It was standing room only at the Statehouse last Thursday morning in the small, third-floor conference room of the House Committee on Health and Welfare. Etched on a chalkboard at the back of the room was a single bill number: H.128. Committee Chairman Thomas Koch (R-Barre Town) has devoted the entire month of February to hearings on this one bill, introduced by freshman lawmaker Anne Donahue (R-Northfield). If approved, this sweeping piece of legislation would radically alter the landscape of Vermont's hospital industry.
Testifying first was Commissioner John Crowley from the Department of Bank-ing, Insurance, Securities and Health Care Administration. Crowley confessed he hadn't read the 65-page bill in its entirety. With a new boss in the governor's office, his agency has yet to nail down the health-care priorities of the Douglas administration.
"You may have to catch up with this committee," warned Chairman Koch, "because we're on a roll."
If anything good has come from the financial debacle that rocked Fletcher Allen in the last year, it's the political momentum building in Montpelier to take a closer look at the quality of hospital care in Vermont. The horror stories have practically become a staple of TV newsmagazines: surgeons amputate the wrong limb or leave instruments inside their patients... nurses administer the wrong drugs because they can't read a doctor's handwriting... patients go in for a simple outpatient procedure and contract a deadly infection because someone didn't wash his or her hands.
Hospital infections are now the fourth leading cause of death in the United States, behind heart disease, cancer and strokes, according to the Centers for Disease Control and Prevention. And medical errors have climbed to eighth, killing more people than car accidents, breast cancer and AIDS.
How safe are you in your local hospital? You can uncover a wealth of financial information about Vermont's 14 community hospitals with relative ease. Thanks to the most stringent reporting laws in the country, you can pull back the curtain and see your hospital's balance sheets, profit-and-loss statements, average staff salaries, even how much it spends annually on employee pensions and benefits.
But what if you want to know how many patients fell out of bed last year? Or how many C-sections were botched? Or how many patients died undergoing the same surgery you're scheduled for? Good luck.
Even though we've lanced the boil of improprieties that erupted from Fletcher Allen's Renaissance Project, it's still easier to find out what went on last year in the hospital's boardrooms than on its medical wards. "Patient safety" and "quality of care" have become the hottest buzzwords in the health-care industry, but it's no simple task for consumers to find accurate, unbiased and easy-to-understand data that measures those nebulous and loosely defined terms.
Many of the vital statistics that are kept have long been hidden behind the cloak of medical confidentiality or buried in the disparate databases of federal, state and local regulatory agencies. And a lot of potentially valuable information is not mandatorily reported or compiled at all. But that may soon change as the interests of business, medical science and politics collide in the Vermont Legislature.
The debate underway in Vermont isn't unique. "It's a movement you're seeing a lot around the country that's empowering consumers to be more involved in their own care, in knowing what things cost and what kind of quality they're getting for their money," explains Donahue. "It creates pressure on the health-care system for quality improvements."
Donahue's bill proposes major changes in how hospitals adopt their budgets, plan for capital improvements, staff their boards of directors and report their operations and finances to the public. The legislation would subject Vermont's hospitals to the state's rigorous public meetings and open records laws. It also includes strong whistleblower protections for health-care employees who come forward to report abuses in their hospitals.
But the bill isn't only about finances. One provision of particular interest to consumer advocates is a requirement that hospitals issue an annual "report card" informing their community about their "quality of care, clinical outcomes and other performance measures." Rather than spelling out what those measures would be, the bill directs the citizen-oriented Public Oversight Commission to make specific recommendations on what a hospital report card should actually look like.
The devil may well lie in those details. Most of us assume that a hospital's performance records are kept at the Vermont Department of Health, the agency that licenses hospitals. In fact, the details about what goes wrong inside a hospital can be spread across a dozen different databases and require a Ph.D. to decipher. As Donahue points out, much of that information is never made public.
"If we're going to reach the goal of consumer education and empowerment in making decisions about their own care, we have to make that information accessible in one place," Donahue says. "We can't have people looking up 10 different Web sites."
So, how can you figure out your chances of picking up a deadly infection in the hospital? Although the Centers for Disease Control and Prevention gather infection rates for statistical purposes, hospitals don't have to report those numbers to the health department. Nor are they required to tell the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a private body that accredits 80 percent of all hospitals in the nation, including 11 in Vermont.
