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August 2002
Volume 66 |
Number 8
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| Leapfrog Group
Report |
Peter J. Pronovost, M.D.
Christine G. Holzmueller, B.L.A.
I did not initially jump at the chance to join the Leapfrog Group's
campaign for mandatory intensivist staffing in intensive care
units (ICUs). It was not a matter of disinterest; in fact, I was
approached because of my April 1999 JAMA article associating ICU
staffing with patient outcomes.1 In
November 1999, Arnold Milstein, M.D., medical director of the
Leapfrog Group, called and asked me to serve as a medical advisor
for their proposed ICU Physician Staffing (IPS) Safety Standard.
I was reluctant and cautious at first because my study on this
subject was observational and had potential for bias.
Since I strongly believed in the intensivist model, I agreed
to visit a company member in the Leapfrog Group and talk about
the evidence supporting ICU staffing. When I stepped up to the
podium at General Motors headquarters, I found myself facing an
audience of CEOs and medical directors from 11 managed care companies
under contract with Leapfrog. I presented; then it was Leapfrog's
turn. The executive vice-president for General Motors was invited
to the front of the room. With his arm around the head of the
United Auto Workers, the vice-president stated, "When a death
occurs on their workshop floor, work stops for three weeks, is
investigated and things fixed. Yet, every day a General Motors
employee dies in this country from lack of intensivist staffing
in their ICUs, and that was unacceptable. They needed better."
This statement moved me, and I accepted Dr. Milstein's invitation.
Also echoing through my mind was Dr. Milstein's statement, "Everyone
was responsible, but no one was accountable for quality."2
I realized this circle-of-quality evasion among providers, insurers,
purchasers, regulators and even consumers had to be broken. I
sat down and wrote the physician staffing guidelines that Leapfrog
requested. Simply put, the IPS standard calls for the presence
of an intensivist in adult medical and surgical ICUs or within
a five-minute window by telephone or in person 24/7.
The Leapfrog Group is a consortium of 105 Fortune 500 companies
that provide health care benefits for about 40 million employees
in the United States. Included in this consortium are Verizon
Communications, General Electric, Ford, General Motors, the Buyers'
Healthcare Action Group and Pacific Business Group on Health.
Collectively, the Leapfrog Group has tremendous purchasing power,
and in some market areas, employees from the Leapfrog companies
occupy the majority of hospital beds. Leapfrog's mission is to
improve patient safety for its workers. Developing purchasing
guidelines for managed care organizations under contract for health
care is one method to reach this mission. The IPS standard is
one of three such guideline standards. ICU Physician Staffing
is one of three standards. The other two call for volume-based
purchasing for five surgical procedures and neonatal care and
computerized physician order entry. Leapfrog would like to see
these standards implemented across the nation.
Because many patients are at risk and because the effect of IPS
is large, the IPS standard has the greatest potential to impact
patient safety and quality care. More than 5 million patients
are admitted annually to ICUs in the United States. Ten percent
of these patients die during their hospitalizations, and nearly
all suffer preventable adverse events.3-5
Currently, only 10 percent of U.S. ICUs are staffed by intensivists.3
Daily rounds by an intensivist can produce a three-fold reduction
in risk-adjusted in-hospital mortality.1 If fully implemented
in nonrural U.S. hospitals, this standard could prevent 54,000
deaths and save $5.4 billion annually.1,6,7
In an effort to gain buy-in, Leapfrog developed a unique incentive
plan to reward employers who offer high-quality care and encourage
employees to use this care. Leapfrog also is helping hospitals
meet these safety standards by partnering with regulators, insurers
and providers in the United States. Seven regional roll-outs were
initiated last year in Georgia (Atlanta), California, Michigan,
Minnesota, Missouri (St. Louis), Tennessee (eastern region) and
Washington (Seattle). Leapfrog is already planning roll-outs in
12 new regions.
Leapfrog initially surveyed hospitals in the six targeted regions
to find out how many met the IPS standard. Ten percent stated
that they met the ICU standard and another 18 percent stated they
planned to meet the standard by 2004.
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"Leapfrog's mission is to
improve patient safety for its workers. Developing
purchasing guidelines for managed care organizations
under contract for health care is one method to
reach this mission."
