- Email: [email protected]
Real numbers tell real stories in health services management
ORIGINAL ARTICLE
Real numbers tell real stories in health services management Michael Heenan, MBA, CPHQ; Brady Wood, MA; D. Wayne Taylor, PhD, FCIM
Abstract—In the words of one hospital manager, “hospital data is currently indigestible and alien to the average user.” Drawing upon the experience of an academic hospital that, contrary to established practice, published real numbers alongside rates and ratios during a Clostridium difficile outbreak, the authors examined the pitfalls of publishing only abstract performance measures and the advantages of releasing real numbers to the public. This article identifies lessons for hospital board governance, media relations, employee communications, and citizen and patient engagement that are applicable across the healthcare industry in many countries. If healthcare is to be a caring industry, then care should be taken in the public reporting of data and information.
T
he convergence of three trends has led to a renewed interest in Canada and elsewhere in the data that hospitals are publicly reporting. First, there is the trend toward greater democratization of knowledge because of the Internet. The general public has increasingly become competent at searching through the World Wide Web for information. Many on-line information searchers expect to find issue-specific data and information that was previously only available to specialists and “insiders.” The consumer and tax-paying public have also become more concerned about quality than ever before. Patients are increasingly making informed choices and advising referring physicians in which hospital they would prefer to be treated. If other industries serve as the example, patientadvocacy groups will soon be demanding much greater transparency in hospital reporting, especially regarding how safe hospitals are and how well they are performing. The media has responded to this increased public interest in health and healthcare by devoting entire sections of major national papers to the topic and often covering any and all performance-related data made available. Governments have also responded with mandatory public reporting on markers of hospital outcomes. The second trend is the renewed focus on patient safety and quality within the healthcare industry over the last decade in which a number of key reports have drawn attention to the significant room healthcare has for improvement. Both Canadian and American reports have drawn attention to significant shortcomings regarding pa-
From The Credit Valley Hospital, Mississauga, Ontario, Canada (Mr Heenan); St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada (Mr Wood); and The Cameron Institute, Hamilton, Ontario, Canada (Mr Taylor). Corresponding author: D. Wayne Taylor, PhD, FCIM, The Cameron Institute, 263 John Street, Suite 203, Hamilton, ON L8N 2C2, Canada. (e-mail: [email protected]). Healthcare Management Forum 2010 23:119 –122 0840-4704/$ - see front matter © 2010 Canadian College of Health Service Executives. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hcmf.2010.07.006
tient safety in hospitals.1,2 Most startlingly was the revelation that Canadian patients faced a 1 in 13 chance of being subject to an adverse event while in the hospital, nearly half of which were deemed preventable, as compared with Six Sigma– certified companies that have three defects per million opportunities. The issue of patient safety is often couched in potentially misleading, clinically abstract terms, and patient advocacy groups are trying to humanize this cryptic discourse by publicizing some of the thousands of heart-breaking tales behind the statistics reporting medical error and iatrogenic afflictions. The third trend is a renewed emphasis in general on the role and oversight of Boards of Directors in light of the recent, high-profile global collapse of financial firms and some US manufacturing sectors. For hospitals, this has meant an increased emphasis on the hospital board’s role in balancing the budget and improving quality of care. This third trend was most recently examined by one of the authors and his colleagues.3 This article identifies a significant disconnect between the way the healthcare industry currently captures, records, and disseminates data and information and for what the public is searching. Hospitals currently use rates, ratios, and other abstractions to ensure that data are comparable and can be used to identify “best practices,” but these abstractions are difficult for the public to understand and mask the human impact behind the numbers. Based on observed experiences during a Clostridium difficile outbreak at St. Joseph’s Healthcare Hamilton (SJHH), a multisite academic hospital affiliated with McMaster University in Hamilton, Ontario, Canada, this study concludes that hospitals should publish real numbers alongside rates and other abstractions of the data so that the public is better informed and served.