Just three weeks ago JCAHO issued a national alert that patient deaths from hospital-acquired infections are being seriously underreported. The CDC now estimates that more than 2 million patients each year develop infections while they're hospitalized for other health problems; nearly 90,000 of them die as a result. And since the average patient these days is more likely than ever to have a compromised immune system, those numbers are likely to rise. Beyond the human toll, the CDC estimates that treating those infections adds another $5 billion to health-care costs every year. Despite those staggering numbers, JCAHO's patient safety database, a voluntary reporting effort that's been around for seven years, includes only 10 reports on 53 patients.
But as JCAHO spokesperson Charlene Hill emphasizes, the Commission is not a regulatory body. As she puts it, "We're not in the business of blame and shame." Instead, it puts pressure on a hospital to voluntarily report those events in order to help the hospital improve its standards of care. In the most extreme cases, JCAHO can revoke a hospital's accreditation, but that rarely occurs.
What other vital signs might show up on a hospital report card? Donahue would like to see a hospital's track record on medical errors: diagnostic mistakes, equipment failures, blood transfusion mix-ups, misread medical orders and so on. In 1999 the Institute of Medicine (IOM) issued a report entitled, "To Err Is Human: Building a Safer Health System." It revealed that some 44,000 to 98,000 people die in hospitals each year from medical errors, costing the nation about $37.6 billion.
If there's a bright side, it's that the IOM also found the majority of medical errors weren't caused by individual negligence or misconduct. In fact, most were avoidable. But preventing mistakes in Vermont requires creating an environment in which hospitals not only gather those statistics but also share them with those outside their walls. And fear of malpractice suits or negative publicity have made hospitals skittish about such disclosure.
Several years ago, for example, a number of the state's hospitals approached the Vermont Program for Quality in Health Care, a private nonprofit group, looking for ways to reduce their incidence of hospital-acquired infections. According to VPQHC Medical Director Cy Jordan, studies had shown that for some surgical procedures, giving patients antibiotics within two hours of an operation reduced infection rates drastically. VPQHC collected local data about this protocol. But the participating hospitals insisted the information be kept confidential. Those hospitals that hadn't been giving the antibiotics, Jordan says, feared a "slam-dunk lawsuit."
"That's the tension between public disclosure and more private reporting," he continues. "The hospitals wouldn't even look for dirty laundry unless they knew they could do it safely."
The public does have a right to more information, Jordan agrees. But he cautions that the goal shouldn't be to point fingers. "The whole concept of quality improvement is not about figuring out who the bad apple is. The whole idea is that everyone wants to get better, so we can move the mean up."
How gathered data are used is also crucial. "Whether it's voluntarily reported or mandated, what's important is what's done with that information," Hill, at the accreditation commission, points out. "Reporting it isn't enough. It needs to be analyzed so that if there is a trend that indicates a need for improvement, the hospitals are acting on it."
And public-safety statistics need to be placed in a meaningful context, warns Ellen Thompson, public health planning chief for the Vermont Department of Health. "We all believe there should be more data available to the public, but none of us has come down on what you should provide," she says. "Sometimes mortality rates are really misleading."
That view is shared by those at the Vermont Association of Hospitals and Health Systems, which represents all the hospitals in the state. Jill Olson, VAHHS vice president of continuing care and quality, couldn't comment on H.128 since she hadn't seen it yet. But she fears hospitals will be required to report data that could be misconstrued or used for the wrong reasons by consumers.
"People want access to information because they really want to make good decisions about their heath care, and we abso-lutely support that," Olson says. "The thing is, hospitals are really complicated places that do all kinds of different work, so finding ways to measure their performance is complicated also. I wish there were one measure I could give you and you could say, 'Aha! Now I know what to do.' But there isn't."
Frustrated by the hospital industry's culture of secrecy, some cyber-savvy consumers have begun turning to the Internet for help. One site, HealthGrades.com, says it "objectively rates the performance of almost every hospital in the United States engaged in the critical medical specialties of cardiac surgery, cardiology, orthopedic surgery, neurosciences, pulmonary/respiratory, vascular surgery and obstetrics." Using raw data from the Centers for Medicare and Medicaid Services, as well as additional statistics from 18 states, including Vermont, HealthGrades created a one- to five-star hospital rating system for a variety of medical conditions and procedures. The site claims its numbers are "risk-adjusted" to account for hospitals' different sizes, enabling consumers to "compare apples to apples" on a nationwide basis.
But critics contend that such simplistic rating systems are more appropriate for restaurant and movie reviews than hospitals, and don't necessarily give consumers the information they think they're getting. As Olson explains, safety performance can be evaluated using either "process" or "outcome" measures. While a process measure might ask whether someone who showed up in the emergency room having a heart attack was given beta-blockers, an outcome measure would just find out whether the patient died.
Process measures are more useful for quality improvement, Olson contends, because they look at what was actually done to treat a patient. Outcome measures like mortality rates can be misleading, she says, because large, urban hospitals like Fletcher Allen tend to attract sicker patients with more serious medical complications. Con-versely, smaller facilities like Porter Medical Center in Middlebury may not see enough patients with a particular condition to make their outcome measures statistically relevant.
"When I say that, people like to say, 'Oh, you're the fox guarding the henhouse and you don't want this information to get out.' But it's really more complicated than that," Olson says. "If people are going to use this data to make comparisons, you want it to be data that allows them to make those comparisons."
A report in the March 13, 2002, issue of the Journal of the American Medical Association (JAMA) arrives at the same conclusion. The article, entitled "Evaluation of a Consumer-Oriented Internet Health Care Report Card," looks at the methods used by HealthGrades.com and concludes "mortality has limited utility as a measure of quality" and "often correlates poorly with quality of care." Moreover, JAMA notes that in the past, publishing Medicare and Medicaid's mortality statistics had the unintended consequence of creating what became known as the government's hospital "death list." The journal report concludes that, while "these ratings do convey some important information in aggregate, [they] provide little meaningful discrimination between individual hospitals' performance in a manner sufficient for a public interested in making informed hospital choices."
All of Vermont's hospitals recently agreed to participate in a voluntary national quality initiative being run by the American Hospital Association, the Centers for Medicare and Medicaid Services, JCAHO, the AFL-CIO and others. Olson believes the data from this initiative will be more "clinically meaningful, scientifically sound and understandable by consumers." The initiative will start by focusing on just three conditions -- acute myocardial infarctions (heart attacks), heart failure and pneumonia -- and look at how care is delivered and measured. Pre- liminary data on that effort are due out this summer.
In the meantime, Olson reassures Vermonters that the quality of care being provided by the state's hospitals remains excellent. She points to a recent JAMA article in which Vermont ranks second in the nation for the care it delivers to Medicare recipients.
Though legislator Anne Donahue commends the hospitals for their voluntary efforts, she still believes it's important to make the available data public and let consumers decide for themselves. She insists patients have a fundamental right to know basic information about their hospitals, such as the frequency of medical complications, the rate of hospital-acquired infections and how many patients die from avoidable errors. And as health-care costs and insurance premiums skyrocket, she says businesses have a right to know how much bang they and their employees are getting for their health-care bucks.
While lawmakers and health-care professionals sort out the particulars, where can consumers turn for reliable information? One Web site worth visiting is maintained by the Leapfrog Group (www.leap froggroup.org), a coalition of more than 130 public and private organizations that provide health-care benefits to employees around the country. Founded by the Business Roundtable, a national association of Fortune 500 CEOs, Leapfrog uses its considerable purchasing power to push for changes in hospital practices that will reduce the frequency of preventable errors. JAMA has called Leapfrog "one of the most ambitious health ratings resources available online today."
Similarly, the Joint Com- mission on Accreditation of Healthcare Organizations has a searchable, online database on all the hospitals it accredits. Aside from its formal inspections once every three years, it also conducts surprise hospital visits and operates a toll-free number to take public complaints. The results of those inspections, and the hospitals' responses to them, can be found at http://www.jcaho.org.
Another excellent source for consumer information is the Web site of the Agency for Healthcare Research and Quality (www.ahrq.org). This division of the U.S. Department of Health and Human Services is currently involved in identifying national standards of care and creating a national patient safety database.
Locally, the Vermont Program for Quality In Health Care (www. vpqhc.org) issues an annual report on the state of Vermont's health care. It could serve as a template for any hospital report card mandated by the Legislature.
How likely is H.128 to be-come law? The bill is ambitious, Donahue admits. But she remains optimistic that widespread support for the issue will keep the bill from being dragged down by its own weight. Already the Vermont Federation of Nurses and Health Professionals is backing the bill for its strong whistleblower protections. Union members say an annual hospital report could also highlight the problems associated with mandatory nurses' overtime and high nurse-to-patient ratios -- factors that have a direct impact on quality of care and patient safety. Likewise, the Vermont Chamber of Commerce has made in-creased consumer information about their health-care choices one of its legislative priorities. Donahue says the time to act is now, while the ball is rolling.
"That's been one of the really frustrating things over the last five or six years in Vermont," Donahue says. "There have been tons of studies and commissions and reports, and nobody does anything about it. If we don't take this on now, nothing will ever get done."
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