Pursuing Perfection – A Lesson from Health Care

Regina Berman cares about performance. It’s in her job title -- she’s the administrative director of performance improvement at the Hackensack University Medical Center in Hackensack, New Jersey. Her experiences at Hackensack and those of other hospitals who are doing the same things have something to teach courts.

Improving Quality
Hackensack and Berman worked for seven years to improve quality and are at the leading edge of a nation-wide movement to reform health care that relies on performance measures. The hospital’s heart attack mortality rate is consistently about 2% lower than the national average, which ranges from 6% to 10%. Other hospitals want to know Hackensack’s secret, but Berman says it doesn’t have one. Hackensack has developed policies and procedures to ensure patients get the care that prevents harm and save lives as evidenced by performance data. Throughout the 781-bed hospital, staff monitor and analyze every process, looking for ways to save time and avoid errors, Berman says. The hospital owes its success to teamwork and good communication about results. “Any hospital could do any of these things, if they understood how beneficial it would be for patients,” she says.

Its track record earned it a $1.9 million grant in 2001 from the Robert Wood Johnson Foundation and the Institute for Health Care Improvement to participate in the Pursuing Perfection program. A principle of the program is that you don’t have to trade quality for cost. “It’s just the other way around: More reliable systems are lower cost,” says Donald Berwick, the president and chief executive office of the Institute.

Measuring the Rate of Harm

The McLeod Regional Medical Center in Florence, S.C., another hospital in the Pursuing Perfection program, has dramatically reduced medication-related injuries. In 2001, the hospital took a baseline measure of its “harm rate” – defined as the frequency at which patients are injured because of a prescribed drug. The medication-related harm rate turned out to be 3.5 per 1,000 doses or about 35 patients per day. Even though this rate was at the low end of the national average, hospital leaders thought it was too high. The hospital staff took a close look at all their routines and made simple changes to reduce errors – they separated drugs with similar names to avoid mix-ups, they began using bar codes to match the right drug with the right patients, and they decreased the steps to fill a prescription. McLeod also tried to replace a “culture of blame” with an attitude focused on improving outcomes for patients. Its harm rate has fallen by 90%, says Natasha Nicol, director of pharmacy services.

Good for the Bottom Line

To be sure, the quality initiatives of Hackensack and McLeod are good for patients. But are they good for the bottom line? Among the reasons given not to measure court performance, is that it takes too much time, effort and money. It hurts the bottom line. The experience of Hackensack proves otherwise.

Hackensack’s quality initiatives have made the hospital more efficient and increased revenues. To avoid getting penalized for helping patients get well sooner and discharging them faster, Hackensack persuaded managed-care companies to agree to higher payments. It also received $850,000 last year from the Centers for Medicare & Medicaid Services as part of an innovative experimental pay-for-performance program that pays hospitals partly based on their performance on 33 standards of care.

The experimental program, which includes 260 hospitals, is a dramatic departure from the way insurance companies typically reimburse hospitals based on the volume and complexity of cases instead of performance outcomes in various categories such as heart bypass surgery, heart failure, pneumonia and hip and knee replacements. Top hospitals like Hackensack get bonuses and low-performing hospitals could see their payments reduced by one to two percent.

Are Courts Ready and Willing?
Are courts ready for a pilot program that “rewards” them with additional resources based performance improvements, instead of just for the volume and complexity of their cases? Following the example of the managed-care companies who were willing to adjust their payments to Hackensack based on quality care, would states, counties and cities provide courts with modest monetary incentives to increase trial certainty, reduce delay, improve enforcement of orders, and satisfy those using their services and participating in their programs?

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