Jun. 2003
PATIENT SAFETY
Little Leaps?

Only one of the 31 hospitals in the St. Louis metropolitan region has filled out a voluntary survey on its success in meeting the Leapfrog Group's much-publicized national patient-safety standards.

And that hospital-859-bed St. John's Mercy Medical Center-hasn't yet noticed tangible benefits from boldly going where no other St. Louis hospital has dared to go by participating in the year-and-a-half-old patient-safety survey effort. Leapfrog, a business coalition that represents more than 135 of the nation's largest healthcare purchasers, has $56 billion in cumulative healthcare purchasing power.

Although Leapfrog's approach is largely based on the assumption that employers can educate and encourage their employees to select hospitals that meet the group's standards, its sole St. Louis- area participant hasn't seen any signs that consumers are rewarding it or punishing its competitors for boycotting the survey.

"We haven't tried to track that specifically," says Don Kalicak, director of planning and public policy for St. John's Mercy Health Care, the medical center's parent company, which submitted its survey data in 2001. "Gateway Purchasers for Health [the St. Louis business coalition that serves as Leapfrog's local contact group] has been very supportive of our initiatives, but we definitely have not tried to quantify any direct benefits."

St. Louis may be something of an anomaly-it's the only one of the 18 regions targeted by Leapfrog prior to April with such an abysmal rate of survey participation-but St. John's Mercy's experience may be indicative of a potentially crippling flaw in Leapfrog's initial approach to influencing hospitals' behavior. Leapfrog has targeted three primary quality objectives-or "leaps," in its folksy lingo. These include use of computerized prescription systems by physicians, the staffing of intensive-care units with trained physician ICU specialists or intensivists; and encouraging referrals to hospitals with "the best results or more extensive experience" with seven high-risk procedures, such as coronary artery bypass surgery and angioplasty.

So far, however, Leapfrog hasn't produced a carrot to financially reward hospitals that work toward meeting its standards or a stick to punish those that don't.

Even many supporters acknowledge that Leapfrog may not have identified the best patient-safety measures, or those that are easiest, quickest and least expensive for hospitals to implement, although they applaud its willingness to try. Some say its deadlines are overly optimistic. And many wonder if, despite its size and financial clout, Leapfrog has sufficient influence and collective willpower to finish the job, especially during tight economic times.

"I very much support what they're trying to do," says Charles B. Inlander, president of the People's Medical Society, an Allentown, Pa.-based consumer health advocacy group with 120,000 members. He argues that Leapfrog has been quite successful in keeping patient-safety issues in the public eye-and on the front burner as far as many hospital executives are concerned-especially with regard to computerized physician order entry.

"There they've raised the bar," says Inlander. "But I'm not sure they've gotten much response yet, and there's been a lot of resistance," he adds, noting that he would have preferred to see Leapfrog assemble a larger group of employers and focus on simpler objectives, such as reducing hospital-acquired infections.

That's not to say the business coalition hasn't made some progress. As of late April, 810 hospitals had voluntarily filled out Leapfrog's questionnaire, including more than 550 in 18 targeted regions and approximately 253 hospitals in regions that haven't yet been approached, according to Suzanne Delbanco, Ph.D., M.P.H., the group's executive director.

In early April Leapfrog officials announced they are targeting three new markets-Hampton Roads, Va.; the state of Maine; and Chicago and other urban areas in Illinois-that represent 150 hospitals and 8 percent of the U.S. population. This means that 1,100 urban and suburban hospitals in areas where 48 percent of Americans live are now included in Leapfrog's targeted regions, according to Delbanco. Moreover, she says, about 58 percent of hospitals in those targeted regions have filled out the group's survey.

"This is the first effort of its kind to have hospitals voluntarily report [quality data]," Delbanco argues, "and we're seeing that it can be very successful."

In terms of implementation, however, the hospitals' self-reported numbers aren't as encouraging. According to Delbanco, only about 5 percent of hospitals that responded to the survey have met the CPOE goal of having 75 percent of doctors prescribing medications electronically, and about 20 percent have met the ICU intensivists' criteria, although much larger numbers say they'll meet those objectives by next year.

Supporters insist that Leapfrog-which was founded in November 2000 by the Business Round Table and a number of Fortune 500 companies, and first posted survey data on its Web site in January 2002-has made a significant impact and continues to evolve.

"You have to look at progress area by area. Some rollout regions have made more progress than others," including the Atlanta area, says Dale Whitney, corporate health and welfare manager for Atlanta-based UPS, a Leapfrog member that provides health coverage to 340,000 employees and another 410,000 dependents and retirees. Whitney says organized resistance by hospital associations has lessened, and that many hospital CEOs are beginning to get the message that employers are serious about effecting change.

