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PubMed2004

Practicing surgeons lead in quality care, safety, and cost control.

OBJECTIVE: To report the experiences of 66 surgical specialists from 15 different hospitals who performed 43 CPT-based procedures more than 16,000 times. SUMMARY BACKGROUND DATA: Surgeons are under increasing pressure to demonstrate patient safety data as quantitated by objective and subjective outcomes that meet or exceed the standards of benchmark institutions or databases. METHODS: Data from 66 surgical specialists on 43 CPT-based procedures were accessioned over a 4-year period. The hospitals vary from a small 30-bed hospital to large teaching hospitals. All reported deaths and complications were verified from hospital and office records and compared with benchmarks. RESULTS: Over a 4-year inclusive period (1999-2002), 16,028 elective operations were accessioned. There was a total 1.4% complication rate and 0.05% death rate. A system has been developed for tracking outcomes. A wide range of improvements have been identified. These include the following: 1) improved classification of indications for systemic prophylactic antibiotic use and reduction in the variety of drugs used, 2) shortened length of stay for standard procedures in different surgical specialties, 3) adherence to strict indicators for selected operative procedures, 4) less use of costly diagnostic procedures, 5) decreased use of expensive home health services, 6) decreased use of very expensive drugs, 7) identification of the unnecessary expense of disposable laparoscopic devices, 8) development of a method to compare a one-surgeon hospital with his peers, and 9) development of unique protocols for interaction of anesthesia and surgery. The system also provides a very good basis for confirmation of patient safety and improvement therein. CONCLUSIONS: Since 1998, Quality Surgical Solutions, PLLC, has developed simple physician-authored protocols for delivering high-quality and cost-effective surgery that measure up to benchmark institutions. We have discovered wide areas for improvements in surgery by adherence to simple protocols, minimizing death and complications and clarifying cost issues.

Adult↗
PubMed2004

Judging trauma center quality: does it depend on the choice of outcomes?

BACKGROUND: Trauma centers routinely benchmark their survival outcomes against a national norm using the TRISS methodology. However, the use of survival as a measure of the effectiveness of trauma care may be too limited in scope because it fails to capture information regarding functional outcomes. METHODS: The objective of this study was to develop a prediction model that allows hospitals to benchmark their functional outcomes in blunt trauma patients, and to determine whether the assessment of hospital "quality" depends on the choice of outcome measure: survival or survival combined with functional outcome. This retrospective cohort study was based on patients, aged 18 years or older, in the National Trauma Database who sustained blunt trauma in 1999 without associated head or spinal cord injury. We developed a sequential logistic model to predict the probability of a good functional outcome. The TRISS methodology was customized to this data set to obtain a survival model. Using each of these prediction models, we then obtained two standardized measures of hospital performance: one based on the number of survivors and the other based on the number of survivors with good functional outcomes. These standardized outcome measures were then used to identify low-performance and high-performance hospitals. The ranking based on these two different measures were compared. RESULTS: Fifteen of the 27 hospitals in the study cohort were categorized differently when their performance was benchmarked using survival versus functional outcome. Kappa analysis revealed minimal agreement between these two quality measures on the identity of hospital quality outliers (kappa = 0.04; p = 0.35). CONCLUSION: The evaluation of hospital quality depends on whether hospital performance is judged by looking at survival or at survival combined with functional outcome. Because functional status is an important outcome of major concern to survivors, it is important to include it in hospital performance assessment. Consideration should be given to including functional outcome in the evaluation of trauma center performance.

Benchmarking↗
PubMed2004

Listening to the occupants: a Web-based indoor environmental quality survey.

