Physician Executives Must Leap with the Frog: Accountability for safety and quality ultimately lie with the doctors in charge. (Quality).

IN THIS ARTICLE...

Take a look at how one New Jersey medical center is tackling The Leap frog Group's mandates far change. Achieving the goals for better quality and high levels of patient safety requires diligence, patience and a strong willingness to change.

THE LEAPFROG GROUP didn't emerge from a vacuum.

The group formed in reaction to public clamor for better safety and quality performance measures that are evidence-based and understandable to patients. The uproar was the result of numerous health care developments including:

* A market shift with consumerism replacing managed care as the prime driver of health care delivery.

* The Institute of Medicine (IOM) report "To Err Is Human" (1) cast a long shadow over the entire issue of health care safety.

* A quest for accountability hit health care as if it were a newly discovered notion.

* A second IOM report, "Crossing the Quality Chasm," (2) and the "Revisions to Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction" (3) also contributed to the call for action.

The Leapfrog Group is one of several initiatives created to meet the demand for understandable performance measurement. Others include the ORYX initiative of JCAHO (4) and the 24 process-of-care measures from the PRO Sixth Scope of Work. (5)

Organizations will look to physician executives for guidance and accountability as they traverse these new performance vistas.

Meet the frog

In its November 17, 2000, editorial, "Naming Hospitals, Good and Bad," (6) the New York Times cited 60 (now over 80) large consumer corporations that demanded providers use three concrete criteria to evaluate safety/quality performance:

1. Computerized physician order entry (CPOE)

2. ICU physician staff (IFS)

3. Evidence-based hospital referrals (EHR)

While some bemoaned and questioned this initiative, (7) others saw the opportunity as another tool to help translate many of the vagaries of clinical performance measures into criteria easily understood by consumers.

Here's a look at how The Leapfrog Group criteria can be integrated into the strategic plan of a hospital or medical center striving to meet the corporations' demands.

Computerized Physician Order Entry (CPOE)

With fierce competition for shrinking dollars, the organization's leaders need to be convinced of the critical role information systems and e-business play in health care delivery of the 21st century.

A cogent, articulate and passionate message emphasizing this critical role must be crafted and repeated over and over again. The message needs to be realistic, as well.

There are no simple off-the-shelf solutions for CPOE. Information systems don't correct bad processes. No single vendor has all the solutions. Done properly and with appropriate work process redesign, safety and quality can be built into the system.

At Somerset Medical Center in Somerville, NJ., we are fortunate to have a board that understands the issues, the IOM reports and the Leapfrog initiative. The result is a three-year, multi-million dollar information system and associated work process redesign that's a fundamental cornerstone of our strategic plan.

Illegible handwriting will no longer be a badge of honor. It will be exposed for the unsafe, poor quality practice that it is. Say farewell to the de-energizing tasks of dealing with penmanship, incomplete orders and unclear verbal commands.

Within 18 months a notice will go out announcing that written orders will not be accepted at this medical center.

That is the vision.

ICU Physician Staffing (IPS)

Most facilities support an "open" ICU where any properly credentialed primary physician can admit and treat patients. (8)

The problem with this model is chaos.

Highly paid ICU staff contact five physicians to get a Tylenol PRN order renewed. Conflicting orders from multiple consultants occur daily. Family communication can be poor. A unanimous vote from all attending physicians is required to transfer a patient.

The political reality is most of us will never move to a closed ICU where patient care is provided by a team of intensivists. So our job is to calm the chaos and make sure the open ICU provides safe, high quality care. We chose to go with an "open-hybrid" ICU. (8)

With the help of the Leapfrog criteria as an impetus to change, this is how Somerset approached it.

An outside expert was brought in to conduct a formal consult of the ICU. An ICU task force of key physicians, clinical hospital personnel and administration was named. The consult, information about Leapfrog and literature about intensivist-staffed ICUs was reviewed.

Reactions to creating a new, intensivist-based system were strong.

* Surgeons, who are reimbursed by case, generally favored the idea.

* Primary care physicians feared loss of ICU privileges.