PUBLIC REPORTING: A MIXTURE OF “CLINICALLY ABSTRACT TERMS” Public hospital reporting in Ontario, the largest province by far in Canada, began with the “report card” series jointly
Heenan, Wood, and Taylor
sponsored by the Ontario Ministry of Health and Long Term Care (MOHLTC) and the Ontario Hospital Association, the industry’s trade association. Launched in 1998, the Hospital Report Card was loosely based on balanced scorecard methodology and presented hundreds of indicators under headings of Clinical Utilization, Patient Satisfaction, Financial Performance, and System Integration and Change. These reports were issued annually in the areas of acute care, emergency departments, rehabilitation services, and mental health. The intent of the report cards was two-fold: (1) to provide the public with data on the performance of hospitals and (2) to give hospitals the means by which to compare their performance against their “peers.” By 2007, the MOHLTC believed that this “project” had “run its course” and canceled the hospital report cards. At the national level, the Canadian Institute of Health Information and the Hay Group partnered to produce an annual benchmarking comparison of Canadian hospitals.4 Hospitals voluntarily participated in the national comparison, and indicators related to clinical efficiency, operational efficiency, quality, and patient safety were reported. For hospital insiders, these tools have been helpful in learning better practices and improving performance, but the limitation of these reports has been in translating the measures for hospital board members, the general public, and the media. Although observers might be able to conclude which hospital is doing better or worse from published data, understanding what the measures mean is another thing altogether. The authors examined the example of the Hospital Standardized Mortality Ratio (HSMR), a publicly reported measure from CIHI and a recently required public report in Ontario. HSMR is meant to capture the mortality rates in Canadian hospitals and provide one indication of hospital quality. As a tool for comparison, it has proven to be helpful because organizations have begun sharing clinical strategies to reduce unnecessary hospital deaths including a greater focus on infection prevention and control. By its nature, HSMR is very abstract and obscures the human impact, in particular, the actual number of deaths occurring in hospitals. A hospital’s HSMR is calculated as a ratio of 100, 100 being representative of the expected number of deaths (the average national rate). For example, a hospital performing better than expected would report an HSMR below 100. Compounding the difficulty in explaining HSMR to a nonacademic, nonclinical public audience is that HSMR is only used to report on 80% of deaths across 58 clinical diagnoses, excluding complex care, rehabilitation, long-term care, and psychiatry. This clearly presents a challenge to members of hospital boards, the public, the media, and even seasoned professionals, especially in figuring out the number of people who actually died in Canadian hospitals. The data reported through HSMR and other such abstractions under-report and obscure reality. At SJHH, for 120
Table 1. Examples of data used in the reporting of hospital performance3 HSMR ⫽ number of observed deaths/number of expected deaths * 100 In-hospital deaths in low-mortality medical case-mix groups per 1,000 medical discharges Obstetric trauma, injury to neonate per 1,000 live births Rate of reported misadventures for surgical patients Documented type 2 (post-admit) Acute Myocardial Infarction (AMI)s per 1,000 major surgical cases Rate of ventilator-associated pneumonia per 1,000 device days Rates of C. Difficile, Vancomycin-Resistant Enterococci (VRE), and Methicillian-resistant Staphylococcus Aureus (MRSA) per 1,000 patient days
example, the HSMR formula only accounted for approximately 68% of the patient deaths in a given year. In 2007 to 2008, despite posting an HSMR of 93 (which was good), HSMR-reported cases actually only accounted for 300 of the 555 people who died at SJHH. Thus, deaths at SJHH were systematically under-reported to the public. When HSMR performance was first published, it was evident that the media struggled to interpret the numbers. Larger print media and web-based news outlets provided general summaries of the data and “ranked” hospitals according to how they performed within their respective province or across the country. Little or no interpretation or contextualization as to why a particular hospital performed as they did was provided nor was the public provided with an understanding of how this information is used as a starting point improving quality of care within hospitals, and the real numbers were never revealed. Local papers likewise struggled. Other media like television and radio were limited by their format, which requires a short clip to deliver information. The complexity, abstraction, and perhaps even prevaricativeness of the reported data inhibit the nuanced dialog that taxpayer-funded hospitals need to have with the tax-paying public about patient safety and quality. Mortality ratios are not the only indicators that are difficult to interpret. Scores, ratios, and rates are used to report on a myriad of safety indicators that are supposed to describe the quality of clinical care in Canada. Hospitalacquired infections are widely known to cause great harm and often lead to death in hospitals around the globe. When presenting data on infections, hospital performance is compared by excluding the real number of people who have been harmed and only report rates using denominators such as 1,000 patient days or 1,000 device days, which gives little reassurance to patients and their families. Table 1 gives other examples of abstracted data for recent reporting that, in and of themselves, are meaningless to patients, the general public, the media, and volunteer hospital lay governors. The public and the media search for more information
