Tagged Patient Safety

Influential Leapfrog Group Jumps In To Rate 5,600 Surgery Centers

The influential Leapfrog Group, which grades nearly 2,000 U.S. hospitals, is launching a national survey to evaluate the safety and quality of up to 5,600 surgery centers that perform millions of outpatient procedures every year.

The group now issues hospitals an overall letter grade and evaluates how hospitals handle myriad problems, from infections to collapsed lungs to dangerous blood clots — helping patients decide where to seek care.

The new surgery center effort will focus on staffing, surgical outcomes and patient experience in facilities that are performing increasingly complex procedures and seeing more aging patients. The grades will also cover surgery centers’ closest competitor, hospital outpatient departments.

Leah Binder, Leapfrog Group’s chief executive, said she wants to fill gaps in information about same-day surgery, which employers and health plans have embraced for its lower costs.

Employers, she said, “don’t have enough information on quality and safety of that care.”

Binder said a recent Kaiser Health News/USA Today Network investigation highlighted the need for independent information about surgery centers. The investigation found that since 2013, more than 260 patients died after care at centers that lacked appropriate lifesaving equipment, operated on very fragile patients or sent people home before they fully recovered.

“Your reporting did highlight the real lack of information from the federal government and the need for us to have an independent means of reporting,” Binder said. “People are going in for surgery, and our federal government doesn’t think it’s important to tell us how it’s going. Maybe that was OK 30 years ago, but now it’s not OK.”

The news report was based on inspection reports, lawsuits and data from many states that tally patient deaths but which refuse to note where they occurred. Seventeen other states collect no data on deaths at all.

The new Leapfrog plan will start with a survey of 250 centers in 2019 and include up to 5,600 surgery centers in 2020. At that point, it will publish data on the outcomes of specific procedures, like total knee replacements, across the hospital outpatient departments and surgery centers nationwide.

The Leapfrog Group is funded by employers and health plans that cover the health care of the half of Americans who get health benefits through their job, Binder said. The organization was founded to shed light on health care quality and safety to help consumers pick high-value providers. It plans to disseminate the new surveys through its 40 business group members that steer millions in health spending.

Bill Prentice, chief executive of the Ambulatory Surgery Center Association, an industry trade group, said he supports the move toward greater transparency. However, he said the work to determine the specific measures is still underway, and “the devil is in the details.”

Ty Tippets, administrator of St. George Surgical Center in Utah, said he welcomes what Leapfrog is doing.

“Anytime [data] is gathered and provided in a transparent, easily accessed forum — it helps empower patients,” said Tippets, who recently testified before Congress about transparency in health care.

The Leapfrog Group announcement comes as Medicare is reviewing the data it will collect to gauge the quality of surgery centers.

The agency previously asked each surgery center to report its emergency transfer rate, or how often a patient 65 or older was sent from a center to the hospital. Yet the agency only required the centers to send data for half or more of its Medicare patients.

In the current rule-making period, Medicare declared the resulting data of little value, given the minimal differences among centers’ scores. The agency proposed dropping the measure, but has not yet finalized the proposal.

Going forward, Medicare has said it will use its own billing data to report the percent of surgery center patients who seek care at a hospital in the week after a procedure.

Medicare recently announced plans to shine more light on the performance of accreditors, which play a key role in granting or denying health facilities approvals to operate. A recent KHN investigation into accreditor performance in California — the only state where the private bodies’ inspection reports are public — showed repeated lapses in oversight.

A Medicare spokesman said new reports will show how well accreditors fare when state health officials inspect the same facilities.  In recent years, Medicare has found that accreditors overlooked the majority of problems that government officials uncovered.

In September, the White House Office of Management and Budget approved another health agency’s proposal to collect and report data about the “culture of safety” in surgery centers. The Agency for Healthcare Research and Quality will ask surgery center staff about issues such as whether staff feel comfortable speaking up about patient care concerns.

The plan says summary data — not facility-by-facility data — on the survey’s results will be reported publicly.

That effort would add to the overall information the public has about surgery centers, said Dr. Ashish Jha, a patient safety expert at Harvard’s School of Public Health.

“Places that do badly on safety culture surveys tend to have worse outcomes,” Jha said. “But you can’t bank on it.”

He said the most useful data for the public would cover actual events — such as deaths after surgery, admissions to the hospital or functional status and pain three months after surgery.

“Those are the things that actually matter,” he said.


KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Must Reads Of The Week From Brianna Labuskes

Just in case our ever-decreasing anonymity in this tech-driven world hasn’t scared you enough, new studies find that within a few years 90 percent — 90 percent! — of Americans of European descent will be identifiable from their DNA. If you fall into that group, it doesn’t even matter whether you’ve given a DNA sample to one of the popular gene-testing sites (like 23andMe). Enough of your distant relatives have, so there’s a good chance you’re in the system.