UNLABELLED: Building occupants are a rich source of information about indoor environmental quality and its effect on comfort and productivity. The Center for the Built Environment has developed a Web-based survey and accompanying online reporting tools to quickly and inexpensively gather, process and present this information. The core questions assess occupant satisfaction with the following IEQ areas: office layout, office furnishings, thermal comfort, indoor air quality, lighting, acoustics, and building cleanliness and maintenance. The survey can be used to assess the performance of a building, identify areas needing improvement, and provide useful feedback to designers and operators about specific aspects of building design features and operating strategies. The survey has been extensively tested and refined and has been conducted in more than 70 buildings, creating a rapidly growing database of standardized survey data that is used for benchmarking. We present three case studies that demonstrate different applications of the survey: a pre/post analysis of occupants moving to a new building, a survey used in conjunction with physical measurements to determine how environmental factors affect occupants' perceived comfort and productivity levels, and a benchmarking example of using the survey to establish how new buildings are meeting a client's design objectives. PRACTICAL IMPLICATIONS: In addition to its use in benchmarking a building's performance against other buildings, the CBE survey can be used as a diagnostic tool to identify specific problems and their sources. Whenever a respondent indicates dissatisfaction with an aspect of building performance, a branching page follows with more detailed questions about the nature of the problem. This systematically collected information provides a good resource for solving indoor environmental problems in the building. By repeating the survey after a problem has been corrected it is also possible to assess the effectiveness of the solution.

Air Pollution, Indoor↗
PubMed2003

What is public health legal preparedness?

Legal preparedness has gained recognition as a critical component of comprehensive public health preparedness for public health emergencies triggered by infectious disease outbreaks, natural disasters, chemical and radiologic disasters, terrorism and other causes. Public health practitioners and their colleagues in other disciplines can prepare for and respond to such an event effectively only if law is used along with other tools. The same is true for more conventional health threats. At first glance, public health legal preparedness may appear to be only a matter of having the right laws on the books. On closer examination, however, it is as complex as the field of public health practice itself. Public health legal preparedness has at least four core elements: laws (statutes, ordinances, regulations, and implementing measures); the competencies of those who make, implement, and interpret the laws; information critical to those multidisciplinary practitioners; and coordination across sectors and jurisdictions. The process of improving public health legal preparedness has begun in earnest with respect to potentially massive public health emergencies. Elected officials, public health, legal, and law enforcement practitioners, and national security organizations have contributed to initial benchmarks for the core elements. A few gaps in legal preparedness have been identified in the context of exercises, actual public health emergencies, and through more general assessments of public health preparedness conducted by CDC and the Department of Justice. While a strong beginning has been made, this work is incomplete. Redoubled effort is needed to define practical, measurable benchmarks or standards of legal preparedness, to identify and correct shortcomings, and to review findings from regular exercises and actual public health emergencies. There is great value in having this work move forward on two converging tracks, one defined by states and localities acting on their own initiative and the other shaped by the federal government as informed by state and local experience. The TOPOFF and Dark Winter exercises exemplify the grounded, case-based approach that teaches practical lessons about benchmarks, gaps, and steps to improve public health's legal preparedness. It goes without saying that action on both tracks should be taken by collaboratives whose membership includes representatives of the many different communities integral to the design and application of laws that affect the health of the public and the effectiveness of the public health system itself. Consistent with the concept of a public health or population health system with which we began this paper, participants in both tracks should include representatives of non-governmental bodies--community-based organizations, non-profit organizations active in disaster preparedness and response, and others. This paper presents a conceptual and analytic framework those groups may apply, one that is sufficiently broad to serve as an integrating schema across sectors and jurisdictions but also sufficiently flexible to accommodate the unique features of the many community and state public health systems which, together with federal partners, comprise the U.S. public health system, in sum, a framework responsive to the exigencies of our times, faithful to the guiding principles of American federalism, and conductive to a new standard of health protection for all our citizens.

Benchmarking↗
PubMedDate not supplied

Achieving excellence in veterans healthcare--a balanced scorecard approach.

This article provides healthcare administrators and managers with a framework and model for developing a balanced scorecard and demonstrates the remarkable success of this process, which brings focus to leadership decisions about the allocation of resources. This scorecard was developed as a top management tool designed to structure multiple priorities of a large, complex, integrated healthcare system and to establish benchmarks to measure success in achieving targets for performance in identified areas. Significant benefits and positive results were derived from the implementation of the balanced scorecard, based upon benchmarks considered to be critical success factors. The network's chief executive officer and top leadership team set and articulated the network's primary operating principles: quality and efficiency in the provision of comprehensive healthcare and support services. Under the weighted benchmarks of the balanced scorecard, the facilities in the network were mandated to adhere to one non-negotiable tenet: providing care that is second to none. The balanced scorecard approach to leadership continuously ensures that this is the primary goal and focal point for all activity within the network. To that end, systems are always in place to ensure that the network is fully successful on all performance measures relating to quality.

Benchmarking↗
PubMed1998

Analysis of health service areas: another piece of the psychiatric workforce puzzle.

Planning for development of a national or regional psychiatrist workforce that is the appropriate size must consider numerous issues. They include the dynamics of workforce distribution, effects of managed care, reduction in potential residency slots, participation of international medical graduates, apathy toward the field of psychiatry, service area variations, and increased interest in allied mental health professions, along with the burgeoning global burden of psychiatric illness. This paper examines the application of two benchmark standards for the number of psychiatrists needed per 100,000 population--the standard developed by the Graduate Medical Education National Advisory Committee and the Average Requirement Benchmark--to the supply of psychiatrists in Georgia in 1996 by county and by health service regions, which are geographical units based on health care utilization patterns of Medicare and Medicaid recipients. Areas with a surplus or deficit of psychiatrists are identified. The findings provide contextual evidence of a surplus of psychiatric physicians in the most populous areas of the state, given a substantial presence of health maintenance organizations. The state's less populated rural areas may potentially benefit from a redistribution of the psychiatrist workforce. The authors recommend continued refinement of models to estimate psychiatric workforce needs and suggest development of a comprehensive model that uses needs-based, demand-based, and benchmarking approaches.

Benchmarking↗
PubMed2000

Determination of a site-specific reference dose for methylmercury for fish-eating populations.

