Myth and management in American hospitals

You can't just spend your way to quality

Excellence in management, not unbridled spending, reduces medical error rates at Solucient's 100 Top Hospitals. Find out what happens when hospitals develop sound business sense.

By Richard Service, Editor

The Institute of Medicine shattered some comfortable suppositions about the quality of U.S. health care with its 1999 study, To Err Is Human, which estimated that as many as 98,000 Americans die every year because of medical errors in hospitals. A new study from the health care information firm Solucient is about to crack another myth: That managing a hospital like a business will somehow impinge on quality of care.

The research reveals that the best-managed hospitals (defined as those on the Solucient 100 Top Hospitals list) have far better patient safety records for often preventable surgical complications than do other hospitals and significantly lower costs as well. Further, when bad things happen in good hospitals, patients fare far better in terms of mortality and quicker return to home. That, too, lowers costs.

Solucient gave Business & Health an exclusive advance look at the soon-to-be released study, titled Variations in potentially preventable complications: Best-managed hospitals vs. peers. It analyzed over 900,000 Medicare surgical patients across all U.S. hospitals to identify complications that are often preventable and to measure the impact of those complications on patients and the economy. Its conclusions fly in the face of some cherished beliefs. (See below for details on how the study was conducted.)

"Historically, hospital executives have claimed that most standard business practices just couldn't be applied to their industry," says Jean Chenoweth, senior vice president of Solucient, headquartered in Evanston, Ill. "In the past they've been slow to adopt concepts like product line management and continuous performance improvement. Now they are skeptical about engineering rapid change through Six Sigma and other current business methods that require use of comparative data in decision-making."

Many have argued, she adds, that only clinical measures should be used to assess hospital performance, preferably those that are disease- or procedure-specific: lowest postoperative hemorrhage rate for coronary bypass surgery, for example.

In the business world, this would translate into measuring an automaker's performance solely on the basis of the tire blowout rate of its SUV division. Hospital patients and road warriors are both at risk for injury or death. Indeed, more people die from hospital errors than from car accidents. Yet a narrow view of one procedure or one piece of equipment says nothing about the performance of an entire organization or the likelihood that most of its products are of good quality.

Much of the health care industry, led by the American Hospital Association, questioned the accuracy of the Institute of Medicine report and claimed that it was greatly exaggerated. They were particularly incensed by one of the studies that the IOM used, which found that 3.7 percent of inpatients experienced injuries caused by medical management. That may sound small, but consider that 58 percent of these events were attributed to errors and 28 percent to negligence.

While many of the errors identified by the IOM are not detectable in administrative data, a significant subset of preventable complications can be measured and evaluated at the hospital level, according to a recent validation study by Harvard researchers. These included the three groups of frequently preventable complications examined by the Solucient study:

• Postoperative complications of the respiratory system, except pneumonia;

• Complications of vascular and hemodialysis devices;

• Other surgical complications, such as iatrogenic hypotension and fragments of cataract left in the eye post-surgically.

Patients fare better at the best-managed hospitals

The research showed that all three kinds of complications occurred far less frequently in hospitals that have demonstrated their business management skills. Moreover, when potentially avoidable complications occurred, the 100 Top award winners deal with the situation in ways that result in lower mortality and shorter stays than at other hospitals.

Respiratory complications, except pneumonia:Post-op complications in this category are very serious. The 89,000 patients who suffered these complications were five times more likely to die in the hospital than the 874,000 patients who did not (14.1 percent vs. 2.5 percent). Those who survived were 61 percent more likely to need significant levels of post-hospitalization medical care.

The study found that patients in hospitals that had been named to the 100 Top list as many as three times were 8 percent less likely to have post-op respiratory complications than those in peer hospitals. The gap was statistically significant, and it widened considerably among hospitals that had won the award four times or more. Their patients were a whopping 21 percent less likely to have these complications.

Complications of vascular and hemodialysis devices: Nearly 910,000 patients were studied for this group. Once again, those who suffered one of these complications (over 35,000 people) were five times more likely to die in the hospital than the 874,000 who did not (12.7 percent vs. 2.5 percent). Patients at the 100 Top were 8 percent less likely to suffer complications of vascular and hemodialysis devices than those in peer hospitals.

Other surgical complications: The pattern continued across 950,000 surgical patients for the final set of complications. The 76,000 patients that suffered miscellaneous surgical complications were twice as likely to die in the hospital as the 874,000 patients who did not (4.9 percent vs. 2.5 percent). Further, patients who had the complication were 44 percent more likely to need significant levels of post-hospitalization medical care (57.5 percent vs. 70.4 percent). Patients at the 100 Top were 14 percent less likely than patients at peer hospitals to experience these complications.