The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.
So what does this report tell us? That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time. Most of us who study “quality of care” look at that number and think – well, that’s pretty good. It surely could have been worse.
Pretty good? Could have been worse? Take a step back for a moment: if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?
So what might state and federal policymakers do if they wanted to get serious about improving these rates? There are lots of potential solutions, including greater training, more oversight, even robust pay-for-performance. I have a simpler request:
Stop setting the benchmark at the state average.
Ashish is right on point. In several earlier posts, I have talked about how the use of benchmarks can be inimical to clinical quality improvement, stating a preference instead for absolute targets, like zero or 100%. For some reason, many state and federal agencies persist in comparing hospitals to the norm.
Regardless of what the government agencies are doing, though, hospitals can do better. The NHS' Jim Easton put the job on the leaders of hospitals:
[We] need to improve ourselves as leaders. [We need to] be intolerant of mediocrity, to hate it. [We must] reject normative levels of harm.
It is not ok to be in the middle of the distribution of the number of people we are killing.
I have told the story of being at a hospital where the CEO said directly to his senior management and clinical leaders that his goal was to be “just above average” when it came to quality and safety metrics. A CEO who has chosen not to do that has, in essence, said that the loss of hundreds of lives at his institution is acceptable.
My objective today is to confess. I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties [by focusing instead on the traditional set of executive duties (financial, planning, and such)].
If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries.