Another hospital quality scorecard seems to appear nearly every month these days, and Wednesday's release of the Joint Commission's "Top Performers" is right on schedule for September.
In March, it was HealthGrades' 50/100 hospitals list and in April, Thomson Reuters released its top 100. June ushered the Leapfrog Group's Safety Scores. And in July, Consumer Reports and U.S. News & World Report published their all-star lineups weeks apart.
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And in late July, the Centers for Medicare & Medicaid Services uploaded to the Hospital Compare website a massive three-year data update for dozens of measures including 30-day readmissions and value-based purchasing scores.
Each of these groups uses different —though sometimes overlapping and often contradictory—criteria, thresholds, and weighted algorithms. It's enough to make you dizzy.
Snubbing Johns Hopkins
Last night I spoke with Peter Pronovost, MD, one of the nation's top quality gurus and medical director for the Center for Innovation in Quality Patient Care at Johns Hopkins, and asked what he thinks about all these scorecards, especially the latest one from the Joint Commission, which snubbed his own 560-bed hospital.
The Commission's second annual list highlights 620 stars out of nearly 3,400 acute care hospitals for achieving 95% or greater compliance in 43 process measures during 2011. The Joint Commission is a powerful force, because as the nation's preeminent healthcare accreditation agency, it determines a hospital's fitness for federal reimbursement.
But although the Joint Commission's list of 'top performers' grew by more than 200 hospitals this year, it left many if not most of the most prestigious hospitals that ranked high on the other lists out in the cold.
Most large academic medical centers, including Johns Hopkins and Massachusetts General, two of the largest and most highly regarded organizations in the country, are nowhere to be found. Also absent are the Mayo Clinic in Rochester, MN; New York Presbyterian; Geisinger Health System; and all the University of California's teaching hospitals.
"It's confusing," Pronovost replies. These reports "all measure different aspects of care. And none of them are really audited, like with financial reports where we have clear auditing standard definitions."
Pronovost cautions that process measures, such as whether a heart attack patient received an aspirin, are what make up the Joint Commission's criteria, exclusively. They're not outcome measures of whether the care provided improved the patient's condition, required readmission, or resulted in death, "which is what the public really cares about."
An SEC for healthcare
What this country needs, Pronovost tells me, is "a Securities and Exchange Commission for healthcare."
"Look at what we have for financial reporting," he says. "There's public rule setting so accountants don't make up the rules, and there's private sector auditing and transparency. You can go on EDGAR and get a list of anyone's financial performance. But in healthcare, we haven't created those rules yet. Everyone's doing their own thing. And the public is left saying, 'what do I do? Here's a report saying a hospital is great and another saying it's not so great.'"
"We have to have some coordination, some standard rules, so there's a common truth to what we're talking about."
Pronovost makes clear that he wishes Johns Hopkins Hospital was on the Joint Commission's list, and says his teams are working very hard to get there. But one of the things he correctly notes is that the list is mainly made up of "a preponderance of very small hospitals that typically perform very well."
After the Commission's first list came out one year ago, Pronovost says, he and other Johns Hopkins quality leaders "called around and asked what would it take to do well on these. And what we found is that these hospitals do what's called 'a concurrent review.' Typically they have a nurse reviewing all of their charts, and if you don't give whatever it is to the patient, there is someone who is there to look after that."
Pronovost says that's an easy thing to do in a 100 or 200-bed hospital, "but if I have a 1,000 bed hospital, a big academic medical center, that's a much bigger investment."
Hopkins is no slouch
Pronovost, an intensivist whose checklist is credited for dramatic reductions of central line and other hospital-acquired infections, notes that Hopkins is no slouch in these same measures. In fact, he says, it would have made the list except for two or three measures that didn't reach 95%, but instead were at 91% or 92% for a month or two.
But Hopkins now publicly reports some 250 measures to external agencies, and Pronovost says it works hard at improving all of them.
"We have this discussion every day," he says. If you're at 92% or 93%, and you have to hire a nurse to assure compliance to get to 95% or 98%, is that the best place to spend your nickel?" Pronovost says that a much better use of effort should be spent "trying to reduce patient harm, not to trying to get listed on a scorecard."
Joanne Conroy, MD, chief healthcare officer for the 350-member Association of American Medical Colleges, agrees. "The Joint Commission's methodology makes invisible a lot of hospitals that perform at a very high level, but they didn't quite tip over 95%."
She explains that the Commission selected measures for common conditions that all hospitals see, like pneumonia or heart attack. For teaching hospitals, that's part of what they do, but a bigger share of their workload is made up of extremely sick, very complicated patients referred to them because other hospitals won't take them.
"People send us patients who might need a hip replacement, but who are also significantly obese, maybe have COPD, cardiac disease and other conditions that make doctors in community hospitals less willing to take."
The Joint Commission's defense
In a news conference Wednesday, Joint Commission President Mark Chassin, MD, described how the Commission's list distinguishes itself from the pack of quality lists that preceded his.
"This report is not a ranking of hospitals, nor is it based on unscientific data such as reputation, nor from measures derived from data created for hospital billing," he said. "We also do not attempt to give a single hospital grade that's intended somehow to reflect its overall quality of care."
"In our view those attempts are misguided. The fact is that hospitals may do some things well and other things not as well...This report focuses on 45 uniformly excellent measures of quality that assess evidenced based care processes that are closely linked to positive patient outcomes."
Chassin acknowledged that at a big hospital, it is more difficult to get a high score, "because [there are] more patients, they're often collecting data on more measures, and the operations are more complicated.
"But on the other hand," he continued, "they have more resources to devote to improvement. And I think we're going to see more academic medical centers stepping up to the plate."
Chassin added that a number of smaller hospitals that are affiliated with big academic medical centers "did make the list," such as two small Mayo Clinic hospitals in New Prague and Fairmont. "So they have got their own local examples of how to do it.
He defended the Commission's list as one that shows how hospitals performed on "16 million opportunities to provide the right care to patients," using "the very best measures of quality that exist."
What I'd really like to see next is a hospital scorecard that zeroes in on "appropriateness" measures. These would tell whether patients admitted for surgery, or pneumonia care, or testing, were there because they really needed to be, and that the care they got was the right care. This list could include in a safety component and maybe an outcome or two as well. I wouldn't quibble.
Maybe such a list will come from somewhere in October.
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