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Department Focus: Quality--Quality on the Front End

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Many hospitals are discovering that preventing infections and other complications costs a lot less than treating them.

When hospital executives talk about improving quality, their stories often involve big-ticket items. Lean, Six Sigma and new construction are among the items mentioned, making it seem as though improving quality and big spending go hand in hand.

“I think there’s a legacy belief in the healthcare industry that says higher quality means higher costs,” says Maureen Bisognano, executive vice president and chief operating officer of the nonprofit Institute for Healthcare Improvement in Cambridge, MA. “We’ve never really broken through that. But the industry is starting to be much more open, and we’re seeing many circumstances where higher quality means saving money.”

Quality has little to do with fancy processes, says Gene Burke, MD, vice president and executive medical director of clinical effectiveness at Norfolk, VA-based Sentara Healthcare, which operates seven acute-care hospitals. Lean and Six Sigma have helped many hospitals improve their processes, but quality improvement, in most cases, is about getting back to basics.

“In healthcare, we’ve been too focused on units of service and production. We need to focus on quality,” he says. Doctors and nurses worry too much about how many patients they can attend to on a specific shift instead of the quality they give each patient they do see. “As a medical professional, you know what you need to do, but there’s a gap between doing it and doing it consistently.”

The time pressures faced by doctors and nurses often cause them to take shortcuts, Burke says. But with those shortcuts often come increased infection rates, which in the long term cost hospitals more money. Eliminating those shortcuts won’t cost your hospital anything, he says, and actually could save money in the long run.

“Ten years ago, ventilator-associated pneumonia was considered a cost of the business,” Burke says. “We thought, sick people are going to get infections, and pneumonia is going to happen. But we recognize now that’s not always the case. Ventilator-associated pneumonia can largely be avoided by consistently executing certain elements of care.”

Sentara found that by following the Institute for Healthcare Improvement’s ventilator “bundle,” or steps of care, that it could reduce the number of infections at its hospitals. By taking the time to elevate the head of the patient’s bed, suction secretions and give patients a daily break from sedation medication, Burke says Sentara was able to drop its ventilator-associated pneumonia rates 25-fold in a five-year period.

IHI estimates that each patient who develops ventilator-associated pneumonia will cost a hospital an additional $40,000 in bed time and other treatment costs. Providing quality care will frequently be less expensive than managing the complications, Burke says. The savings are particularly important later this year when the Centers for Medicare & Medicaid Services stops reimbursing hospitals for costs associated with treating certain hospital-acquired infections, says Cathie Furman, senior vice president of quality and compliance for Virginia Mason Medical Center in Seattle.

When a Medicare patient comes in for treatment, Furman says, her hospital knows it will be reimbursed a certain amount to treat that patient. But if that patient acquires an infection while at the hospital, “suddenly, it’s costing us more to treat that patient than we’re getting reimbursed,” she says.

Virginia Mason, a 280-staffed-bed hospital, also used IHI bundles to improve quality processes and reduce infection rates.

“We were able to go from an average of 34 cases per year down to three,” Furman says. “For those 31 cases that didn’t end up with ventilator-associated pneumonia, there was a cost savings in that we didn’t spend more than our reimbursement. You could say the same for central line infections and others.”

Ventilator-associated pneumonia is just one example of an infection that costs a lot to treat but not to prevent, says Burke. By actively screening patients for methicillin-resistant Staphylococcus aureus upon their admission to the hospital and isolating those that carried the disease, the system was able to prevent the spread of infection.

 “The goal isn’t to save money, but to give patients the best care they
can get. By doing the right thing, it actually helps with your economics,” Burke says.
—Maureen Larkin