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2010
REAL NUMBERS TELL REAL STORIES IN HEALTH SERVICES MANAGEMENT
on hospital performance in their communities; they want to be better informed about the institution in which they will be treated. The Government of Ontario has followed recent American and European initiatives by publishing a number of indicators for hospitals on its MOHLTC web site (http://www.health.gov.on.ca/en/pro/) including wait times, hospital-acquired infection rates, HSMR, administration of surgical-site antibiotics, and hospital staff handwashing compliance rates. These efforts have enabled the public to review performance results and have assisted hospitals to identify and collect more meaningful quality and safety data, yet the data remain cryptic. At the same time, disparate organizations such as the Institute for Healthcare Improvement in the US, the Canadian Patient Safety Institute, the Ontario Hospital Association, and the Quality Healthcare Network (in Ontario) are encouraging hospital boards to play a greater role in governing hospital quality. For example, the Ontario government requires hospital boards to review key performance indicators as part of their wait time and hospital-accountability agreements. This is a lot to expect from lay volunteer board members. As one hospital board member stated during our study, “. . . board members spend approximately 75 hours a year in hospital compared to management who can spend upwards of 75 hours every 6 days.”
peers and the recognized standard. The board was less concerned about the hospital’s relative performance and more concerned with the fact that eight people died because they contracted a virus as a result of hospital practice after they were admitted to their hospital. The real numbers prompted the board to ask questions about process. Questions posed included the following: (1) How does a patient contract the disease? (2) How does clinical staff treat the disease? and (3) What are the challenges the organization faces in terms of treatment and prevention? Discussions focused on staff handwashing compliance, the appropriate cleaning agents used in the process (and their risk to housekeeping staff safety), the challenge of isolation in older buildings in which patient transfers were not uncommon, and the increasing financial costs related to the outbreak. By asking for the raw data and discussing the process gaps that resulted in a patient acquiring an infection, the board was fulfilling their duty to protect the community, their leadership role in building a quality culture, their risk-management responsibility in ensuring management had taken the right steps in terms of staff safety, and their financial responsibility in monitoring costs associated with ending the outbreak.
Frontline staff and management implications THE IMPACT OF PUBLISHING REAL NUMBERS Publishing real data would mean publishing the actual numbers of people and incidents as well as abstracted ratios. This would include publishing the actual number of people who died in a given hospital alongside the hospital’s HSMR rate and publishing the actual number of people who contracted or died from a hospital-acquired infection alongside the hospital’s infection rate. Standardized rates and ratios have their role to play in quality improvement. Publishing real numbers would have a number of benefits for governance, public education, building a culture of patient safety within hospitals, and media relations. Above all, real numbers would have a greater impact on staff and external communities, thus heightening the pressure for accountability. The following observations were made by the authors during an outbreak of C. Difficile across Ontario hospitals and long-term care facilities in September 2008.
Governance implications In addressing the C. Difficile outbreak, the Board of Trustees of SJHH, in assuming their new responsibility for quality,3 continually asked for updates on the situation. After receiving reports of “rates per 1,000 patient days,” the board questioned management regarding the relevance was of the per 1,000 patient days denominator. Management explained that the rate was a generally accepted measure of how well the hospital performed as compared with its
For frontline staff, the C. Difficile outbreak was all about real numbers and real stories. Frontline staff, both clinical and ward support, dealt with patients directly. For them, although the rates were a barometer of performance, they paled in comparative value to the actual number of cases. It was the frontline staff who treated the infected patients, addressed the concerns of families, and worked together as a team to protect each other from being infected. In explaining both the rate and real number to staff, management was able to acknowledge their efforts in two ways: by describing improvement against benchmark and by advising how staff efforts ended the outbreak and saved lives. Real numbers told stories about patients but also helped management realize that they also told stories about staff, which, in turn, helped in the efforts to build a culture of teamwork, patient safety, and staff satisfaction. When hospital management publishes only rates, it isolates staff from their patients as well as their responsibility for quality care and being mindful of what they do and how they do it.