Environmental risk-management decisions in the U.S. involving potential exposures to methylmercury currently use a reference dose (RfD) developed by the U.S. Environmental Protection Agency (USEPA). This RfD is based on retrospective studies of an acute poisoning incident in Iraq in which grain contaminated with a methylmercury fungicide was inadvertently used in the baking of bread. The exposures, which were relatively high but lasted only a few months, were associated with neurological effects in both adults (primarily paresthesia) and infants (late walking, late talking, etc.). It is generally believed that the developing fetus represents a particularly sensitive subpopulation for the neurological effects of methylmercury. The USEPA derived an RfD of 0.1 microg/kg/day based on benchmark dose (BMD) modeling of the combined neurological endpoints reported for children exposed in utero. This RfD included an uncertainty factor of 10 to consider human pharmacokinetic variability and database limitations (lack of data on multigeneration effects or possible long-term sequelae of perinatal exposure). Alcoa signed an Administrative Order of Consent for the conduct of a remedial investigation/feasibility study (RI/FS) at their Point Comfort Operations and the adjacent Lavaca Bay in Texas to address the effects of historical discharges of mercury-containing wastewater. In cooperation with the Texas Natural Resource Conservation Commission and USEPA Region VI, Alcoa conducted a baseline risk assessment to assess potential risk to human health and the environment. As a part of this assessment. Alcoa pursued the development of a site-specific RfD for methylmercury to specifically address the potential human health effects associated with the ingestion of contaminated finfish and shellfish from Lavaca Bay. Application of the published USEPA RfD to this site is problematic; while the study underlying the RfD represented acute exposure to relatively high concentrations of methylmercury, the exposures of concern for the Point Comfort site are from the chronic consumption of relatively low concentrations of methylmercury in fish. Since the publication of the USEPA RfD, several analyses of chronic exposure to methylmercury in fish-eating populations have been reported. The purpose of the analysis reported here was to evaluate the possibility of deriving an RfD for methylmercury, specifically for the case of fish ingestion, on the basis of these new studies. In order to better support the risk-management decisions associated with developing a remediation approach for the site in question, the analysis was designed to provide information on the distribution of acceptable ingestion rates across a population, which could reasonably be expected to be consistent with the results of the epidemiological studies of other fish-eating populations. Based on a review of the available literature on the effects of methylmercury, a study conducted with a population in the Seychelles Islands was selected as the critical study for this analysis. The exposures to methylmercury in this population result from chronic, multigenerational ingestion of contaminated fish. This prospective study was carefully conducted and analyzed, included a large cohort of mother-infant pairs, and was relatively free of confounding factors. The results of this study are essentially negative, and a no-observed-adverse-effect level (NOAEL) derived from the estimated exposures has recently been used by the Agency for Toxic Substances and Disease Registry (ATSDR) as the basis for a chronic oral minimal risk level (MRL) for methylmercury. In spite of the fact that no statistically significant effects were observed in this study, the data as reported are suitable for dose-response analysis using the BMD method. Evaluation of the BMD method used in this analysis, as well as in the current USEPA RfD, has demonstrated that the resulting 95% lower bound on the 10% benchmark dose (BMDL) represents a conservative estimate of the traditional NOAEL, and that it is superior to the use of "average" or "grouped" exposure estimates when dose-response information is available, as is the case for the Seychelles study. A more recent study in the Faroe Islands, which did report statistically significant associations between methylmercury exposure and neurological effects, could not be used for dose-response modeling due to inadequate reporting of the data and confounding from co-exposure to polychlorinated biphenyls (PCBs). BMD modeling over the wide range of neurological endpoints reported in the Seychelles study yielded a lowest BMDL for methylmercury in maternal hair of 21 ppm. This BMDL was then converted to an expected distribution of daily ingestion rates across a population using Monte Carlo analysis with a physiologically based pharmacokinetic (PBPK) model to evaluate the impact of interindividual variability. The resulting distribution of ingestion rates at the BMDL had a geometric mean of 1.60 microg/kg/day with a geometric standard deviation of 1.33; the 1st, 5th, and 10th percentiles of the distribution were 0.86, 1.04, and 1.15 microg/kg/day. In place of the use of an uncertainty factor of 3 for pharmacokinetic variability, as is done in the current RfD, one of these lower percentiles of the daily ingestion rate distribution provides a scientifically based, conservative basis for taking into consideration the impact of pharmacokinetic variability across the population. On the other hand, it was felt that an uncertainty factor of 3 for database limitations should be used in the current analysis. Although there can be high confidence in the benchmark-estimated NOAEL of 21 ppm in the Seychelles study, some results in the New Zealand and Faroe Islands studies could be construed to suggest the possibility of effects at maternal hair concentrations below 10 ppm. In addition, while concerns regarding the possibility of chronic sequelae are not supported by the available data, neither can they be absolutely ruled out. The use of an uncertainty factor of 3 is equivalent to using a NOAEL of 7 ppm in maternal hair, which provides additional protection against the possibility that effects could occur at lower concentrations in some populations. Based on the analysis described above, the distribution of acceptable daily ingestion rates (RfDs) recommended to serve as the basis for site-specific risk-management decisions at Alcoa's Point Comfort Operations ranges from approximately 0.3 to 1.1 microg/kg/day, with a population median (50th percentile) of 0.5 microg/kg/day. By analogy with USEPA guidelines for the use of percentiles in applications of distributions in exposure assessments, the 10th percentile provides a reasonably conservative measure. On this basis, a site-specific RfD of 0.4 microg/kg/day is recommended.

Adult↗
PubMed2005

Mortality prediction using SAPS II: an update for French intensive care units.

