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Rating Metro Detroit's Top Hospitals

The Report Card Tells All

Hospitals have been using public performance assessments for years. Here's why the rest of us should, too.

By Cathy Nelson

Imagine you're in charge of a college admissions department and have to select just one high school student to attend a prestigious program. You have students' report cards and can clearly see how they've performed - who earned A's, who were C students and who outright flunked. Now imagine you ignore those grades and just pick the student who lives closest to the school. It sounds like an unlikely scenario.

Yet the situation is similar to what many Americans do when it comes to one of the most important decisions they'll ever make: choosing a hospital. Despite the public availability of hospital performance reports on quality and safety, many of us skip over these "report cards," where one can compare scores in critical areas of care, and instead simply choose the facility closest to our home or go, no questions asked, where a doctor sends us

"I'm not sure consumers are really using them [public performance reports], although I think people are getting more savvy," says Michelle Schreiber, M.D., head of the quality department for Detroit Medical Center (DMC). "Sometimes the data is hard for a layperson to understand. Most people choose a hospital based on where the doctor tells them to go. That's not necessarily a bad thing, but nobody would buy a car without looking at Consumer Reports."

By the same token, you should choose a hospital only after doing thorough research, says Vernice Davis Anthony, president and CEO of the Greater Detroit Area Health Council (GDAHC), a multi-stakeholder regional coalition that addresses issues of health-care quality, access and cost in southeastern Michigan, and a partner of Vital. GDAHC'S Save Lives Save Dollars Hospital Performance Report, which appears on page 14, provides comparative data on the quality of care area hospitals provide in the critical areas of heart attacks, heart failure, pneumonia, infection prevention, mortality and safety.

"You can't repeat often enough: People need to take a certain level of responsibility for being informed and being aware of quality," says Davis Anthony. "They need to use public performance reports as a tool to open dialogue with physicians and hospitals. They need to use it as a tool to raise questions. They need to use it as a tool to understand what quality is.

"It's not just the taste of food or bedside manner. Quality has to do with the outcome. One example is infection prevention. You have quality when there are no infections."

Seeking top grades

While consumers might just be catching on to the benefits of public performance reports, it's a well-known fact in the medical community that hospitals have been using them to improve and gain a competitive edge for years.

According to Davis Anthony, hospitals take public performance reports very seriously, using them as a means to compare themselves to other hospitals and to improve performance and quality.

"They don't want to be at the bottom of the list," she says. "They work very hard to improve, and if the ranking is excellent, they want to maintain it. Most hospitals would like to see themselves in at least the top 20%. Their benchmark is 90% to 95% - and even some 100% - in some specific areas."

A combination of public reporting and transparency is the most effective of all the measures for health-care improvement in place at Henry Ford Health System (HFHS), according to William Conway, M.D., the system's chief quality officer

"The improvement across the nation in core measures has been very dramatic, and it all happened just because the info has been put out there," he says. "Health-care people are very competitive; they didn't get into the schools they did by not being competitive. Public performance reports are a very powerful tool when hospitals want to compete against each other, regardless of what the consumer does."

At HFHS, that means reports are looked at every month and strategies put in place to maintain high scores. If scores need to be improved, multidisciplinary teams are formed and weekly reports are given to those in charge, according to Conway.

"We aim to position ourselves in the 75th to 95th percentile in any publicly important measure," Conway says.

The same holds true at DMC. "We use core measures at senior- level meetings to track quality performance," Schreiber says. "If you see the performance wasn't where you expected it to be, you have to look at the nittygritty details to find out what's wrong. This forces us to ask questions around process improvement. It's crucial to deliver the right care to every patient every time."

The economic realities

But in Michigan's slumping economy, delivering that high level of care is becoming more difficult. One of the greatest challenges hospitals currently face is not only more uninsured but more underinsured patients than ever before. Because they either can't get or can't afford preventive care, many patients now hold off seeking a doctor until they are at later stages of their diseases and experiencing serious problems.

"DMC has always had uninsured patients, but what we're seeing now is more underinsured and more in the middle class whom you wouldn't expect to be un- or underinsured," says Schreiber. "It's a world [DMC is] used to, but it's made patients more choosy on how or what tests to get done because some are paying out of pocket."

Schreiber says the lack of insurance also causes patients to engage in risky behaviors, such as splitting or sharing medications, or not seeking prescribed follow-up care.

This presents a conundrum to hospitals because they must provide the same high level of care to patients whose deteriorating health conditions present challenges from a medical standpoint.

"The number of uninsured is going up, and the number of less insured is going up even more. Yet hospitals' margin of profitability is down compared to a couple years ago," says Conway. "But you don't fall back on quality and service. We can't do that."

Schreiber agrees: "It hasn't changed what we are doing. We aim at all times to provide quality care."

Reporting plays a major role

With the current economic situation, public health-care reporting has never been more important. That's because studies have shown it is one of the strongest catalysts in the improvement of care.

"The bottom line is, when a public report card is out, hospitals do pay attention, hospital boards do pay attention, and physicians do pay attention, and hospitals improve as a result of public reporting," says Davis Anthony.

There is good news for Michigan's hospitals and its residents. According to GDAHC, southeastern Michigan hospitals rank high nationally in health-care quality indicators, with many in the top 25% to 50%.

The public can look forward to having even more information at its disposal, as public reports begin to expand into more areas. Davis Anthony says GDAHC expects to have a Physician Organization Performance Report available on its Save Lives Save Dollars Web site this summer.

The Centers for Medicare & Medicaid Services, which already conducts quality reports and is the source for many of the measures on the GDAHC Web site, began releasing information publicly in March from its CAHPS (Consumer Assessment of Health Providers and Systems) Hospital Survey. A new government review for measuring patient satisfaction at hospitals across the country, the survey is composed of patient ratings in areas such as communication with doctors and nurses, responsiveness of hospital staff, cleanliness and discharge information

"We are striving to deliver true quality, such as giving the right care and the right medications, as well as customer satisfaction, things like being friendly and kind," says Schreiber. "Both are important, and that's why both are being reported publicly. Now we need to give customers the tools to be able to understand these issues."

Conway agrees, saying he hopes to see focus groups formed to make public reports more consumer friendly and public reporting expand into more areas, such as outcomes in elective procedures.

elective procedures. "For decades, we've ignored all these things. Now the industry has gotten the message, and we're seeing improvements in safety and quality," he says.

And that competition and progress are a good thing for Michigan consumers, says Davis Anthony.

"It definitely gives you an edge when you rank high in patient experience and quality. But what a thing to compete in. It helps us reach a common goal of providing top care for the community."