Take your mind off that by checking out what you may have missed in health care this week.

The biggie, of course, was President Donald Trump’s opinion piece in USA Today about “Medicare-for-all.” (And the rebuttal from Vermont Sen. Bernie Sanders.)

Fact checkers came out in droves to comb through Trump’s arguments and found that nearly every paragraph contained a misleading statement or falsehood.

The Washington Post: Fact-Checking President Trump’s USA Today Op-Ed on ‘Medicare-for-All’

More than shedding any kind of light on the complicated topic, the back-and-forth highlights how much of a role health care is playing in the upcoming midterm elections. Each side has doubled down on its respective talking points (read: preexisting conditions and Medicare-for-all — I warned you you’d get tired of me saying that). In fact, health care is featured so heavily in ads that it trumps the topics of jobs or taxes.

The Wall Street Journal: Health Care Crowds Out Jobs, Taxes in Midterm Ads

(Side note: If you do want some light shed on Medicare-for-all and single-payer systems, check out these great pieces from KHN’s own Shefali Luthra.)

Speaking of midterms, the Democrats’ attempt to block the administration’s expansion of short-term plans (very predictably) failed, with only Maine Republican Sen. Susan Collins joining the Democrats. It was never about winning, though. What it did was force Republicans to go on record with a vote that is potentially politically dangerous in the current landscape.

Politico: Senate Democrats Fail to Block Trump’s Short-Term Health Plans

In stark contrast to the sharply partisan discourse, Trump signed two bipartisan health care measures into law this week. The bills banned “gag clauses” on pharmacists, which had prohibited them from offering consumers cheaper options. The legislation won’t directly affect drug prices, but it might mean people will pay less at the register.

The New York Times: Trump Signs New Laws Aimed at Drug Costs and Battles Democrats on Medicare


For the first time, premiums for the most popular level of insurance sold in the health law marketplaces have gone down. The numbers are the latest sign that the marketplace is stabilizing. (Centene’s expansion into new states is another from this week.) CMS Administrator Seema Verma touted the success, saying the news counters any accusations of sabotage. Health experts, however, said those price tags would have been even lower if not for the administration’s actions over the past year.

The Washington Post: Premiums for Popular ACA Health Insurance Dip for the First Time


The Justice Department approved CVS’ $69 billion merger with Aetna, and although the deal still needs approval from state regulators, the green light is a major hurdle cleared. The merger would reshape the health landscape and mark the end of an era for free-standing pharmacy benefit managers. The potential consolidation is just one of many in recent years in a fast-evolving industry — a trend critics worry will lessen competition and drive up prices for consumers.

The New York Times: CVS Health and Aetna $69 Billion Merger Is Approved With Conditions


Hospitals scrambled to ensure patient safety as Hurricane Michael battered Florida and Georgia this week. “It was like hell,” said one doctor who rode out the storm at Bay Medical Center in Panama City, Fla. The hurricane brought with it memories of last year’s power outages that came with Hurricane Irma and were linked to the deaths of several nursing home residents.

The New York Times: Hospitals Pummeled by Hurricane Michael Scramble to Evacuate Patients


Now that the Brett Kavanaugh battle is over and he’s taken a seat on the Supreme Court, Planned Parenthood has gone into planning mode in case anything happens to Roe v. Wade. A key component of the organization’s plan is to shore up networks in states where abortion would likely remain legal (with longer hours for clinics, for example). On the other side, abortion-rights opponents are getting primed for a new high court that’s likely friendlier to them by strategizing what cases would be best to move forward with.

NPR: With Kavanaugh Confirmed, Both Sides of Abortion Debate Gear Up for Battle

How do you fight measures to expand abortion rights in progressive states? Make it about money. A battle in Oregon illustrates a strategy that — although unlikely to be successful — gives opponents of the bills at least a hope of winning.

Politico: Oregon’s Unlikely Abortion Fight Hinges on Taxes


Holes in the court system have allowed state judges to grant full custody of migrant children to American families — without notifying their parents. Federal officials say it should never happen, but oversight of the problem is scattershot and challenging because states handle adoption proceedings differently.

The Associated Press: Deported Parents May Lose Kids to Adoption

Democrats have been vocal about what they don’t like when it comes to immigration policy. But they have a problem: a lack of cohesion within the party about the correct way forward.

The New York Times: The Democrats Have an Immigration Problem


In the miscellaneous, must-read file:

• A gripping piece takes you into the bowels of a Philadelphia neighborhood dubbed the “Walmart of heroin.” “Drug tourists” come from all over to buy the cheap, pure heroin flowing through the veins of the streets, and some never make it out. (Warning: Make sure you have some time before you start, it will suck you in completely.)

