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Interviewer: Going to help you understand hospital rankings, that's coming up next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: When a hospital says they're number one in this ranking or in the top 10 in another ranking, what does ultimately mean for you as a patient? And are there some rankings that are more prestigious than others? All right. Hopefully, we'll get some help understanding this. Dr. Robert Pendleton is a Chief Medical Quality Officer at University of Utah Health Care. And one time, I was listening to you speak and you referred to as these rankings kind of like merit badges because there are so many of them, right? What exactly do you mean by "they're just merit badges"?

Dr. Pendleton: Well, you have to understand my perspective is five years ago, I was just a doc in the hospital who knew nothing about any of this, other than what patients see, right? These banners and everything. And when I took on the role of Chief Quality Officer, it was really eye-opening to me because depending on which ranking you're talking about, every hospital has one, right? Every hospital has a banner or whatever. And pretty quickly, it felt like I was back in Boy Scouts, collecting merit badges. And there are so many rankings that it becomes really confusing for patients to understand, "Well, what actually matters?"

Interviewer: Yeah, how many are there? Do you have any sort of a guess at that?

Dr. Pendleton: Yeah, there are probably a dozen or so very popular ones, but then another 20 or 30 merit badges that are maybe sort of less developed, but still things that people will put up on their or their hospital marquees and that sort of thing.

Interviewer: Yeah, so what are these ratings usually based on? And should we make some differentiation at this point where we talk about, "From now on we're talking about the meaningful ones and we're kind of forgetting about the merit badges"? Or how do you think we should best organize that to help a patient understand?

Dr. Pendleton: Yeah, I think that the most common ones that hospitals talk about, even within that pool, are very different. You have some rankings that are almost entirely on things like reputation or what are called structural measures. So a structural measure may be something like how many intensive care unit doctors does your hospital staff at night.

And although those kinds of things, reputation and structural measures like staffing, on the surface, are important, my belief is that in health care we've moved beyond that where we can start measuring more meaningful things and actually start looking at measures of safety, complications, how likely patients are to survive a severe illness when they get hospitalized, whether their doctors and nurses and health care team communicates effectively in a way that patients can understand what the game plan is. We're now at a point where those objective measures should be used almost entirely in these rankings because I think that reputation, staffing ratios etc. just feels like more merit badges to me.

Interviewer: Sure. So beyond that, just kind of the, "Are you going to go in and have a good outcome," sort of thing, are there things that go into these rankings that measure in terms of patient benefits? You talk about patient benefits a lot.

Dr. Pendleton: Yeah. There are. There are things like how long do you stay in the hospital for a given problem, compared to what we would expect. Most patients don't want to spend any more time in the hospital than they need to. They measure things like, do you get a common complication in health care, which is like a new infection. And again, a whole Interviewer of very patient-oriented things, like you know, how well did your doctor communicate with you? How responsive was the staff if you used your call light to summon for help? Did the pharmacist talk about your medications in a way that you can understand them?

When you were discharged from the hospital, did you understand your follow-up plan? And then measuring, did you actually need to have an unexpected return back to the emergency department or the hospital after you were discharged?

Interviewer: So you talk about kind of which of the metrics matter. How can I determine now which of these merit badges matter? Like, for example, I go to a hospital's website and I see that they have one of these merit badges. How do I know if that's the real deal or if it's just a merit badge?

Dr. Pendleton: I think most of these merit badges are starting to become more publicly available. So if you Googled, for example, "US News and World Report methodology," most patients now can get to a website that still is oriented in a way that patients can get something out of that and click through to see whether there are meaningful, actual measures of care that are part of these scorecards.

Interviewer: So University of Utah Health Care just recently got number one on the Vizient Quality and Accountability Study. Is that a good one?

Dr. Pendleton: Well, of course, it is. We're number one.

Interviewer: But you've been very honest with me up to this point so I know you're going to be honest with me on this.

Dr. Pendleton: Yeah, absolutely. We actually, every year, go through and look at all these merit badges as an organization, and really in great detail, we go through a process to say, "Is this the right thing for us to focus on as an organization where we can help our organization get better?" Vizient is one where we have been particularly enamored by, if you will, over the last seven years or so. And the reason is it is entirely objective measures of better care: survival rates across the entire enterprise, not just one or two areas; a broader range of complication rates, broad range of patient-reported feedback about the experience of their care, costs of care, efficiency of care.

And it allows us to benchmark that each of those measures with our peers so that we know, "Well, how are we doing compared to other really well-known health systems, like Johns Hopkins or the Mayo Clinic?" And for us, that really allows as to understand where our opportunities are to be better.

Interviewer: So it sounds like that the quality of the award or the ranking really has a lot to do with what are they measuring in the first place. And you talked about some meaningful versus not-so-meaningful metrics. Sounds like they also would apply to day-to-day care, in addition to more complicated stuff. Like I guess at one point, I thought, "Well, if I'm getting a knee replacement, then I'm really going to want to pay attention to these ratings." But it sounds like day-to-day stuff's included in these as well.

