I’ve had several discussions with Health Roundtable members recently, focussed on Hospital Acquired Complications (HACs). I want to share some reflections on useful ways to frame the discussion and some pitfalls to avoid, especially around how we engage staff on reducing HACs.
HACs are a hot topic for a number of reasons. First there was joint work by the ACSQHC defining a set of HAC indicators with follow up work by IHPA on Pricing and Funding for Safety and Quality. The Health Roundtable followed this with a series of reports of our own, emulating the methodology of the ACSQHC and IHPA and giving our members a view of their own HAC data. The Grattan Institute have also published a series of reports on HACs, the most recent being Safer care saves money: How to improve patient care and save public money at the same time.
In any discussion on indicators derived from administrative data there will be the inevitable distractions. When you see your facility lined up against others, rates compared, there is a natural tendency to be defensive if you find yourself at the high end. We know that levels of documentation vary for some HACs and this leads to uncertainty around the comparisons. “Are we just high because we focussed on this and are really good at documenting and reporting it? The rate isn’t risk adjusted, we’re a facility with a lot of complex patients.”
Many of the staff who will be engaged in the process of looking at and dealing with reported HAC rates will be of a scientific mindset. For the scientifically minded, myself included, the natural inclination is to question the numbers. Scepticism of the numbers is healthy, but sometimes you have to take a step back and turn the question around. An indicator, represented in a report as a trend, is not the definitive answer to a scientific hypothesis. It is a starting point for an understanding, a step in the collection of evidence that helps us to better understand the array of possible real world scenarios that underly the data.
Faced with the following information, what do you do? Your facility had 500 reported hospital acquired infections over the previous year (as per the ACSQHC indicator this includes UTIs, surgical site, gastrointestinal and bloodstream infections, central and peripheral line associated bloodstream infections, pneumonia, multi-resistant organisms and infections associated with prosthetics). As well as the raw number, this is presented as a rate, divided out by a large number of episodes in which there was an opportunity for an infection. Your rate is high compared to your peers.
It’s very easy to come up with a lot of untested hypotheses as to why this comparison might be inaccurate. But here’s the thing. Either you are very good at documenting, in which case you are in possession of some accurate information about hospital acquired infections in your facility, or you are not so good at documenting and your actual rate is worse. Regardless of whether you think the comparison is wrong for any number of other reasons, even if you are in fact a high performing hospital, you have 500 infections to start on and possibly some work to do on improving your documentation.
So instead of arguing the rate, look at the information you have and decide what to do with it. Maybe you think the 500 infections are mostly unavoidable. The report breaks the infections down into each of the 8 categories. You had 80 central and peripheral line infections. Start with those. If you are still standing there arguing and haven’t taken that information and acted on it then you have missed an opportunity to improve the care in your hospital.
The Health Roundtable INSIGHTS tool enables you to slide and dice your HAC results, and collaborate on it with your team.
Start by aligning the number in your report with actual cases. Talk to us if you’re not sure how to go about that, we’re happy to help. This will be the shortest path to dealing with the concerns of the sceptics. Find the group of patients that no-one is going to argue about, the ones with a clearly avoidable hospital-acquired condition. Patient stories are powerful. If you can articulate your solution around cases that clearly demonstrate the problem then you will have a much better chance of getting others on board.
In the end, the data are only the beginning, the seed from which a plan of action emerges, but even a plan of action isn’t worth much if you can’t influence the hearts and minds of the people around you. There’s a lot to unpick in this process and some of my colleagues are better placed to take you on that journey. In future blog posts we’ll cover these topics and more. I’ll also be back with some more data focussed discussions.
One last thing. The rates are still important. The HACs where you have the highest rate compared to your peers will be your best bet as to greatest opportunity to improve. Understand and accept the limitations of the information you have but focus on what you can do with it, not what you can’t.
The Health Roundtable provides a number of reports and tools to assist members with investigating HACs. There is a quarterly pdf report comparing facilities to peers, an interactive workbook that allows drill down into the detail and our HRT Insights web platform that combines charting and drill down capability.