Media relations and public education Before the C. Difficile outbreak in September 2008, local newspapers published many negative articles about hospital secrecy regarding data and the public’s right to know how to protect against acquiring hospital-based infections. Learning from this experience, when the outbreak was declared, SJHH proactively released all the requested in-
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2010
121
Heenan, Wood, and Taylor
formation, including its rate per thousand patient days (0.9), total cases (13), and associated deaths (8). The hospital’s medical chief of staff and the manager of infection prevention and control engaged the media in a dialogue about how this information formed the baseline to support improvements in infection prevention and control practices. The hospital explained to the media why the rate per thousand patient days was just as important as the real numbers. Daily media briefings updated the total number of cases and associated deaths, in other words, the real numbers. Disclosing the raw data was difficult but allowed the SJHH hospital to build a sense of trust with the media and the public to the point in which the local newspaper praised the hospital corporation’s approach to transparency in an editorial after the outbreak’s conclusion.
Whether real numbers or rate based, data are not perfect There are two limitations to this honest, plain-language approach to disclosure: (1) privacy concerns and (2) possible hysteria about hospital outcomes. To the first concern, there is no ideal solution. In larger communities, privacy is most likely not an issue because it is harder in a larger center for a member of the public to track outcomes to individual patients. In smaller communities, there is a greater chance personal information may be made public in a small number of cases. This reduces itself to a constitutional issue that only Parliament can interpret of whether individual privacy rights in this case trump the taxpayer’s right to know. Regarding the second concern, the public should indeed be concerned about outcomes in a taxpayer-funded healthcare system in which billions of tax dollars are poured each year. For instance, researchers have estimated that generally there were between 9,000 and 24,000 preventable hospital deaths in Canada each year, making preventable hospital deaths the fifth leading cause of death in Canada.3 No other industry would expect to emerge unscathed from the public arena given such abysmal safety outcomes. Hospitals need to get ahead of this curve, first, by improving their performance, and second, by becoming more open, transparent, and accountable using plain language all can understand. Whether real numbers or rate based, hospital data are not always perfect, but by publishing both the real and relative numbers, future discussions about data will help
122
lead to the greater question of how to improve care rather than just how to measure it.
CONCLUSIONS Hospitals and healthcare providers, in general, are extremely left-brained (ie, focused on analytic matters, logical, and objective). This is grounded in Western society’s scientific approach to allopathic medicine and its collateral training programs from medical schools to business schools. The medical profession, like the other professions, has also created its own lexicon, algebra, and communications methods, which are quite confusing and impenetrable to the general public. To date, the data being reported by hospitals heavily reflects this left-brain heritage. In light of recent trends including the healthcare industry’s initiative to improve outcomes and to provide safer care environments, the public’s growing awareness and skepticism toward taxpayer-funded organizations, the media’s increased interest in healthcare topics, and governments’ push for transparency, hospitals need to adapt both to ensure they are truly transparent organizations and to never lose sight of the individual patients and families that depend on them. By publishing real numbers, no patients are left behind. By publishing real numbers, real stories are told. By recognizing each and every patient who is affected, patients and their families become full participants in their delivery of care; board members can ask questions that help identify gaps in the care process; a culture of patient safety can take root; quality and risk management can be managed better; and, finally, partnerships can be built with the media to communicate the truth in language the public can understand.
