How Do We Reduce Our In Hospital Death Rates?

(Posted on Tuesday, April 14, 2020)

Never has it been more critical for Americans to understand the importance of in hospital death rates and survival rates associated with hospital stays. Hospitals and emergency rooms today are increasingly overcrowded with those who are critically ill, either from COVID-19 or from other acute illnesses that require immediate medical care.

In these trying times, many are seeking and accepting care wherever they are used to receiving it, without any exploration of which hospital or emergency room will give them the best shot at survival. Yet the facts show that there is a significant difference – even among the best hospitals – in survival rates, with the chances of survival in some hospitals nearly twice as high as others.

Even prior to the COVID-19 outbreak, more than 400 people died in US hospitals each day due to poor hospital performance, according to a 2019 report. Many of these deaths could be prevented—if hospitals were to prioritize saving the lives of their most ill and patients were to prioritize hospital performance in their choice of care.

Hospital mortality rates, which include deaths that occur both on site and 30 days after discharge, are a visceral measure of hospital performance. But they are poorly understood by most patients, perhaps because of how hard the numbers are to track and how inconsistent those numbers can be. A recent article published in NEJM Catalyst observed that quite a few quality rating systems either ascribe mortality rates the same weight as readmissions or exclude them from their calculations altogether.

Still, there are options for consumers who care about where they are tended to. US News and World Report includes hospital mortality rates in their annual rankings of the best hospitals in the nation, but there are few other patient facing websites that rank hospitals on the issue.

The omission is troubling because it signals to hospitals that reducing mortality is not of the utmost priority. What happens, then, when an institution decides that it is?

Plummeting mortality rates

Such was the case at the University of Pennsylvania Health System, otherwise known as Penn Medicine. After a targeted effort to reduce mortality rates, the risk adjusted mortality index—a ratio that accounts for how sick patients are prior to admission—of their flagship hospital dropped, over six years, by nearly 50 percent. Since 2015, the mortality index of the academic medical center as a whole has seen an impressive overall reduction of 21 percent.

Two other academic medical centers committed to mortality reduction, NYU Langone Health and Rush University Medical Center, have achieved even greater gains. Between 2009 and 2019, according to data obtained from the Vizient Clinical Database, the mortality index at NYU Langone plunged from 1.18 to 0.53—more than half. Theirs remains by far the lowest of any hospital in New York City, as well as the lowest of any hospital in the U.S. News & World Report Top 10. Rush, which rose to the top of Vizient’s Quality and Accountability rankings this year but until recently maintained uneven mortality rates, reached a mortality index just below 0.50 in the first half of 2019.

At Rush, NYU Langone, and Penn Medicine, the mortality index falls well beneath the national average of 0.90. While this is a far cry from the most dangerous hospitals in the United States, where the risk of preventable death is twice as high as normal, it bears mentioning that even accredited institutions of supposedly comparable caliber can do poorly when it comes to their mortality index. An investigation conducted in 2017 found this to be the case at hundreds of “gold star” hospitals—some with violations “so bad,” Ars Technica reported, that they were “likely to cause serious injury or death to patients.”

Given that mortality reduction is, quite literally, a matter of life or death, their success—and, more specifically, how they achieved it—should not be taken for granted. In all three cases, it took several years of steadfast quality and safety improvements and widespread organizational change.

Identifying the problem

Initially, if patients outside the intensive care units at NYU Langone showed signs of deterioration, the critical interventions they needed to recover came too little or too late. Claims records show that this continued even after the installation of rapid response teams, which healthcare teams could call upon to intervene before patients ended up in intensive care. Mortality rates dropped, but not nearly enough.

No secret is it that physicians are generally reluctant to let other personnel, like the rapid response teams, “take over” patient care. For bedside nurses and novice nurses in particular, these misgivings dovetail with, in the words of a 2019 analysis, a common fear of “critical, intimidating, and judgmental” exchanges with rapid response teams to strongly discourage their activation.

