coe, technical services specialist at the 65-bed hospital.
Oroville (Calif.) Hospital also dropped out in the second year because of budget constraints. "We had to cut costs somewhere, but we didn't want to cut patient services," said a spokeswoman for the 120-bed facility, which scored "average" in 2001.
Some industry observers even blamed Los Angeles County's budget crisis for the region's disappointing PEP-C participation rates. Only 27 of the county's 99 hospitals volunteered for the survey in 2002, up from 15 the year before.
But Jim Lott, executive vice president of the Hospital Association of Southern California, said participation remained low because hospital administrators deliberately rejected PEP-C's methodology. "Our membership reviewed the survey but didn't find much value in it because it's statistically invalid in many areas," Lott said, adding that his association is developing its own criteria for hospital report cards.
Many large health systems also said they preferred their own performance measures. None of Sharp's five hospitals volunteered for PEP-C, for instance, because the company already uses another tool, which gauges patient satisfaction and quality on a more continuous basis, said Sharp spokesman Gustavo Friederichsen.
"PEP-C takes a `slice in time' approach; it gives you a snapshot of healthcare delivery for one specific period," Friederichsen said. "We're more committed to having an ongoing survey process whereby we can access results on a real-time basis ... so that we can continually change and enhance the healthcare experience."
The state's largest chain, Santa Barbara, Calif.-based Tenet Healthcare Corp., said it omitted all of its California hospitals from PEP-C because the company preferred its own survey methods.
However, Tenet, which faces federal probes into its billing and physician-recruitment practices, simply may have bigger fish to fry. Two of its hospitals-Alvarado Hospital Medical Center, San Diego, and San Ramon (Calif.) Regional Medical Center-joined the first PEP-C survey but dropped out in 2002, the year the former was raided by federal agents and the latter was served with civil subpoenas seeking information on its provider contracts. Both hospitals had scored "average" and "above average" on all measures.
Smith, however, emphasized the need for a standardized-and mandatory-hospital reporting and measurement system. He equated it to the auto industry, where all carmakers are subject to national standards. "Imagine how you would feel if you walked into a (car) showroom and the managers there said, `Well, we use our own internal crash-test measurements,' " he said.
Efforts already are under way. The Centers for Medicare and Medicaid Services has incorporated the Picker approach into a standardized quality reporting initiative. Hospitals in Arizona, Maryland and New York are taking part in a pilot study of the survey, which eventually will be expanded nationwide. Participation will be mandatory for all hospitals in the Medicare program, and the CMS is expected to adjust its reimbursement rates according to each hospital's performance.
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