REFERENCES 1. Kohn L, Corrigan J, Donaldson M. To Err Is Human, Building a Safer Health System. Washington DC: National Academy Press; 1999. 2. Baker GR, Norton P. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170:1678-1686. 3. Heenan M, Khan H, Binkley D. From boardroom to bedside: how to define and measure hospital quality. Healthcare Q. 2010;13:55-60. 4. Canadian Institute for Health Information–Hay Group. Benchmarking Comparison of Canadian Hospitals. Ottawa: Canadian Institute for Health Information; 2008.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2010
Real numbers tell real stories in health services management Michael Heenan, MBA, CPHQ; Brady Wood, MA; D. Wayne Taylor, PhD, FCIM
Abstract—In the words of one hospital manager, “hospital data is currently indigestible and alien to the average user.” Drawing upon the experience of an academic hospital that, contrary to established practice, published real numbers alongside rates and ratios during a Clostridium difficile outbreak, the authors examined the pitfalls of publishing only abstract performance measures and the advantages of releasing real numbers to the public. This article identifies lessons for hospital board governance, media relations, employee communications, and citizen and patient engagement that are applicable across the healthcare industry in many countries. If healthcare is to be a caring industry, then care should be taken in the public reporting of data and information.
T
he convergence of three trends has led to a renewed interest in Canada and elsewhere in the data that hospitals are publicly reporting. First, there is the trend toward greater democratization of knowledge because of the Internet. The general public has increasingly become competent at searching through the World Wide Web for information. Many on-line information searchers expect to find issue-specific data and information that was previously only available to specialists and “insiders.” The consumer and tax-paying public have also become more concerned about quality than ever before. Patients are increasingly making informed choices and advising referring physicians in which hospital they would prefer to be treated. If other industries serve as the example, patientadvocacy groups will soon be demanding much greater transparency in hospital reporting, especially regarding how safe hospitals are and how well they are performing. The media has responded to this increased public interest in health and healthcare by devoting entire sections of major national papers to the topic and often covering any and all performance-related data made available. Governments have also responded with mandatory public reporting on markers of hospital outcomes. The second trend is the renewed focus on patient safety and quality within the healthcare industry over the last decade in which a number of key reports have drawn attention to the significant room healthcare has for improvement. Both Canadian and American reports have drawn attention to significant shortcomings regarding pa-
From The Credit Valley Hospital, Mississauga, Ontario, Canada (Mr Heenan); St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada (Mr Wood); and The Cameron Institute, Hamilton, Ontario, Canada (Mr Taylor). Corresponding author: D. Wayne Taylor, PhD, FCIM, The Cameron Institute, 263 John Street, Suite 203, Hamilton, ON L8N 2C2, Canada. (e-mail: [email protected]). Healthcare Management Forum 2010 23:119 –122 0840-4704/$ - see front matter © 2010 Canadian College of Health Service Executives. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.hcmf.2010.07.006
tient safety in hospitals.1,2 Most startlingly was the revelation that Canadian patients faced a 1 in 13 chance of being subject to an adverse event while in the hospital, nearly half of which were deemed preventable, as compared with Six Sigma– certified companies that have three defects per million opportunities. The issue of patient safety is often couched in potentially misleading, clinically abstract terms, and patient advocacy groups are trying to humanize this cryptic discourse by publicizing some of the thousands of heart-breaking tales behind the statistics reporting medical error and iatrogenic afflictions. The third trend is a renewed emphasis in general on the role and oversight of Boards of Directors in light of the recent, high-profile global collapse of financial firms and some US manufacturing sectors. For hospitals, this has meant an increased emphasis on the hospital board’s role in balancing the budget and improving quality of care. This third trend was most recently examined by one of the authors and his colleagues.3 This article identifies a significant disconnect between the way the healthcare industry currently captures, records, and disseminates data and information and for what the public is searching. Hospitals currently use rates, ratios, and other abstractions to ensure that data are comparable and can be used to identify “best practices,” but these abstractions are difficult for the public to understand and mask the human impact behind the numbers. Based on observed experiences during a Clostridium difficile outbreak at St. Joseph’s Healthcare Hamilton (SJHH), a multisite academic hospital affiliated with McMaster University in Hamilton, Ontario, Canada, this study concludes that hospitals should publish real numbers alongside rates and other abstractions of the data so that the public is better informed and served.
