Hospital quality in the United States is surprisingly inconsistent. New efforts to facilitate the sharing of information on clinical and administrative procedures show promise in making them better-and safer.
We've all heard the horror stories: A man goes into the hospital to have a leg amputated and wakes up in the recovery room with the wrong limb removed; a woman being treated for breast cancer is given a five-fold dose of a chemotherapy drug and suffers fatal heart damage; a child is sent home from the emergency room diagnosed with a virus only to return in an ambulance several hours later with a burst appendix.
"The cracks in the system can be very large," says Andrea Kabcenell, a senior research associate in the Department of Policy Analysis and Management and director of Cornell's Program for Improving the Quality of Hospital Care. "They look even bigger from the patient's point of view."
The quality of hospital care in the United States varies tremendously. And in some hospitals it's getting worse. Kabcenell says that part of the problem is managed care. "Patient care decisions are being driven more than ever by economic forces, and although the goal is to reduce costs without affecting quality of care, that's not always what happens."
But perhaps one of the most unnerving reasons for the disparity in hospital quality - and one that few health care consumers are aware of - is the lack of communication between hospitals. Driven by the fear of losing customers, hospitals have traditionally operated in virtual isolation, jealously guarding information and data from one another to remain as competitive as possible.
"Even sister hospitals within the same system haven't shared information very well," says Kabcenell. "They're just not used to talking to each other."
This secretive nature has resulted in wide variations in efficiency in different aspects of patient care. One hospital might have a low incidence of postoperative infection among its surgical patients while another hospital just a few blocks away has a dismal record. At the same time, the first hospital might have a long history of medication errors while the second hospital rarely has a problem in that area. They clearly have much to learn from one another, but without the proper mechanisms in place, such communication rarely, if ever, occurs.
This finally is beginning to change. Hospitals are waking up to the fact that cooperation and communication are critical to improving quality. Their efforts range from formal business arrangements designed to increase access to human and financial resources to simple information exchanges where hospital representatives compare notes on how different clinical procedures are handled.
The value of these new levels of cooperation is evident in the results of a recently completed demonstration project directed by Kabcenell and funded by the Robert Wood Johnson Foundation. The seven-year project involving four hospital consortia around the country was begun in 1989 and completed last January. It showed that when the lines of communication are opened between hospitals, care does indeed get better.
The four consortia included the Institute for Quality Healthcare, a 43-hospital group based at the University of Iowa; Interwest Quality of Care, Inc., of Salt lake City, which is composed of 12 rural hospitals in Utah and surrounding states; the Public Hospital Institute, a 14-hospital consortium based in Berkeley, California; and the 16-member Vermont Program for Quality Health Care. The Iowa and Utah groups were formed specifically to participate in the program. The California and Vermont groups existed prior to the program.
As a model for cooperation between hospitals, Kabcenell and other health care professionals involved in the demonstration project used a system operating in the Netherlands.
"Hospitals in the Netherlands have been doing this for years," she points out. …