What’s worse: Losing face or losing money?
Under laws in more than two dozen states and new Medicare rules that went into effect earlier this year, hospitals are required to report infections, risking their reputations as sterile sanctuaries, or pay a penalty. That’s left hospital administrators weighing the cost of 'fessing up against the cost of fines.
For Clark Todd, CEO of Pacific Hospital in Long Beach, there's only one way to go: "If we hide from the public then the tendency to keep the status quo is stronger than ever," he said. "And that's just not going to get the job done."
It's been more than a decade since a panel of top scientists declared hospital safety a national priority. Yet, about 90,000 patients still die each year from preventable infections resulting from routine surgeries and hospital care, according to the U.S. Centers for Disease Control and Prevention. Examples include infections resulting from contaminated tubes that deliver food and medications, and catheters that remove urine. Staph infections, which can be deadly, are a particularly serious problem.
Many more patients are irreparably harmed. Dave Meyer of Fair Oaks, Calif., a Sacramento suburb, was a general contractor before he broke his ankle in a motorcycle accident. Records indicate he contracted an infection at a local hospital that prevented his ankle from healing. He endured several surgeries and excruciating wound cleanings.
"Imagine taking an ice cream scoop and just taking half of your foot off. It looked like just this gaping hole," said Meyer, adding: "I know that it would have been so much better if they used the proper hygiene in the hospital."
Dr. Alfonso Torress-Cook of Pacific Hospital couldn’t agree more. "Hospitals are dirty," he said. An epidemiologist and head of the hospital's infection control program, Torress-Cook came to this for-profit teaching hospital five years ago with a clear goal: to sharply reduce the hospital’s infection rate.
Back then, the medical staff viewed infections at the 184-acute care bed facility as largely unavoidable and treated them with antibiotics, he said. The approach was costly: An infection can add $42,000 to a patient's bill in the intensive care unit, according to the Leapfrog Group, an advocacy group that represents large employers like General Motors, Chrysler and Sprint.
Now, hand washing at Pacific Hospital, especially in the ICU, is so routine nurses complain their hands are chapped. That's just one of many changes. Nurses here wash patients every day. Janitors are given enough time to properly clean rooms. Even those coming in for surgery are asked to take a shower before showing up.
Torress-Cook opened a closet to show off another weapon in the hospital’s anti-infection arsenal: an ultraviolet light, hooked up to the hospital’s air ventilation system, that kills airborne germs.
At first the employees were skeptical, said Todd. But California’s new public reporting law, which went into effect in 2010, and Medicare’s decision to start withholding two percent of payments from hospitals that keep their rates secret, have helped his cause.
"I think that gives administrators like me even more reason to get involved in this matter," said Todd. "And more clout with our medical staff to work against some of these traditional behaviors."
Pacific Hospital is working to bring down bloodstream infections that result from tubes that deliver medication and nutrients, and has virtually eliminated methicillin-resistant Staphylococcus aureus (MRSA) and surgical infections.
That has caught the attention of competitors and potential customers. And it’s become a source of pride for its employees.
Indeed, researchers have found concern over a hospital’s public image is an even more powerful motivator than fear of losing market share.
"Many hospitals will measure quality and voluntarily put it up, even without the government involved," said Dr. Michael Rapp, director of the Quality Measurement and Health Assessment Group of the Centers for Medicare and Medicaid Services. "But certainly once it’s required for all hospitals to do that there's the peer pressure and they’re going to be looking at how they do compared to others."
The fear of losing millions of dollars isn’t an idle threat either. Starting this year, hospitals have to reveal their catheter-associated blood stream infections if they want their Medicare bills paid in full. Next year, they’ll have to report surgical-site infections. The list will grow longer in the coming years.
Rapp anticipates that nearly all U.S. hospitals will comply. Now, only half volunteer their data, he said.
Still, the stigma of unclean wards and fear of lawsuits can make hospitals reluctant to report. When the law went into effect in California, 19 hospitals out of 400 didn’t send in any data. State regulators, who acknowledge the first year of data collection was riddled with errors, are not imposing penalties.
There are other concerns: Competitors may undercount, making more honest players look bad, and some hospitals simply do more surgeries or have sicker patients, said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association.
"The measures aren't perfect and don't adequately account for the differences among patients," said Foster.
For hospitals in cities like Long Beach or quieter, rural areas like Ukiah, keeping track of the frenetic activity in their facilities can be daunting.
Ukiah is a verdant and woodsy town north of San Francisco, in Mendocino County. At the small, 78-bed nonprofit hospital, patients and staff all seem to know each other, trading warm hellos on a warm spring day. It’s not hard to imagine how quickly word of even one infection can spread.
That’s something Sue Mason, a half-time nurse at Ukiah Valley Medical Center, worries about. "We have nothing to hide," she said.
Mason has a big job and only 20 hours a week to do it: She’s charged with tracking and preventing infections. Every morning, she checks the computerized lab tests and tries to chase down new cases. In the nationwide push for greater transparency of hospital performance, though, Mason is an overwhelmed foot soldier. She has little time to eliminate the very infections she’s charged with reporting.
"I’d like to be out on the floor more with the nurses. I could monitor their hand hygiene compliance and educate them as I see them doing their job," Mason said. Instead, she spends most her day in front of the computer crunching data.
Mason must report not just the infections that occur, which are rare here, she said, but details of every surgery, every patient who tests positive or negative for gruesome antibiotic-resistant bugs, like MRSA.
Even at Pacific Hospital, where infection rates are some of the lowest in the nation, hospital chief Todd preaches constant vigilance, "These initiatives have to be felt with some passion and they have to be implemented with consistency and strong will."
It will take some time before patients can know the full risk of entering their local hospital. At present, most states and Medicare publish just a short list of infections.
In the coming years, though, as the federal health law continues to take effect, the noose will tighten even more. Starting in 2012, Medicare will reduce payments to hospitals with poor infection rates in their intensive care units.
There is great hope, among researchers and hospital chiefs, that this double-barreled approach of public reporting and financial sanctions may be the best cure for what has proven to be a chronic condition in hospitals.