Quality Initiatives
Hospital quality improvement often involves the implementation of a range of protocol bundles. Stony Brook University Medical Center (SBUMC) takes part in the Institute for Healthcare Improvement’s (IHI’s) multiple quality initiatives. First, SBUMC has adopted a two-level sepsis treatment bundle to curb inpatient cases of sepsis and sepsis-related mortality rate. The first protocol covers initial response/actions (first six hours) after a patient presents with sepsis, while the second one provides for 24-hour treatment actions. Following the implementation of this bundle, the hospital achieved a 33% decline in sepsis mortality and a three-day reduction in length of stay (LOS) after a year (Swensen, Dilling, McCarty, Bolton, & Harper, 2013).
Second, SBUMC has also implemented an evidence-based protocol to reduce central line infection rates in ICU. It involved a standardized method for accessing and evaluating central lines as well as for tubing (Swensen et al., 2013). As a result, there was a 41% and 66% decline in the central line infection rate in the pediatric ICU and surgical ICU, respectively, between 2012 and 2013 (Swensen et al., 2013). Third, the facility has established ‘an exemplary clinical unit’ modeled around the ‘Plan-Do-Check-Act’ methodology to reduce inefficiencies and medical errors. The quality initiative has led to reductions in falls, medication errors, and mortality.
Reduction of Health Care Costs
Quality gains and cost reductions result from well-executed initiatives that improve clinical efficiency and reduce hospital-acquired infections (HAIs) and readmission rates. The factors that can help SBUMC achieve a reduction in healthcare costs without compromising quality relate to collaborations with national and state-level independent organizations dedicated to quality.
The AHRQ through the Comprehensive Unit-based Safety Program (CUSP) offers staff training on “evidence-based protocols” or tools for quality improvement (Swensen et al., 2013, p. 48). Therefore, by participating in programs like ‘On the CUSP: Stop CAUTI’ SBUMC would achieve lower HAIs that account for high hospital costs ($758 per CAUTI case) (Swensen et al., 2013). In addition, SBUMC’s collaboration in similar programs, e.g., ‘Stop BSI’ can reduce central line-associated bloodstream infection (CLABSI). Participating hospitals were able to reduce CLABSIs in their ICUs by 40% and costs by $35 million (Swensen et al., 2013).
Disseminating quality improvement priorities and strategies across the facility is another way of achieving health care cost reduction. A learning collaborative approach could be used to communicate practice bundles in the facility. Quality bundles are assigned to multidisciplinary teams that devise quality interventions and implementation strategies. Using this approach, Ascension Health in Missouri reduced mortality by over 13.5% and annual health care costs by $6.8 million due to decreased HAI cases.
Free Market Health Care System vs. Single Payer Government System
While in the single-payer model, health care spending is controlled through government interventions, in a free-market system this monopoly is lacking, favoring the entry of diverse coverage options into the market. The two systems differ in terms of accessibility/waiting times, new technologies, and rationing with implications for quality. The single-payer model is considered more efficient than the free-market system. However, according to Capretta and Dayaratna (2013), the waiting times are higher in the single-payer system than in a free-market system, a scenario that decreases HCAHPs scores and quality. An example involves Canada’s single-payer system where waiting times to see a physician increased following a flu outbreak. The long waiting list worsened the patients’ condition, leading to increased ER visits.
Unlike in a free-market system, scarce funding and rationing can affect quality in a single-payer model. In the latter, the government decides on the funding levels to allocate to health care; hence, hospitals resort to a rationing strategy that targets the marginal cases (Capretta & Dayaratna, 2013). An example is the UK system (single-payer) where patients in need of dialysis died because facilities could not run the machines full time due to funding constraints. In contrast, a free-market system attracts investments into the sector, which leads to competitive or quality healthcare products for patients. For example, the U.S. free-market system offers diverse products tailored to diverse patient needs and budgets.
The two systems also differ in terms of investment in healthcare technology. While in a single-payer system funding limitations and bureaucracy affect the adoption of medical technology, a free-market system spurs investment in technology, which results in quality improvement. For example, due to limited CT scans in an Ontario hospital (single-payer), thousands of patients are kept on a waiting list for over two months. In contrast, the free-market system delivers quality and affordable packages to patients. For example, insurers can contract low-cost facilities to provide quality and affordable services to patients. In addition, the system allows patients to pay more for specialized services. For example, Swiss patients can pay more for improved inpatient amenities.
