January 2009 Volume 33 No. 1

Moving metrics to the bedside

By: Bryan D. Bohman

You’ve been hearing a lot lately about continuing efforts to improve the quality of medical care at SHC. The impetus, aside from what I’d like to think is an innate desire to continually improve everything in our medical center, has to do at least in part with publicly reported quality metrics emanating from multiple sources ranging from CalHospitalCompare.org to the University Health Consortium.

SHC traditionally does very well in popular rankings such as those published annually by US News and World Report, due at least in part to an outstanding reputation based on Nobel Prizes, competitiveness for NIH grants, and other features of excellence in basic and clinical research. But as we move forward, actual measurements of clinical quality will be increasingly important determinants of our reputation and rankings, and therefore we are well-advised to focus considerable effort on initiatives to bolster our performance on these measurements.

I suppose that would be true even if the metrics were occasionally of dubious validity and subject to various manners of manipulation, and to some degree they are. But despite their current limitations, I think it’s clear that objective measurements of quality and transparency of those metrics must be a key component of any rational attempt to improve the quality of health care delivered locally at SHC as well as nationally. So the best reason to attempt to excel at these measures is that, at least in the long run, it will help us to actually provide better care to our patients.

We’ve chosen at SHC to embrace this movement toward quality metrics and to become leaders who help improve the metrics and steer them in the most productive directions rather than to be detractors who see only the present deficiencies and limits, not future potential and possibilities.

So far so good: the results to date of our aggressive attempts to improve our metrics have been excellent. Our overall ranking in the University Health Consortium, which we consider most relevant to our own institution, has improved dramatically. A particularly gratifying example comes from surgery. Under the leadership of service chief Tom Krummel, who has implemented several measures aimed at improving clinical care, our surgical mortality rates were actually the best in the nation in the most recent UHC ratings.

But what about the art of medicine? Can we really reduce the true quality of care to a bucket of objective measurements such as whether the antibiotics were given on time and all the I’s dotted and the T’s crossed? Certainly not.

This notion of medicine as an art, encompassing certain unquantifiable clinical skills as well as a generally more humanistic approach to medical care, is captured in part by the concept of “patient centeredness”, a phrase which captures the qualities of compassion, empathy and responsiveness to the needs and values of each individual patient.
Well, it turns out you can measure that too. Maybe not directly, and maybe not comprehensively, but carefully designed surveys of patient satisfaction can at the very least provide important clues about our patient-centeredness. And, put simply, we’re clearly not doing well enough.

Our recent scores in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a federally supported, publicly reported measure of service excellence and patient-centeredness, reveal profound opportunities for improvement.

Survey measures where we scored be-low the nationwide average include such vital areas as:

• Communication with doctors
• Communication with nurses
• Communication about medicines
• Pain management
• Responsiveness of hospital staff
• Quietness of the environment
• Discharge information
• Cleanliness

Our patients’ satisfaction with communication with their doctors, the item most directly relevant to the medical staff, puts us at the 19th percentile nationwide. We needn’t debate whether that is acceptable; the question is whether we have the capacity and will to attack these challenges with the same vigor and success that has been previously applied to the UHC and related metrics. The answer, of course, has to be yes. For the benefit of our patients, for our own professional self-respect, and for our economic survival, we must excel in all of these measures of quality of care. We’re certainly not the low-cost leader in health care, and for many good reasons we never will be, so we had better be able to demonstrate high quality — or prepare to be punished by the marketplace for our failure to do so.

In some ways, the patient-centeredness measures present a greater challenge than the UHC type of quality metrics. For example, a significant portion of our improvement in the UHC ratings was accomplished simply by better documenting the care we were already providing. But patient satisfaction scores really can’t be improved in any way other than by changing the way we practice and interact with our patients, so that those patients truly are more satisfied when they complete their surveys.

Under the able leadership of Sri Seshadri, vice president for organizational effectiveness, we are formulating and expanding various institutional responses to these challenges, and you will hear and see more about this in the near future. But there’s no need to wait for that before taking stock of our own roles in improving the patient-centeredness and general quality of our own care.

Each of us might ask ourselves, for instance, whether we are communicating as fully and empathetically with our patients as possible. And in a teaching institution, it’s critical that each attending physician takes responsibility for ensuring that his or her patients have at least a basic understanding of the team members who are involved in their care. A central part of that understanding is for every patient to know that they do in fact have an attending physician. The buck stops with us, and it’s important that our patients are aware that we are closely supervising the care they receive from the house staff — and that we really care.
Our individual efforts are necessary, but not sufficient. We also need to work hard to identify institutional and process-related obstacles to optimal quality of care, and we must take advantages of any opportunities for improvement. Though Sri is already leading these efforts, here is yet another example of why it is so critical that we continue our efforts to become a learning institution, from the ground up, as discussed in last month’s column (http://med.stanford.edu/shc/update/archives/DEC2008/chief.htm).

We very much need to hear from front line caregivers their own suggestions for improvements, and we need to develop better systems to facilitate that kind of communication. We are continuing to work on that. Meanwhile I would encourage medical staff members to directly contact Sri (sseshadri@stanfordmed.org) or me (bbohman@stanfordmed.org) with any comments or suggestions.