Still, even many Leapfrog supporters say it's extremely difficult to get hospitals to tackle capital-intensive projects such as CPOE, which can create nasty disputes with their physicians, when employers and health plans haven't yet put significant amounts of money on the table to pay for these improvements. "Without Leapfrog, I don't think CPOE would be on a lot of hospital CEOs' radar screens," says Sandy Lutz, a Dallas-based national healthcare research director for PricewaterhouseCoopers. "Without Leapfrog, you wouldn't have the consensus that you have. Implementation is a different issue."

Lutz says financially strong hospitals are more likely to take these steps than others, and that there have to be more financial incentives to make these changes. "You can't shove these things down the throats of the doctors," she says, "and frankly, we have an industry where one-third of hospitals are losing money."

Officials at Leapfrog say they're well aware of the need for a degree of flexibility and pragmatism in dealing with often-recalcitrant hospitals and physicians.

In early April, in fact, the group adjusted some of its standards, in part because of complaints by hospitals, broadening its definition of intensivists, changing some of its volume-related criteria for hospital referrals, and allowing hospitals in states with publicly reported outcomes data to use that data in place of volume data to meet the guidelines. The group also announced a yearlong delay, to January 2005, in the implementation deadline of its CPOE standard. Officials positioned the moves as a sign of Leapfrog's flexibility. "We recognize how dynamic healthcare is and how rapidly it changes," Delbanco says. "We want to start rewarding quality where we have the opportunity to do so."

So far, Leapfrog has been able to lure several large hospital systems into becoming members, including giant Nashville, Tenn.-based HCA Inc. and Atlanta's Promina Health System. The Robert Wood Johnson Health Network, a New Brunswick, N.J.-based network of seven acute-care hospitals that plans to spend $40 million to meet the standards by 2007, joined Leapfrog last October.

But Leapfrog's ability to directly influence hospital behavior is severely limited, especially in regions where the preponderance of hospitals fail to participate in its efforts. In St. Louis, for example, Gateway Purchasers for Health and an affiliated business coalition, the St. Louis Area Business Health Coalition, have had no success in persuading other local hospitals to join in the Leapfrog effort.

Lauren Tran, director of health policy for the two organizations, which plan to merge later this year, says many small hospitals in St. Louis can't meet Leapfrog's volume standards and aren't convinced that consumers will understand subtle distinctions concerning quality. Tran says others believe their own homegrown quality and patient-safety initiatives are at least as valid as Leapfrog's and don't require the large capital expenditures involved in meeting its CPOE standard.

But sheer market clout is another consideration, according to Tran, who emphasizes that St. Louis' hospital market is extremely consolidated.

"We support Leapfrog and would like the hospitals in the St. Louis market to report," she says, noting St. Louis was one of Leapfrog's first rollout regions. "It's voluntary. There's only so much we can do."

Despite efforts by Leapfrog's member companies to educate their employees and push for national quality standards and outcomes measurements, skeptics say Leapfrog's mixed track record isn't likely to change dramatically in the near future.

"Leapfrog is one of the perceived national leaders in the [patient-safety] field, but I still think the proof is in the pudding," says David B. Nash, M.D., MBA, associate dean and director of the office of health policy at Philadelphia's Jefferson Medical College. Nash says he's seen no evidence of "dramatic market shifts" of patients from hospitals that are not Leapfrog-compliant or working in that direction to those that have met its standards or are working toward them.

"I support intellectually what they're trying to do," he says, "but they were very idealistic, and perhaps unrealistic, about having a dramatic, short-term impact."

The American Hospital Association, meanwhile, while willing to work with Leapfrog to some extent, is quick to point out its own, quite separate quality-improvement projects and to echo industry complaints about some of Leapfrog's quality criteria. Many hospitals "have expressed concerns regarding the three leaps and whether it's the right thing for every hospital to do," says Nancy Foster, the AHA's senior associate director.

And at Grinnell Regional Medical Center in Grinnell, Iowa, CEO Todd Linden has yet to feel any pressure to implement the Leapfrog guidelines, although he first feared he might lose business to hospitals in larger metropolitan areas because of Leapfrog's volume-based hospital referral standards. Instead, he says, none of Iowa's hospitals is making a big push to meet the Leapfrog standards.

"Leapfrog doesn't have the corner on the market on this topic," he says.

Linden says problems with CPOE installations at much larger urban facilities, such as Cedars-Sinai Medical Center in Los Angeles, have convinced him that it's more important to continue making incremental changes, such as improving laboratory and pharmacy department information systems in ways that might ultimately become parts of a CPOE project.

"Instead of a sprint, we're talking about a 10K run, maybe a marathon," Linden says.

Chris Rauber is senior editor with HealthLeaders. He can be reached at: chris.rauber@healthleaders.com

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