PUBLIC REPORTING: A MIXTURE OF “CLINICALLY ABSTRACT TERMS” Public hospital reporting in Ontario, the largest province by far in Canada, began with the “report card” series jointly
Heenan, Wood, and Taylor
sponsored by the Ontario Ministry of Health and Long Term Care (MOHLTC) and the Ontario Hospital Association, the industry’s trade association. Launched in 1998, the Hospital Report Card was loosely based on balanced scorecard methodology and presented hundreds of indicators under headings of Clinical Utilization, Patient Satisfaction, Financial Performance, and System Integration and Change. These reports were issued annually in the areas of acute care, emergency departments, rehabilitation services, and mental health. The intent of the report cards was two-fold: (1) to provide the public with data on the performance of hospitals and (2) to give hospitals the means by which to compare their performance against their “peers.” By 2007, the MOHLTC believed that this “project” had “run its course” and canceled the hospital report cards. At the national level, the Canadian Institute of Health Information and the Hay Group partnered to produce an annual benchmarking comparison of Canadian hospitals.4 Hospitals voluntarily participated in the national comparison, and indicators related to clinical efficiency, operational efficiency, quality, and patient safety were reported. For hospital insiders, these tools have been helpful in learning better practices and improving performance, but the limitation of these reports has been in translating the measures for hospital board members, the general public, and the media. Although observers might be able to conclude which hospital is doing better or worse from published data, understanding what the measures mean is another thing altogether. The authors examined the example of the Hospital Standardized Mortality Ratio (HSMR), a publicly reported measure from CIHI and a recently required public report in Ontario. HSMR is meant to capture the mortality rates in Canadian hospitals and provide one indication of hospital quality. As a tool for comparison, it has proven to be helpful because organizations have begun sharing clinical strategies to reduce unnecessary hospital deaths including a greater focus on infection prevention and control. By its nature, HSMR is very abstract and obscures the human impact, in particular, the actual number of deaths occurring in hospitals. A hospital’s HSMR is calculated as a ratio of 100, 100 being representative of the expected number of deaths (the average national rate). For example, a hospital performing better than expected would report an HSMR below 100. Compounding the difficulty in explaining HSMR to a nonacademic, nonclinical public audience is that HSMR is only used to report on 80% of deaths across 58 clinical diagnoses, excluding complex care, rehabilitation, long-term care, and psychiatry. This clearly presents a challenge to members of hospital boards, the public, the media, and even seasoned professionals, especially in figuring out the number of people who actually died in Canadian hospitals. The data reported through HSMR and other such abstractions under-report and obscure reality. At SJHH, for 120
Table 1. Examples of data used in the reporting of hospital performance3 HSMR ⫽ number of observed deaths/number of expected deaths * 100 In-hospital deaths in low-mortality medical case-mix groups per 1,000 medical discharges Obstetric trauma, injury to neonate per 1,000 live births Rate of reported misadventures for surgical patients Documented type 2 (post-admit) Acute Myocardial Infarction (AMI)s per 1,000 major surgical cases Rate of ventilator-associated pneumonia per 1,000 device days Rates of C. Difficile, Vancomycin-Resistant Enterococci (VRE), and Methicillian-resistant Staphylococcus Aureus (MRSA) per 1,000 patient days
example, the HSMR formula only accounted for approximately 68% of the patient deaths in a given year. In 2007 to 2008, despite posting an HSMR of 93 (which was good), HSMR-reported cases actually only accounted for 300 of the 555 people who died at SJHH. Thus, deaths at SJHH were systematically under-reported to the public. When HSMR performance was first published, it was evident that the media struggled to interpret the numbers. Larger print media and web-based news outlets provided general summaries of the data and “ranked” hospitals according to how they performed within their respective province or across the country. Little or no interpretation or contextualization as to why a particular hospital performed as they did was provided nor was the public provided with an understanding of how this information is used as a starting point improving quality of care within hospitals, and the real numbers were never revealed. Local papers likewise struggled. Other media like television and radio were limited by their format, which requires a short clip to deliver information. The complexity, abstraction, and perhaps even prevaricativeness of the reported data inhibit the nuanced dialog that taxpayer-funded hospitals need to have with the tax-paying public about patient safety and quality. Mortality ratios are not the only indicators that are difficult to interpret. Scores, ratios, and rates are used to report on a myriad of safety indicators that are supposed to describe the quality of clinical care in Canada. Hospitalacquired infections are widely known to cause great harm and often lead to death in hospitals around the globe. When presenting data on infections, hospital performance is compared by excluding the real number of people who have been harmed and only report rates using denominators such as 1,000 patient days or 1,000 device days, which gives little reassurance to patients and their families. Table 1 gives other examples of abstracted data for recent reporting that, in and of themselves, are meaningless to patients, the general public, the media, and volunteer hospital lay governors. The public and the media search for more information