Dr. Pendleton: It does. And the true day-to-day stuff for healthy people like you or I, who are getting care in clinics and we may never enter the walls of a hospital emergency department in any given year, Vizient also is sort of becoming a leader in how we assess ambulatory-based care, that sort of common care. And it is going to be a very nice companion to the one where we were ranked number one, which is still focused more on acute care. And so I'm excited because I think that the more meaningful measurement that health systems have, the more transparent that is to patients, the more we can engage in actually making things better, which is what we're in the business for.

Interviewer: Are there any other ones that are worth looking at?

Dr. Pendleton: I think one that has gotten a lot of popular press is Medicare. So Medicare has taken data and worked through a whole set of meaningful metrics and come up with their own five-star rating. And currently, I think that for patients, that's another helpful one to look at. But the limitations with that one are sometimes it will compare apples and oranges. So, as an example, a large tertiary care academic medical center, like University of Utah, will get put in the same bucket and has a center in New York who only does hip replacement surgery. And those are two very different missions in how they deliver care. And so, aside from those caveats, it's another one that I think is fairly meaningful.

Interviewer: So, at the end of it all, are these different rankings, you do find that some of them do have value and would have value to a patient?

Dr. Pendleton: Absolutely. I think that as health care embraces how we think about and measure the care that we deliver continues to evolve and get better, these rankings similarly continue to evolve and get more and more meaningful.

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Tom: Reducing re-admissions, reducing infections and doing the right thing at all times during your hospitalization. This is Tom Miller on The Scope Radio.

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Tom: I'm here with Dr. Bob Pendleton and he is a Professor of Medicine in the Department of Medicine here at the University of Utah. Bob is the Chief Quality Officer for the university. Tell us how you keep patients safe.

Dr. Pendleton: Saying that I keep patients safe is true when I'm at the bedside but in my role as Chief Quality Officer, it's not so much me keeping patients safe. It's really supporting employees and physicians who are at the bedside and having the knowledge, skills and awareness to actually be successful.

Tom: You've had some great projects in the last couple of years that you've assisted doctors, nurses and support personnel in improving care. One of those was in reducing infection rates in the hospital. Could you talk a little about how that was done?

Dr. Pendleton: Infections are just one part of keeping patients safe when they come into the hospital. It's an important area because current estimates are that up to 440,000 patients a year in the United States may actually come into a hospital and die due to unsafe care.

Tom: This is not an infection that they came in with. This is they came in for something else and acquired an infection in the hospital.

Dr. Pendleton: Exactly right. Of those 440,000 infections are a very important and preventable area. So us, like other health care systems, have been really working diligently on standardizing care and improving practices to keep patients safer.

Tom: Now your area I think was to focus on reducing a couple of types of infections in the Intensive Care Unit setting. Is that correct?

Dr. Pendleton: Yes, Intensive Care Units are areas where patients are the most vulnerable. They're very sick. They also have lots of sort of supportive interventions to keep them safe and get them through their acute illness. These include catheters that can go into the veins or the blood vessels as well as the urinary tract. These things help doctors provide the care that's necessary but they also...

Tom: Increase the risk for infection, right?

Dr. Pendleton: Exactly right. The team really lead by our Infection Prevention Office, our hospital Epidemiologist Dr. Jeanmarie Mayer, as well as the clinical teams have really embraced this challenge to reduce those infection rates. They've taken best practices from around the country, developed very detailed protocols and process that then are executed at the bedside. Through their efforts we've really had a remarkable reduction in these infection rates so our patients are a lot safer for that.

Tom: Is that because each time that they perform a particular procedure in putting in a catheter, they do the same thing every time?

Dr. Pendleton: Exactly right but rather than having people rely on their memory or their best practices it's really hardwiring things, very much like the airline industry does with pilots and co-pilots, being very, very standard about what they do every time so that the outcome is always good. This is really the same construct.

Tom: That's interesting because a lot of times one physician will have a very different way of treating a particular problem compared to another. In the past we have said, "Well there may be several concepts about treatments of illness." But what you're saying is with certain things it's best if we develop protocols and pathways and follow those very strictly if we're going to keep our infection rates at a minimum.

Dr. Pendleton: Absolutely. We have to think back, health care a hundred years ago we didn't know very much. We didn't have very many treatments. We didn't know how to keep patients alive and so the development of the health care industry was really one of a craftsman approach where you have individual doctors doing the best that they can but without a lot of evidence about what the right thing to do is. Well, 50 years, 100 years later we have lots of evidence about what the right thing to do is. So that's very...

Tom: In a way we don't need six different approaches.

Dr. Pendleton: Exactly right. You move away from that craftsman approach to those things where we do know the right thing. The challenge now becomes doing the right thing 100% of the time.