Common-Law Quality Initiatives
Certain 21st-century quality initiatives have their roots in the common law. They include medical error prevention, adoption of healthcare technology/innovation, and continuing education for professionals (Cunningham, 2015). Medical errors account for the high sentinel events and mortality rates in hospitals. Medical error reduction through nurse/physician communication initiatives like bedside reporting contributes to better clinical and patient outcomes. The adoption of healthcare technology, e.g., EHRs, facilitates hospital reporting and performance monitoring. In addition, technology helps streamline clinical processes and increase efficiency/quality. Professional education is required to improve the staff’s capacity to adapt to best practices. Specialized knowledge, skills, and competencies are required for improved efficiency and clinical outcomes.
Importance of Healthcare Quality for the Organization
The business case for healthcare quality relates to an improvement in clinical outcomes and associated incentives. Hospital quality improvement initiatives have been associated with better clinical outcomes, e.g., increased cancer screening, fall reduction, low adverse events, decreased CAUTI rate, etc. (Swensen et al., 2013). Investing in quality improvement would bring significant financial gains to the organization in terms of increased quality-related incentive payments and reduced process inefficiencies. There are two main rationales for this argument. First, preventing sentinel events would result in significant cost savings – human and financial resources – due to reduced readmissions and LOS. Second, improved hospital/physician quality outcomes are associated with growth in the market share (Swensen et al., 2013). Therefore, there is a compelling case for offering quality care to patients.
Examples
Quality improvement not only benefits patients but also hospitals and insurers. Process streamlining removes care variability for patients and brings a significant return on investment. An example illustrating this view involves a Mayo Clinic that implemented a project to standardize processes (lean methodology) at its orthopedic and cardiovascular outpatient clinics. The project achieved annual cost savings of $2.6 million attributed to LOS reduction from 3.8 to 2.6 days, improved utilization of CT scanners, and a decline in 30-day hospital readmissions by 0.4% (Swensen et al., 2013). This shows that quality improvement can yield cost savings through clinical process efficiency.
Another example illustrating a business case for quality initiatives involves the Virginia Mason Medical Center. The facility adopted a low back pain protocol for its patients. There was a reduction in waiting times from over 30 days to one day and clients undergoing MRI scans (Swensen et al., 2013). In addition, patient satisfaction and Medicare reimbursements related to improved patient experience measures increased. Enhancing inpatient efficiency is associated with improved HAI-reduction reimbursements. For example, Covenant Health System in Texas adopted a clinically integrated system in its five hospitals. The hospital achieved reduced LOS, CAUTIs, and ventilator-related pneumonia cases (Swensen et al., 2013). The hospital qualified for VBP incentives for the reductions in the HAIs identified by the CMS. Thus, a focus on quality improvement would bring a positive return on investment directly or through Medicare incentives.
Protecting Patient Information
Compliance with the HIPAA provisions would avert costly audits and non-compliance penalties. To facilitate secure information exchange without compromising its security, a holistic and HIPAA-compliant information protection plan should be adopted. First, the organization should protect patient data from unauthorized access through system login passwords. Enhanced security controls would ensure that confidential information is not disclosed to unauthorized groups, including insurers (Cunningham, 2015). Second, the facility should implement certified EHRs to support the secure transmission of patient data to meet meaningful use requirements. Compliance with meaningful use would ensure secure generation and transmission of clinical data related to 23 objectives over a given reporting period. Third, developing a risk management process would not only ensure compliance with the HIPAA security rule, but it will help detect and mitigate security threats. Therefore, ongoing risk assessments will help prevent threats that could compromise the security of patient information.
References
Capretta, J., & Dayaratna, K. (2013). Compelling evidence makes the case for a market-driven health care system. New York, NY: The Heritage Foundation.
Cunningham, R. (2015). Once a welfare add-on, Medicaid takes charge in reinventing care. Health Affairs, 34(7), 1080-1083.
Swensen, J., Dilling, J., McCarty, P., Bolton, J., & Harper, C. (2013). The business case for health-care quality improvement. Journal of Patient Safety, 9, 44-52.