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2010
REAL NUMBERS TELL REAL STORIES IN HEALTH SERVICES MANAGEMENT
on hospital performance in their communities; they want to be better informed about the institution in which they will be treated. The Government of Ontario has followed recent American and European initiatives by publishing a number of indicators for hospitals on its MOHLTC web site (http://www.health.gov.on.ca/en/pro/) including wait times, hospital-acquired infection rates, HSMR, administration of surgical-site antibiotics, and hospital staff handwashing compliance rates. These efforts have enabled the public to review performance results and have assisted hospitals to identify and collect more meaningful quality and safety data, yet the data remain cryptic. At the same time, disparate organizations such as the Institute for Healthcare Improvement in the US, the Canadian Patient Safety Institute, the Ontario Hospital Association, and the Quality Healthcare Network (in Ontario) are encouraging hospital boards to play a greater role in governing hospital quality. For example, the Ontario government requires hospital boards to review key performance indicators as part of their wait time and hospital-accountability agreements. This is a lot to expect from lay volunteer board members. As one hospital board member stated during our study, “. . . board members spend approximately 75 hours a year in hospital compared to management who can spend upwards of 75 hours every 6 days.”
peers and the recognized standard. The board was less concerned about the hospital’s relative performance and more concerned with the fact that eight people died because they contracted a virus as a result of hospital practice after they were admitted to their hospital. The real numbers prompted the board to ask questions about process. Questions posed included the following: (1) How does a patient contract the disease? (2) How does clinical staff treat the disease? and (3) What are the challenges the organization faces in terms of treatment and prevention? Discussions focused on staff handwashing compliance, the appropriate cleaning agents used in the process (and their risk to housekeeping staff safety), the challenge of isolation in older buildings in which patient transfers were not uncommon, and the increasing financial costs related to the outbreak. By asking for the raw data and discussing the process gaps that resulted in a patient acquiring an infection, the board was fulfilling their duty to protect the community, their leadership role in building a quality culture, their risk-management responsibility in ensuring management had taken the right steps in terms of staff safety, and their financial responsibility in monitoring costs associated with ending the outbreak.
Frontline staff and management implications THE IMPACT OF PUBLISHING REAL NUMBERS Publishing real data would mean publishing the actual numbers of people and incidents as well as abstracted ratios. This would include publishing the actual number of people who died in a given hospital alongside the hospital’s HSMR rate and publishing the actual number of people who contracted or died from a hospital-acquired infection alongside the hospital’s infection rate. Standardized rates and ratios have their role to play in quality improvement. Publishing real numbers would have a number of benefits for governance, public education, building a culture of patient safety within hospitals, and media relations. Above all, real numbers would have a greater impact on staff and external communities, thus heightening the pressure for accountability. The following observations were made by the authors during an outbreak of C. Difficile across Ontario hospitals and long-term care facilities in September 2008.
Governance implications In addressing the C. Difficile outbreak, the Board of Trustees of SJHH, in assuming their new responsibility for quality,3 continually asked for updates on the situation. After receiving reports of “rates per 1,000 patient days,” the board questioned management regarding the relevance was of the per 1,000 patient days denominator. Management explained that the rate was a generally accepted measure of how well the hospital performed as compared with its
For frontline staff, the C. Difficile outbreak was all about real numbers and real stories. Frontline staff, both clinical and ward support, dealt with patients directly. For them, although the rates were a barometer of performance, they paled in comparative value to the actual number of cases. It was the frontline staff who treated the infected patients, addressed the concerns of families, and worked together as a team to protect each other from being infected. In explaining both the rate and real number to staff, management was able to acknowledge their efforts in two ways: by describing improvement against benchmark and by advising how staff efforts ended the outbreak and saved lives. Real numbers told stories about patients but also helped management realize that they also told stories about staff, which, in turn, helped in the efforts to build a culture of teamwork, patient safety, and staff satisfaction. When hospital management publishes only rates, it isolates staff from their patients as well as their responsibility for quality care and being mindful of what they do and how they do it.
