December 4, 2015
As you may be aware, this past fall Consumer Reports Magazine posted an article on their blog which included a list that ranked hospitals across the United States by their infection control rates. Charlotte Hungerford Hospital (CHH) received a low rating. Because we have always taken infection control so seriously, and pride ourselves on our overall patient safety accountability ratings over the years, we found this portrayal at first very perplexing and ultimately motivating.
At CHH, we constantly measure our infection rate using two of the most respected and knowledgeable Hospital Quality Rating Systems in the nation – The Joint Commission and the Federal Medicare Quality Reporting System. Our most recent Joint Commission score is 97.8% on a scale of 100%, which is based on more than 50 measures and 10,000 data points including measures based on patient safety. Our Medicare infection report (available at www.medicare.gov/hospitalcompare) demonstrates that our infection rate is within range and “No Different than National Benchmark” for all of the applicable quality measures used by Consumer Reports.
We felt that in order to offer the magazine and our community an informed response, we needed to undertake an investigation to gain a full understanding of the process used to determine the ratings. We examined the data and methodology used by the magazine, as well as the ways that we record and communicate our patient care data. Most importantly, we conducted a top to bottom review of our policies, procedures, and daily infection prevention efforts.
We also pledged to be transparent and informative to our constituents and report our findings. Upon completing our analysis, we focused on four critical points, including: ZERO Infections is our Ultimate Goal, Accurate infection rate reporting is critical, ranking methodologies vary and have complexities and limitations, and the digital world is a powerful medium. Here’s what we found regarding these points.
Zero Infections is our Ultimate Goal
Regardless of what ranking methods that we or our patients choose to trust and utilize to make healthcare decisions, we know in the end it comes down to how effective we are each day at preventing infections. No hospital has zero infections – but we continue to strive for that goal in every possible way. Consequently, we conducted an inventory of all our infection control activities searching for improvements to our infrastructure, process, procedures and protocols, education, and equipment. Specifically,
- We have conducted a Mandatory Skill and Information Sessions to all clinical staff to review all infection control practices and collection of Infection Control related lab specimens.
- We are strengthening our collaborations with our local Skilled Nursing Facilities in order to improve Infection Control practices, since 14.7% of our admissions are coming from skilled nursing or congregate living.
- We are purchasing new Ultraviolet wave technology as an added measure for disinfecting patient rooms.
- We are introducing Polymerase Chain Reaction (PCR) testing for screening patients with MRSA so that appropriate isolation procedures can be undertaken at admission.
Accurate Infection Rate Reporting is critical
An issue that CHH encounters often when being compared to larger hospitals is our relatively small sample size. With such a small incidence of infections at CHH, just 1 or 2 cases could change our ratings, as in the case of our rating by Consumer Reports. In light of this, we reviewed the information that the Hospital reported to the Centers for Disease Control (CDC), which is the primary source data used by Consumer Reports.
This research yielded the following findings:
- A portion of the statistics we reported to the CDC used in the Consumer Reports ranking was inaccurate, in that we had over-reported two cases and under-reported our patient days which served as the denominator.
- One Surgical Site Infection-Colon was subsequently found to be not reportable after a clinical documentation review discovered that the wound was clean, dry and intact from the day of surgery until discharge.
- One reported case of C-Difficile was determined to be a keypunch error with the wrong date. The change in date would move this infection from Hospital-Acquired to Community Onset.
- Since guidelines for observation patients vary by state, they are counted as patient days differently. In our case, the addition of observation data would have recognized the impact of an additional 1,682 to the denominator.
We regret the data submission errors and have taken several steps to improve future reporting.
Ranking Methodologies have Complexities and Limitations
We had bio statistical experts in the field evaluate why CHH ranked low in the survey, given that CHH had nearly “zero” infections in three out of five categories examined by Consumer Reports. We found that the analysis is extremely volatile and that a very small drop or increase in the number of infections easily changes the Consumer Report rating. Further, our deviation from the standard infection rates was incredibly small, but, it existed across all five infections examined, resulting in our unfavorable rating.
Very importantly, this begs a question: How many hospitals had extremely high infection rates in all but one infection category, and in that one remaining performed better than the standard infection rate and as a result did not make Consumer Reports’ listing? The fact that this was not a focus of the reporting strains the value added by the Consumer Reports’ rating which aims to be helpful to consumers. In this context, CHH’s overall true performance and rating relative to others is masked by the rating system used, and these facts remain unknown to us despite several efforts to retrieve this data from Consumer Reports.
The Digital World is a Powerful Medium
The unfortunate headline of the original blog posting and the attention it slowly gained locally was troubling to us. We know that in today’s digital world, something as small as a mention in a blog makes its way to people very quickly thanks to social media. Our research showed that the original Consumer Reports story with the CHH ranking was shared among people 99% through Facebook. We have since strengthened our presence on various social media platforms to position ourselves better in the future to present our findings and facts.
The attention will no doubt continue. We have learned, for example, that Consumer Reports will be publishing a healthcare supplement detailing how their efforts have helped make hospitals better and that CHH will be mentioned for its efforts to improve infection control. Clearly, stories and blogs have a longer shelf life in the digital world than traditional media, and we must be prepared to ensure that our quality standards and evaluation methods are easily communicated and available to our patients so they have access to all the facts.
In conclusion, this has been a learning process, and has made us a stronger and more effective institution. We appreciate that Consumer Reports afforded CHH the opportunity to bring these issues and concerns to its editors and researchers in an open and frank dialogue, and hope that they as well will improve upon the ways in which they evaluate healthcare institutions.
But, we have something in common with Consumer Reports: a desire to improve health care and embrace transparency of our care with those we serve. To all the caregivers at CHH, upon whose shoulders we stand, thank you for your unwavering commitment and desire to remain rightfully focused on building our future and improving our quality consistent with our mission and strategic plan.
Charlotte Hungerford Hospital