Hospital rankings intensify medical error prevention efforts

ALBANY — In addition to giving a snapshot of how a hometown hospital is serving its population, the latest Leapfrog Hospital Safety Grade brings to light a factor of those scores that has gotten increased emphasis in recent years.

The most recent report, released earlier this month, cited figures from the Journal of Patient Safety saying that more than 1,000 people a day are estimated to die from preventable errors. Greater public awareness in recent years has brought to the forefront innovative solutions to strengthen the health care industry’s commitment to patient safety.

“When we launched the Leapfrog Hospital Safety Grade in 2012, our goal was to alert consumers to the hazards involved in a hospital stay and help them choose the safest option. We also hoped to galvanize hospitals to make safety the first priority day in and day out,” said Leapfrog President and CEO Leah Binde. “So far, we’ve been pleased with the increase in public awareness and hospitals’ commitment to solving this terrible problem.

“But we need to accelerate the pace of change because too many people are still getting harmed or killed.”

Phoebe Putney Memorial Hospital, Phoebe North, both in Albany, and Phoebe Sumter Medical Center in Americus all received “C” scores in the most recent Leapfrog ratings. Officials at Phoebe said the score itself is attributed to the decision not to participate in the survey that might have resulted in a higher rating more consistent to the care Phoebe provides to a 35-county region.

“Reporting to every one of a growing number of private organizations that gather hospital data takes an enormous amount time,” Phoebe CEO Joel Wernick said. “One organization in particular, Leapfrog, conducts a survey that is especially time-consuming. Because of the significant time and resource commitment required – time that our safety and quality officers typically spend managing programs to improve patient safety and reduce infections – we made the decision not to participate in Leapfrog’s survey.

“We don’t have infinite resources. We prioritized our focus based on what we thought was in the best interest of our patients. As a result, our most recent survey result is an incomplete review of our operations and is not an accurate reflection of our high standards of safety and quality. Hospitals that don’t participate in the surveys are automatically penalized, leaving many of the most elite and well-respected hospitals in the country with rankings they would not boast about. It’s also important to point out that many rating groups profit from their rankings by charging hospitals steep licensing fees to publicize the rankings.

“While we didn’t participate in Leapfrog’s previous surveys, we recognize that the data gathered by Leapfrog and other organizations is important to some of our patients. Be assured, we will continue to consistently evaluate our practices to ensure we offer the best possible care and service to our patients.”

Dr. Steve Kitchen, chief medical officer at Phoebe, said patient safety is a top priority and that Phoebe Putney Health System has a Patient Safety and Quality Committee devoted to the purpose.

“Reduction (and) prevention of errors in one of the initiatives we have undertaken,” he said.

Kitchen said the goal is to achieve a 20 percent reduction in preventable errors each year. So far during the current fiscal year, the health system overall has seen a 25 percent reduction in such errors — nearly 16 percent of which are accounted for at Phoebe Putney Memorial Hospital.

He said preventable errors include medication errors, falls and hospital acquired infections, and that specific measures are considered to get to the 20 percent reduction rate.

For falls, Kitchen said there is a Falls Prevention Team, which reports fall incidents to the patient safety officer to determine why the fall happened and, hopefully, prevent similar incidents. There is also a team that meets daily to examine catheters and central lines to ensure they are not in longer than they need to be, in turn reducing the chance of them getting infected.

To combat medication errors, pharmacists are tasked with doing a thorough analysis of the orders that come to them with the goal of catching errors before they have a chance to reach the patient.

“Medication errors are very, very low, and that’s because pharmacists manage that very effectively,” Kitchen said. “Blood thinners, for example, take a sophisticated system to manage. (The pharmacists) monitor it with every patient, every day.

“They identify potential medical errors before they ever reach the patient.”

Kitchen said Phoebe has enhanced the science of error reduction by borrowing from other industries. Communication improvements have been worked on to reduce adverse situations during periods of vulnerability, such as shift changes, while also enforcing read-backs on orders taken over the phone.

There has also been an intensivist model implemented that puts a physician solely devoted to the intensive care unit on those floors for 12 hours a day.

“We have to accept that human infallibility can never be achieved, but we can do things to (greatly reduce) human error,” he said.

Kitchen added that improvement in safety is something consistently being worked on, saying that needs to be the case as long as errors exist.

“I think it’s at the very core of what we do and why we exist,” Kitchen said. “We are constantly working on this. It is the journey (for which) you fully never reach the destination.”

Tift Regional Medical Center in Tifton received a “B” in the latest Leapfrog ratings. Officials with the hospital said the facility’s status as a regional referral hospital brings in a volume and patient mix that makes for even greater incentive to do better for those the hospital serves.

“We are proud to be a volunteer participant in the Leapfrog Group’s bi-annual patient safety assessments,” said Dr. William Guest, senior vice president and chief medical officer for Tift Regional Health System. “Tift Regional Medical Center consistently ranks in the top percentile of hospitals nationwide graded by Leapfrog. We received a ‘B’ grade for this recent release, but received an ‘A’ grade for the previous three survey periods. Only 13 of 74 hospitals in the state received an ‘A’ grade in this latest release of scores.

“Facilities like TRMC, with higher volume and a more complex patient mix, also have a higher risk of complications. That’s why we go above and beyond on performance improvement initiatives that are designed to keep patients safe from infections, errors and accidents.”

In terms of medical error prevention, Guest said Tift Regional has a seasoned registered nurse with special training who serves as a dedicated patient safety director. Facilitated each day by a member of the TRHS executive team, the system holds a daily patient safety check-in, which serves as a huddle for managers to provide a brief roll call report on patient census and to identify and discuss safety events and risks.

Guest said TRMC makes a conscience effort to identify and document adverse events and has made strides in performance improvement. He said the hospital has initiatives in place to continuously improve patient safety, prevent infections and enhance the overall environment of care.

“We have structured programs and active physician, administrative and board member participation in improvement of performance,” he stated.

John D. Archbold Memorial Hospital received a “C” during the most recent Leapfrog analysis. Officials at the Thomasville hospital said they are using the data on their performance to determine how they can serve patients better.

“Quality is one of our core values, and a large part of our efforts every single day,” said Archbold President and CEO Perry Mustian. “Many different public rating systems exist, and each system uses different data sources, methodology and rating standards. That’s why the overall assessments of hospital quality differ.

“Our efforts to prevent medical errors and increase quality and safety are evident at every level of our organization. Some examples include our voluntary participation with the national Hospital Improvement Innovation Network on patient safety improvements, including physician-led teams dedicated to reducing certain types of infections. Our medical staff recently formed two brand new committees to provide an even greater focus on both quality and mortality. We have a team dedicated to reducing patient falls. We survey our staff annually on our ‘Culture of Safety’ and use the results to target specific areas for improvement.

“Across our health system, we discuss quality and safety during daily staff huddles, hourly rounding on patients, in staff meetings and at board meetings. We’re regularly recognized and awarded nationally and locally for quality care and patient safety, including recognition for best practices to emulate. We were founded in 1925 on these principles, and they’re a big part of our culture and reputation today.”

South Georgia Medical Center and Smith Northview Hospital, both received “B” scores. Colquitt Regional Medical Center in Moultrie received an “A,” and Crisp Regional Hospital in Cordele received a “C” on Leapfrog.