Physicians, in their defense, express concern that opening up a closed circuit of caregivers to colleagues unfamiliar with the patient’s condition would disrupt treatment and create more room for error. A valid qualm but certainly no excuse for perpetuating a culture of distrust that undervalues nursing staff, impedes collaboration, and allows patients to suffer. All members of a healthcare team have a part to play in administering care.

Reaching a solution

In fact, an “interdisciplinary care approach,” Penn Medicine declares on their website, is the main reason for their success in mortality reduction. Back in 2006, their flagship hospital tasked an interdisciplinary Mortality Review Committee with promoting a “collaborative problem solving culture” powerful enough to erode the reluctance of physicians and bolster the capabilities of nursing staff.

The Penn Medicine 2017 – 2018 Quality and Patient Safety Report confirms that mortality reduction, like patient satisfaction, is a prominent “Shared Team Goal”—and that nurses are a driving force behind the assessments, non pharmacological interventions, and care coordination that power a diverse set of integrative clinical pathways. In the event that the condition of a patient worsens and their care must be escalated, specialized rapid response teams like the Pulmonary Embolism Response Team or Airway Rapid Response Team deliver interdisciplinary support and expertise directly to their bedside.

The problem with rapid response teams at NYU Langone was not necessarily their ability to perform, but their inability to beat the existing status quo. Like Penn Medicine, departments across hospitals had to develop escalation pathways, policies, and procedures that aligned with existing workflows—the whirlwind of decisions, interactions, and relationships that structure everyday life in the hospital—but explicitly rewarded healthcare teams who called for assistance sooner than later.

After years of sustained education, training, and codification, healthcare teams across hospitals have learned to activate rapid response as soon as patients begin to deteriorate—and mortality rates have plummeted. According to Martha Radford, Chief Quality Officer at NYU Langone Medical Center, it is now “no longer acceptable not to call a response team when you first think one may be needed.” Rather than a culture of distrust, healthcare providers at NYU Langone uphold a culture of shared responsibility.

For Rush, building a culture around a common set of values is one key to attaining a level of patient care high enough to prevent in hospital deaths. Another, which goes hand in hand with the first, is routine data collection and analysis. By framing a set of democratically selected quality metrics—mortality among them—as drivers of collective improvement, the analytics team at Rush gradually brought the competing goals of individual physicians and staff into alignment. Lastly, the adoption of lean management practices, which identify patient perspective as a central determinant of value, provides further basis for a shared vision. Thanks to these three measures combined, an old hierarchy and its attendant codes of professionalism is giving way to a new focus on quality and safety.

All too often, hospitals attribute higher rates of mortality and preventable deaths to the social or environmental risk factors that affect the populations they serve, essentially claiming that the danger is beyond their control. But the methods deployed by NYU Langone, Rush, and Penn Medicine, while far from one size fits all, can be adapted from one hospital to the next. Both Tisch Hospital and NYU Langone Hospital – Brooklyn, formerly known as NYU Lutheran Medical Center, have a mortality rate that hovers around 0.5. Given that NYU Langone Hospital – Brooklyn is a safety net hospital that serves a majority Medicaid population—a patient mix that differs significantly from that of Tisch Hospital—the equivalency is nothing short of remarkable.

Insurance companies also have a role to play in dispelling the notion that hospital mortality is some kind of inevitability. They must be willing to cover the cost of extra quality and quantity of care that, in some cases, is the difference between a life saved and a life lost. When insurers are ready to pay more to save lives, and when hospitals are held accountable for the patients that die on their watch, a sense of shared responsibility over patient care becomes the new norm—just as it has at NYU Langone, Rush, and Penn Medicine. New norms and higher standards, especially regarding the quality and safety of service delivery, are what hospitals need to not just reduce in hospital deaths, but replace profit centered care with person centered care.

Read full article on Forbes

Originally published on Forbes (April 14, 2020)