* Medical specialists feared unfair competition from physicians employed by the medical center.

Through a deliberate and extremely delicate process, a job description for an IGU intensivist medical director was developed and endorsed by the task force. A new intensivist was hired as a medical center employee responsible for daytime triage, coordination of care, rounding on all patients, performing emergency procedures and teaching residents and staff.

The challenge ahead is to monitor a rigorous database of ICU indicators including:

* Length of stay

* Expense per day

* Severity-adjusted survival

* Nosocomial infections and other key measures (9)

Our purpose is to build a case to expand intensivist staffing if it improves quality and efficiency. Such programs do not appear able to be justified dollar for dollar, particularly when set up to avoid direct competition with voluntary medical staff. (8)

Navigating these choppy waters requires a strong patient-centered value system, extreme patience and finely honed negotiation skills.

In the end, the change in ICU has been nothing short of remarkable. Leapfrog was the key to jump-start the transition.

Evidence-based hospital referrals (EHR)

EHR is Leapfrog's weakest link.

The real issue is outcomes.

That's where it will all come together--information systems, technology, staffing, work processes, best practice identification, unnecessary variation reduction, documentation and severity adjustment.

Ultimately, all this information will be distilled to a number on a rating scale defining each hospital. Some providers will perform better than others.

Outcomes measurements and reporting are a major part of our strategic plan. The initiatives include:

* Investing in clinical profiling systems with severity adjustment

* Physician practice variation analyses

* A clinical documentation program for the entire medical center set up in conjunction with Milliman & Robertson (M&R) (10)

It's foolhardy to ignore EHR.

If you do, you may have to explain performance outcomes listed on a proprietary Web site such as healthgrades.com that's based on old Medpar data that may not be adequately analyzed.

Leapfrog: another tool for physician executives

Patients have always trusted us to care about their safety and do our jobs well.

Now, they're demanding proof.

A recent JAMA report suggests that the safety issue is overstated, (11) however, it is unlikely that demand for quality outcomes will diminish anytime soon.

Leapfrog is one more instrument in the physician executive tool kit. It helps assure stakeholders that they will not be on the wrong end of an illegible order, that a safe environment exists in the intensivist-staffed ICU and that serious resources are being devoted to volume/outcome measurements.

The accountability for safety and quality ultimately rests with all physician executives.

References:

(1.) Kohn, L., corrigan, J., Donaldson, M., editors. Committee on Quality of Health care in America. To Err Is Human. Building a Safer Health System. Institute of Medicine, 2000.

(2.) Committee on Quality of Health care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine, 2001.

(3.) Joint commission on Accreditation of Healthcare Organizations. Revision to Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction, Joint Commission Web site, www.jcaho.org, July 1, 2001.

(4.) Joint Commission on Accreditation of Healthcare Organizations. 2001 Hospital Accreditation Standards. Oak Brook, Illinois, 2001.

(5.) Jencks, S., Cuerdon, T. "Quality of Medical Care Delivered to Medicare Beneficiaries." JAMA. October 4, 2000, 284:1670-76.

(6.) New York Times editorial staff. "Naming Hospitals, Good and Bad." The New York Times. November 17, 2000.

(7.) Dagmore, D. "The Leapfrog Effect." Hospitals & Health Networks. May, 2001, 75: 32-6.

(8.) Halpern, N., Pastores, S., Oropello, J. Critical Care Clinics: ICU Bedside Technology: A Look into the 21st Century, W.B. Saunders Company, Philadelphia, P.A. October 2000, pp. 733-48.

(9.) Clinical Advisory Board, Intensivist Programs: Elevating the Standard of Care. The Advisory Board. Washington, D.C., 2001.

(10.) Cors, W., Zenner, P., Fitch, K, Mirkin, D. Clinical Documentation Program Using M&R Care Guidelines. Milliman&Robertson 7th Annual User Group Forum, Scottsdale, Ariz, December 2, 2000.

(11.) Hayward, K., Hofer, T. "Estimating Hospital Deaths Due to Medical Errors." JAMA. July 25, 2001, 286: 415-20.