Media relations and public education Before the C. Difficile outbreak in September 2008, local newspapers published many negative articles about hospital secrecy regarding data and the public’s right to know how to protect against acquiring hospital-based infections. Learning from this experience, when the outbreak was declared, SJHH proactively released all the requested in-
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2010
121
Heenan, Wood, and Taylor
formation, including its rate per thousand patient days (0.9), total cases (13), and associated deaths (8). The hospital’s medical chief of staff and the manager of infection prevention and control engaged the media in a dialogue about how this information formed the baseline to support improvements in infection prevention and control practices. The hospital explained to the media why the rate per thousand patient days was just as important as the real numbers. Daily media briefings updated the total number of cases and associated deaths, in other words, the real numbers. Disclosing the raw data was difficult but allowed the SJHH hospital to build a sense of trust with the media and the public to the point in which the local newspaper praised the hospital corporation’s approach to transparency in an editorial after the outbreak’s conclusion.
Whether real numbers or rate based, data are not perfect There are two limitations to this honest, plain-language approach to disclosure: (1) privacy concerns and (2) possible hysteria about hospital outcomes. To the first concern, there is no ideal solution. In larger communities, privacy is most likely not an issue because it is harder in a larger center for a member of the public to track outcomes to individual patients. In smaller communities, there is a greater chance personal information may be made public in a small number of cases. This reduces itself to a constitutional issue that only Parliament can interpret of whether individual privacy rights in this case trump the taxpayer’s right to know. Regarding the second concern, the public should indeed be concerned about outcomes in a taxpayer-funded healthcare system in which billions of tax dollars are poured each year. For instance, researchers have estimated that generally there were between 9,000 and 24,000 preventable hospital deaths in Canada each year, making preventable hospital deaths the fifth leading cause of death in Canada.3 No other industry would expect to emerge unscathed from the public arena given such abysmal safety outcomes. Hospitals need to get ahead of this curve, first, by improving their performance, and second, by becoming more open, transparent, and accountable using plain language all can understand. Whether real numbers or rate based, hospital data are not always perfect, but by publishing both the real and relative numbers, future discussions about data will help
122
lead to the greater question of how to improve care rather than just how to measure it.
CONCLUSIONS Hospitals and healthcare providers, in general, are extremely left-brained (ie, focused on analytic matters, logical, and objective). This is grounded in Western society’s scientific approach to allopathic medicine and its collateral training programs from medical schools to business schools. The medical profession, like the other professions, has also created its own lexicon, algebra, and communications methods, which are quite confusing and impenetrable to the general public. To date, the data being reported by hospitals heavily reflects this left-brain heritage. In light of recent trends including the healthcare industry’s initiative to improve outcomes and to provide safer care environments, the public’s growing awareness and skepticism toward taxpayer-funded organizations, the media’s increased interest in healthcare topics, and governments’ push for transparency, hospitals need to adapt both to ensure they are truly transparent organizations and to never lose sight of the individual patients and families that depend on them. By publishing real numbers, no patients are left behind. By publishing real numbers, real stories are told. By recognizing each and every patient who is affected, patients and their families become full participants in their delivery of care; board members can ask questions that help identify gaps in the care process; a culture of patient safety can take root; quality and risk management can be managed better; and, finally, partnerships can be built with the media to communicate the truth in language the public can understand.
REFERENCES 1. Kohn L, Corrigan J, Donaldson M. To Err Is Human, Building a Safer Health System. Washington DC: National Academy Press; 1999. 2. Baker GR, Norton P. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170:1678-1686. 3. Heenan M, Khan H, Binkley D. From boardroom to bedside: how to define and measure hospital quality. Healthcare Q. 2010;13:55-60. 4. Canadian Institute for Health Information–Hay Group. Benchmarking Comparison of Canadian Hospitals. Ottawa: Canadian Institute for Health Information; 2008.
Healthcare Management Forum ● Forum Gestion des soins de sante´ – Fall/Automne 2010