Improving Clinical Quality Under Fire
On March 7, 2019, USA Today published an in-depth report on maternal morbidity and mortality with a focus on the Touro Infirmary in New Orleans. As I read the article and the response of Touro officials, it was a recapitulation of the problems with continuous quality improvement. First, a disclaimer. I have no information other than the news article and a more detailed response from the Touro officials published by the New Orleans Times-Picayune on March 9, 2019.
The article begins with the story of a young woman who died following childbirth. The family has filed a malpractice suit. While the death of a young woman is sad, lawsuits don’t establish data useful for quality improvement. The article reported 700 maternal deaths and some 50,000 complications annually identified in from a claims database, which is the sort of data useful for starting CQI. USA Today made comparisons with other programs and reported a state-wide median complication rate of 1.6%, compared to 2.8% for Touro Infirmary.
Touro officials responded to queries with the statement Touro Infirmary served a medically vulnerable population. “Lifestyle diseases, the high cost of healthcare, delaying or non-compliance with medical treatment, limited care coordination, poor health, high rates of poverty, and high rates of morbidity are all realities in our State and community.”
In the Times-Picayune posting, officials elaborated on this theme further, saying:
“In a statement, LCMC Health objected to the use of billing data to look at rates of complications, arguing that it did not provide a full picture of prior health conditions patients were coming in with. They also said the data was of limited usefulness in comparing ‘one hospital to another or against other populations because of the variable risk among populations…Dr. John Heaton, the chief medical officer and president of clinical and system operations for LCMC Health, noted that Touro Infirmary is an academic program that is also a regional referral center for high-risk obstetric patients, so their patient population has a ‘relatively higher incidence of maternal morbidity than a community OB program.’"
The Times-Picayune quoted the Louisiana Maternal Mortality Review Report, which studied the 47 maternal deaths in the state from 2011-2016 and deemed 21 were preventable. They concluded with the following quote from Touro officials about the USA Today report.
“The data cited in the story represent an independent media review of unpublished raw data, not a scientific analysis subject to critical peer review, evaluation and verification by knowledgeable experts,” LSU Health said in the statement. “Absent this rigorous and transparent process, which is standard practice in the scientific community, conclusions drawn from it are questionable at best.”
Anyone who has done quality improvement knows these statements are variations on two common themes: my patients are sicker and the data are wrong anyway. Now when the newspapers, or 60 Minutes, is knocking on the door, the lawyers are going to be involved and everyone is going to be defensive. But what really needs to happen once the spotlight goes off? What should any medical institution do when confronted with bad quality news?
The hardest thing to do is avoid the tendency to blame. It does not help to blame the patient, the physician, the staff, or the previous administration. If your patient population is “at-risk,” this is a fact you must deal with. You must build your systems to deal with the patients you have, not the ones you would like to have. You also must include all the patients in your data set. Excluding the “outliers” does not improve your situation, it just fools you into thinking you have.
The second, equally challenging, issue is admitting you really have a problem. All institutions do. But since medical organizations are staffed with people accustomed to excelling, we often fall into the Lake Woebegone effect, (where all the children are above average.) While tempting, the organization must resist grabbing onto the quick fix. If the problem were simple and easily addressed, someone would have already fixed it. Problems of this magnitude always reflect deeper problems—uncovering them and addressing them will be difficult and will take time. With the spotlight shining, trustees and the public want to see quick action, but that won’t fix the problem and may make it worse.
Third, recognize there are no perfect systems for risk-adjustment. Pick one you have confidence you can use consistently in your organization and then use it. Doctors often forget perfect is the enemy of the good. But we practice on what we know today, not what would like to know, but won’t know until later.
Fourth, recognize the goal is to get better, not necessarily to be perfect. It is probably true that Touro Infirmary patients have pre-existing conditions that increase the rate of maternal mortality. My suggestion for a goal is not zero mortality, but zero preventable mortality. If you want to go for the more aggressive goal recognize you are going to have to go beyond the walls of your institution.
Too many organizations don’t have a practical way to cooperate with other agencies addressing the same population, but with different agendas. In this case, the health department undoubtedly has programs designed to address obesity, hypertension, and diabetes in potentially pregnant women. And drug abuse treatment programs undoubtedly treat women of child-bearing years. Charitable organizations need to be in the mix, along with community activists, and probably the court system. Finding a way to get all these organizations to the table and developing a coordinated plan is a huge task, and not one that is likely to get quick results. But if the goal is to reduce maternal mortality rates toward zero, it is going to take more than medical care.
22 March 2019
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