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What we need to find out now is what has been done over the past
year to implement the IPS standard in these six regions. We want
to find out what efforts have been put in place, what are perceived
factors that facilitate or hinder these efforts and what leaders
and ICU physicians perceive to be the clinical and economic impact
of this standard. The plan is to interview leaders from hospitals,
insurance companies and employers in each regional roll-out to
obtain this information. From there, we will evaluate the effect
of IPS on patients' clinical and economic outcomes. Potential
funding for this study will come from the Commonwealth Fund in
New York, and award decisions should be announced by the time
this article is printed.
Empire Blue Cross/Blue Shield also has taken the "Leap"
to save lives. In a New York Times article dated October 18, 2001,
IBM, PepsiCo, Inc., Verizon Communications and Xerox announced
plans to join Empire in a $2 million incentive program in the
state of New York. This program will give bonuses to hospitals
that hire critical care physicians in ICUs and to companies that
cover intensivist care for employees. Empire estimates that employers
can save 4.5 percent of their health care costs by implementing
the standards. Hospitals may have to spend money to implement
the standard. Moreover, depending on how hospitals are paid, much
of the savings from IPS will be passed on to insurers. Efforts
by Empire will help to overcome financial barriers. This is an
exciting development because it truly aligns the incentives of
the purchasers and the insurers to do what is right for quality.
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) also has agreed to adopt Leapfrog's three standards. JCAHO
recently created and asked me to chair an advisory panel to develop
standard measures of ICU quality. I believe the JCAHO advisory
panel will create empiric measures of ICU quality that can supplant
the Leapfrog measures. These ICU measures are expected to be available
in 18 months and will be part of the core set of hospital measurements.
Quality means improvement, and the Leapfrog Group holds true
to its mission. Earlier this year, a national advisory panel was
assembled to consider refinements to the safety standards. I am
chairing the group that will revise the ICU Physician Staffing
Standard. Some issues being considered are: including pediatric
ICUs; excluding ICUs that care exclusively for cardiac surgery
patients; adding a grandfather clause that considers experienced
ICU providers as intensivists; and reducing required hours for
weekend coverage.
While some can argue that the Leapfrog Group could have selected
other leaps, I believe the ICU focus is important because the
opportunity to improve is great. Given that most ICU patients
in the United States are not cared for by intensivists, a major
shift by hospitals toward intensivist staffing would provide a
significant opportunity to improve the quality of care for ICU
patients while reducing costs. Efforts by the Leapfrog Group are
leading to dramatic changes in health care, changes that other
improvement efforts have yet to realize. Nonetheless, the effect
of these efforts on clinical and economic outcomes has yet to
be determined.
References:
1. Pronovost PJ, Jenckes MW, Dorman T, et al.
Organizational characteristics of intensive care units related
to outcomes of abdominal aortic surgery. JAMA. 1999; 281:1310-1317.
2. Milstein A, Galvin RS, Delbanco SF, Salber
P, Buck CR Jr. Improving the safety of health care: The Leapfrog
initiative. Eff Clin Pract. 2000; 3(6):313-316.
3. Angus DC, Kelly MA, Schmitz RJ, White A, Popovich
J. Committee on Manpower for Pulmonary and Critical Care Societies
(COMPACCS). Caring for the Critically Ill Patient. Current and
projected workforce requirements for care of the critically ill
and patients with pulmonary disease: Can we meet the requirements
of an aging population? JAMA. 2000; (284)2762-2770.
4. Andrews LB, Stocking C, Krizek T, et al. An
alternative strategy for studying adverse events in medical care.
Lancet. 1997; 349:309-313.
5. Lipsett PA, Swoboda SM, Dickerson J, et al.
Survival and functional outcome after prolonged intensive care
unit stay. Ann Surg. 2000; 231(2):262-268.
6. Birkmeyer JD, Birkmeyer CM, Wennberg DE, Young
M. Leapfrog patient safety standards: The potential benefits of
universal adoption. The Leapfrog Group, Washington, DC; 2000.
7. Pronovost PJ, Waters H, Dorman T. The economic
impact of the Leapfrog Group intensive care unit physician staffing
standard. In: Economic Implications of the Leapfrog Safety Standards.
Birkmeyer JD, Birkmeyer CM, Skinner JS, eds. The Leapfrog Group,
Washington, DC; 2001.
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Peter
J. Pronovost, M.D., is Associate Professor of Anesthesiology
and Critical Care Medicine, Johns Hopkins University, Baltimore,
Maryland. |
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Christine
G. Holzmueller, B.L.A., is Research/Administrative Coordinator
and Writer, Johns Hopkins University, Baltimore, Maryland. |
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