INTRODUCTION: The standardized mortality ratio (SMR) is commonly used for benchmarking intensive care units (ICUs). Available mortality prediction models are outdated and must be adapted to current populations of interest. The objective of this study was to improve the Simplified Acute Physiology Score (SAPS) II for mortality prediction in ICUs, thereby improving SMR estimates. METHOD: A retrospective data base study was conducted in patients hospitalized in 106 French ICUs between 1 January 1998 and 31 December 1999. A total of 77,490 evaluable admissions were split into a training set and a validation set. Calibration and discrimination were determined for the original SAPS II, a customized SAPS II and an expanded SAPS II developed in the training set by adding six admission variables: age, sex, length of pre-ICU hospital stay, patient location before ICU, clinical category and whether drug overdose was present. The training set was used for internal validation and the validation set for external validation. RESULTS: With the original SAPS II calibration was poor, with marked underestimation of observed mortality, whereas discrimination was good (area under the receiver operating characteristic curve 0.858). Customization improved calibration but had poor uniformity of fit; discrimination was unchanged. The expanded SAPS II exhibited good calibration, good uniformity of fit and better discrimination (area under the receiver operating characteristic curve 0.879). The SMR in the validation set was 1.007 (confidence interval 0.985-1.028). Some ICUs had better and others worse performance with the expanded SAPS II than with the customized SAPS II. CONCLUSION: The original SAPS II model did not perform sufficiently well to be useful for benchmarking in France. Customization improved the statistical qualities of the model but gave poor uniformity of fit. Adding simple variables to create an expanded SAPS II model led to better calibration, discrimination and uniformity of fit, producing a tool suitable for benchmarking.

Adult↗
PubMed2005

Predictive mortality models are not like fine wine.

The authors of a recent paper have described an updated simplified acute physiology score (SAPS) II mortality model developed on patient data from 1998 to 1999. Hospital mortality models have a limited range of applicability. SAPS II, Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III, and mortality probability model (MPM)-II, which were developed in the early 1990s, have shown a decline in predictive accuracy as the models age. The deterioration in accuracy is manifested by a decline in the models' calibration. In particular, mortality tends to get over predicted when older models are applied to more contemporary data, which in turn leads to 'grade inflation' when benchmarking intensive care unit (ICU) performance. Although the authors claim that their updated SAPS II can be used for benchmarking ICU performance, it seems likely that this model might already be out of calibration for patient data collected in 2005 and beyond. Thus, the updated SAPS II model may be interesting for historical purposes, but it is doubtful that it can be an accurate tool for benchmarking data from contemporary populations.

Benchmarking↗
PubMed1997

When it comes to information systems, too often the blind lead the blind.

A new survey of health care systems' chief information officers (CIOs) indicates that most are not able to collect the cost information they need to make decisions. Some 60% admit that they cannot calculate whether their managed care contracts are profitable or not. While 70% of these organizations benchmark other health care organizations, only 8% go outside the industry. Leading health system CIOs and benchmarking experts say systems managers must benchmark outside the health care industry if they want current and competitive information technology.

Administrative Personnel↗
PubMed1997

Merging departments saves $400,000.

With hospital systems constantly pressured to cut costs, benchmarking can help managers make good decisions about where to focus attention. Once opportunities for improvement are identified, benchmarking provides data on how to improve. One children's hospital used benchmarking to bring a department's cost and efficiency in line with those of its peers.

Benchmarking↗
PubMed1999

Exceed your goals.

Benchmarking may not be the panacea it once seemed--especially the old model of buying data about competitors. Savvy managers have found new ways to set and beat their goals. Some are benchmarking against their own past performance, some are comparing with top performers instead of just local competition, and others are even looking outside the field for role models. "You need to identify best practices," urges one top benchmarking guru. "Look at the data clusters of those who do it significantly, whatever 'it' is."

Benchmarking↗
PubMed2000

Competition is no barrier to cooperation for children's hospital groups.

While many think the competitive nature of modern health care may prevent rival organizations from working together, two groups that specialize in children's hospitals have proven them wrong by joining forces to benchmark on bed control. The National Association of Children's Hospitals and Related Institutions, an association of 150 children's hospitals based in Alexandria, VA, has started a benchmarking project with Medical Management Planning, a Bainbridge Island, WA-based benchmarking and consulting company.