Tom: One of the other areas that we have worked on is to reduce re-admissions. Obviously this is of great interest to patients who are being sent home, because they want to know their procedure, their operation or their health care time they leave the hospital is solid and they won't need to be coming back for a complication. How have you sort of worked through that with other doctors, nurses and staff to help prevent re-admissions? How does that work?

Dr. Pendleton: One in five patients who are sent home nationally will wind up coming back into the hospital unexpectedly for treatment of complications and other things within 30 days. So this is a really big problem. It's something as patients, we expect that when we leave the hospital we're well.

Tom: We're done. We're well.

Dr. Pendleton: And on our path to recovery. So it's a complicated area. For us as an example, we have patients who get sent to us from 10% of the geographic land mass of the United States. We've got patients from Idaho, Wyoming, Nevada as well as locally. So again, it requires back to standardizing what we do and at the time of discharge really thinking about things in terms of having a checklist.
Do patients know their medications that they're supposed to take? Do they understand why they're taking them? Do they understand when they're supposed to take them? Do they understand the follow-up that's required? Then, have we communicated with the patient's primary care doctor or next provider out in the community so that we have what we call a good and effective hand off. Sounds simple but...

Tom: It's complicated.

Dr. Pendleton: It's very complicated. So it really requires commitment, understanding and consistency really by all health care providers from the physicians, the nurses, the pharmacist to the care the patients receive out in the community.

Tom: I think that's a great point. It's interesting because I think the Center for Medicare and Medicaid Services has also taken up the position that if patients are coming back into the hospital, they're actually going to be paying less for those services.

Dr. Pendleton: That's absolutely true. That's a controversial area.

Tom: It reminds me a little bit about if the mechanic works on your car and it's not fixed then you have to take it back in. The health care industry has not sort of brought into that concept yet, but I think with the government being involved there's more of this need for perfect care.

Dr. Pendleton: Yes, it's absolutely an opportunity for the health care system to think about care in a different way and really being creative about how we give patients the tools and the support that they need when they leave the hospital. That's in the future. I predict that's going to look like use of mobile technology, like our smartphones, with how we open up channels of communication to answer questions when patients leave and other things like that.
But like I said, it's not a simple preposition to really help patients who have dealt with a very severe illness kind of get back to their best state of health.

Tom: Some physicians have embraced the electronic medical record in the revolution around digital technology and others haven't. But I see it as a way to promote what you're talking about in terms of enhancing communication and collaboration not only with the patient's physician but the patient as well. Do you see that as being a big plus at this point or do you think it's difficult?

Dr. Pendleton: Difficult but has what I call potential. I think we're early in this journey. As health care moves from really working in silos to really being coordinated enough to deliver the care that we all want and expect as patients. We don't think about hospital versus clinic versus I go to my local pharmacy and others. We view all of that as sort of how we get health care as a whole.

Tom: Continuum for most people if you think about it.

Dr. Pendleton: Yes, and the electronic medical record starts to give key building blocks that help the health care coordinate better, together to deliver that end for our patients.

Tom: I like the craftsman analogy that you brought up earlier because it is the way we sort of were getting health care in the past and still is to a large extent. We go to physicians and then the physician would then send us to the pharmacy or he would send us to the physical therapist and each was a separate entity. A lot of times there wasn't a great amount of communication between the different parties except for an order to perform some type of procedure. Going forward, a lot more information will be available I think to the different sources. I think that's a good thing.

Dr. Pendleton: That's an absolutely good thing but it also requires new skills, right?

Tom: In time.

Dr. Pendleton: So as the airline industry moved from small prop planes to jumbo jets, there were new skills acquired to fly those jumbo jets successfully and in health care is no different. As we really look to the future, there are new skills that health care providers and health care systems have to have to help be successful in this new world:

Tom: Bob you mentioned checklist in standard work. Can you talk about that a little bit? Now that kind of goes to the point that I started off the radio broadcast with, getting it right every time.

Dr. Pendleton: When you don't know what the right thing to do is then you sort of do what you think. But as we've gotten more and more knowledge through studies and others to know what the right thing to do is, the challenge then becomes how do you execute that. One of the simple ways that health care has gone about trying to do that is developing checklists and really standard work processes that health care has really not invented. It's taken from other industries, like the nuclear industry where the stakes are high, like the airline industry where the stakes are high.
In health care though, it's about integrating this checklist and standard work but really in an inclusive and open culture. As an example, there was a study in Canada showing that checklists are fine but unless you have the culture to use them every time...

Tom: They fall apart.

Dr. Pendleton: They fall apart.

Tom: Culture eats everything else for lunch if you don't have it aligned with your purposes.

Dr. Pendleton: Absolutely. So really it is an inclusive team oriented culture with the use of these standard processes like checklists that when done together, clearly have dramatically improved the safety of patient care across the country.

Tom: It is a very different culture than the one that has existed in the past in health care.

Dr. Pendleton: Absolutely.

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