Leaders of the HENs say the CMS made the right call. Kosel said the VHA's HEN would not have been able to recruit 191 hospitals if the partnership's protocols were more rigid. “They made a judgment: Get more hospitals in the program and take whatever data they can give us,” he said. “I think that was one of the smartest things they did.”
During 2012 and 2013, VHA's HEN hospitals achieved overall reductions in all nine of the initiative's preventable harm types, including a 58% drop in early elective deliveries, a 48% drop in ventilator-associated pneumonia and a 30% drop in falls with injury, according to an annual report. Kosel acknowledged that it's difficult to say whether the Partnership for Patients was the direct cause of those improvements when other quality-improvement programs were operating at the same time, including Medicare value-based purchasing. “Peter Pronovost is right that this is not designed as an experiment, but the reality is we've seen tremendous improvement,” he said.
One of VHA's HEN hospitals is Jennings (La.) American Legion Hospital, a 60-bed rural facility. Through the Partnership for Patients, the hospital has achieved success in improving venous thromboembolism prophylaxis rates through the use of a scorecard that tells each unit how it's doing, said Phyllis Theriot, the hospital's director of clinical systems improvement. Compliance rates have jumped from 50% to 93%, she added.
Jennings CEO Dana Williams said resource-strapped rural facilities like hers reap particular rewards from the collaborative approach of HENs. “We have the same compliance requirements as larger hospitals, but we have to rely on a smaller subset of resources,” Williams said. “Networking and sharing with peers through the HEN is so beneficial to us.”
Urban public hospitals also benefit greatly from sharing best practices and lessons learned, said Thomas Holton, patient safety officer and director of education and training at 460-bed San Francisco General Hospital. His facility is part of America's Essential Hospitals' 22-member HEN. The hospital focused primarily on pressure ulcers and falls with injury. Pressure-ulcer rates have fallen significantly, from eight or nine a month down to zero or one, though progress on falls has been more uneven, Holton said.
Dignity Health, San Francisco, which runs its own system-wide HEN, has reported significant safety gains in early elective deliveries. The system halted nonmedically indicated early elective deliveries before 39 weeks gestation and reduced rates from 7% to .03%, said Barb Pelletreau, Dignity Health's senior vice president of patient safety. The system also has seen big drops in central line-associated bloodstream infections and catheter-associated urinary tract infections.
Like other HEN leaders, Pelletreau said the CMS' flexible measurement policy was needed to get hospitals on board. She argued that it has not hindered Dignity's ability to generate data that can be used to compare performance both within its own HEN and across other HENs. “We don't all need to agree on the same numerator and denominators,” she said. “If CMS had taken that approach, I think we would still be arguing about metrics right now.”
Dr. Maulik Joshi, president of the Health Research & Educational Trust, agreed that stringent rules can lead to “data collection paralysis.” HRET's massive HEN has nearly 1,600 hospitals across 31 states. In an annual report released in December 2013, HRET said its HEN-related efforts have prevented harm for 69,072 patients over two years, equivalent to an estimated $200 million in savings.
“We have an encyclopedia of process and outcomes measures posted on our website,” said Charisse Coulombe, HRET's vice president for clinical quality who oversees the HEN. “If we told hospitals exactly what to submit, they might not have joined.”