Bed Occupancy↗
PubMed2001

New study surveys data on operating room efficiency.

The folks doing knee and hip replacement surgery at Bryn Mawr (PA) Hospital must be doing something right: For the second year in a row, the 330-bed hospital has been named Best Performer for operating room effectiveness and efficiency by OR Benchmarks, a Santa Fe, NM-based benchmarking company. The hospital was one of a dozen studied that provided data to OR Benchmarks on 51 cases of total knee replacements. Thus far, the company has collected data on 880 cases over the past five years. Data collected ranged from cost of supplies to use of clinical pathways.

Arthroplasty, Replacement, Hip↗
PubMedDate not supplied

Prioritized list of health services in the Islamic Republic of Iran.

We aimed to provide a prioritized list of preventive, diagnostic and therapeutic procedures and their appropriate classification based on a cost-benefit analysis. Functional benchmarking was used to select a rationing model. Teams of qualified specialists working in community hospitals scored procedures from CPT according to their cost and benefit elements. The prioritized list of services model of Oregon, United States of America was selected as the functional benchmark. In contrast to its benchmark, our country's prioritized list of services is primarily designed to help the government in policy-making with the rationing of health care resources, especially for hospitals.

Attitude of Health Personnel↗
PubMedDate not supplied

Relative value units: from A to Z, Part 4.

The previous three articles in this series discussed relative value unit (RVU) basics and touched on some of the more practical applications of RVUs for managing a medical practice. 1-3 This fourth and final article illustrates the what, why, when, where and how of benchmarking RVUs. Benchmarking is often defined as a standard of measurement or evaluation, but in its truest sense, it is the ongoing process of establishing a standard of excellence and comparing activities to that standard. Health care has yet to establish true benchmarks, but it does have performance indicators for better-performing practices based on several criteria.

Benchmarking↗
PubMed2002

Cross-disciplinary competency standards for work-related assessments: communicating the requirements for effective professional practice.

The purpose of this article is to introduce the cross-disciplinary competency standards for work-related assessments, why they are needed and how they have been developed in New South Wales (NSW). Cross-disciplinary competency standards communicate the benchmarks for effective performance of work-related assessments. They outline what is expected of rehabilitation professionals, including the ability to apply and transfer competence across different conditions and workplace contexts. Outcomes in occupational rehabilitation are affected by the efficacy of the work-related assessments performed, which is dependent upon competent, clinical decision-making by rehabilitation professionals. However, in Australia, work-related assessment practice is not governed by universally accepted competency standards or by any competency-based training/education and assessment system. To enhance professional practice, WorkCover NSW has developed cross-disciplinary competency standards for work-related a ssessments. The competencies provide (i) quality standards for professional workplace training and development, (ii) benchmarks for assessing the competence of rehabilitation professionals, (iii) a framework for evidence-based practice, (iv) benchmarks for measuring service quality and (v) "real world" learning outcomes and assessment criteria for professional education programs.

Australia↗
PubMed2004

Introduction to the IWA task group on biofilm modeling.

An International Water Association (IWA) Task Group on Biofilm Modeling was created with the purpose of comparatively evaluating different biofilm modeling approaches. The task group developed three benchmark problems for this comparison, and used a diversity of modeling techniques that included analytical, pseudo-analytical, and numerical solutions to the biofilm problems. Models in one, two, and three dimensional domains were also compared. The first benchmark problem (BM1) described a monospecies biofilm growing in a completely mixed reactor environment and had the purpose of comparing the ability of the models to predict substrate fluxes and concentrations for a biofilm system of fixed total biomass and fixed biomass density. The second problem (BM2) represented a situation in which substrate mass transport by convection was influenced by the hydrodynamic conditions of the liquid in contact with the biofilm. The third problem (BM3) was designed to compare the ability of the models to simulate multispecies and multisubstrate biofilms. These three benchmark problems allowed identification of the specific advantages and disadvantages of each modeling approach. A detailed presentation of the comparative analyses for each problem is provided elsewhere in these proceedings.

Bacteria↗