The New York Times: Trapped by the ‘Walmart of Heroin’

• Why were nursing home residents getting extremely pricey therapy in the last weeks of their lives? Bloomberg takes a closer look at these cash-strapped facilities and the questionable decisions made about patients’ rehab.

Bloomberg: Nursing Homes Are Pushing the Dying Into Pricey Rehab

• In good news from the segment of people who were too old to take advantage of the HPV vaccine, the Food and Drug Administration just approved its use for those up to age 45.

The Associated Press: FDA Expands Use of Cervical Cancer Vaccine up to Age 45


As an office of ardent dog lovers, we were distressed to hear the news that therapy dogs in hospitals are little germ machines, leaving behind happiness but also superbugs.

Have a great (hopefully superbug-free) weekend!

‘Grossly Unfair’? Widower Takes Ban On Military Injury Claims To Supreme Court

Walter Daniel, a former Coast Guard officer, filed a wrongful death lawsuit after his wife died following childbirth at a military hospital in 2015, but it was dismissed based on a 68-year-old federal ruling. After two failed appeals, he petitioned the U.S. Supreme Court to allow active-duty service members to seek legal damages for medical malpractice harm the same way civilians can.(Heidi de Marco/KHN)

More than four years after Navy Lt. Rebekah Daniel bled to death within hours of childbirth at a Washington state military hospital, her husband still doesn’t know exactly how — or why — it happened.

Walter Daniel, a former Coast Guard officer, demanded explanations from officials at the Naval Hospital Bremerton, where his wife, known as “Moani,” died on March 9, 2014.

He says he got none. No results from a formal review of the incident, no details about how the low-risk pregnancy of a healthy 33-year-old woman — a labor and delivery nurse herself — ended in tragedy, leaving their newborn daughter, Victoria, now 4, without a mom.

“There was no timeline, no records of what steps were taken,” recalled Daniel, 39, sitting in his Seattle lawyer’s high-rise office last month. “I’ve had no answers.”

Daniel, who now lives in Dublin, Calif., filed a wrongful death lawsuit in 2015, but it was dismissed, as were subsequent appeals.

The dismissals were based not on the facts of the case but on what’s known as the Feres doctrine, a 68-year-old federal ruling that bars active-duty military members from suing the federal government for injuries.

This week, Daniel is taking his quest for answers to the U.S. Supreme Court.

Through his lawyer, he petitioned the high court on Thursday to amend the 1950 ruling, creating an exception that would allow service members to sue for medical malpractice the same way civilians can.

The military health system, with 54 hospitals and 377 medical clinics, serves about 9.4 million beneficiaries, including nearly 1.4 million active-duty members.

“I don’t want this to happen to any other family,” Daniel said.

The Supreme Court hasn’t considered the Feres doctrine in more than 30 years, since the 1987 case U.S. v. Johnson, where the justices ruled 5-4 to uphold the ruling. That decision drew a scathing dissent from Justice Antonin Scalia, who declared the rule should be scrapped.

Feres [v. United States] was wrongly decided and heartily deserves the widespread, almost universal criticism it has received,” Scalia famously wrote.

Since then, however, the court has refused to accept at least two petitions that would have allowed reconsideration of Feres. And chances are slim now. Of the 7,000 to 8,000 cases submitted to the Supreme Court each term, only about 80 are accepted.

But Daniel and his lawyer, Andrew Hoyal of the Luvera law firm in Seattle, insist that the circumstances of Moani Daniel’s death warrant new scrutiny.

“We thought if we’re ever going to take a shot at the Feres doctrine, this is the case to do it,” Hoyal said. “It was clear negligence. It was an awful situation. And every civilian in the country would be able to bring a lawsuit to get accountability, except for members of the service.

“She was treated differently because she had lieutenant’s bars.”

Walter Daniel, a former Coast Guard officer, holds a photograph of his wife, Navy Lt. Rebekah Daniel, known as “Moani.” She died hours after giving birth to their daughter, Victoria, at the Naval Hospital Bremerton. Daniel says he received no details about how the low-risk pregnancy of his healthy 33-year-old wife, a labor and delivery nurse, ended in tragedy.(Heidi de Marco/KHN)

 

Walter Daniel plays with daughter Victoria near their apartment in Dublin, Calif., on Sept. 27, 2018.(Heidi de Marco/KHN)

A photo of Walter and Moani Daniel sits in the living room of the Daniels’ apartment. More than four years after Moani bled to death following childbirth at a Washington state military hospital, Daniel still doesn’t know exactly how or why it happened. (Heidi de Marco/KHN)

Daniel disputes the findings of a Navy autopsy that concluded Rebekah Daniel died of “natural” causes possibly linked to an amniotic fluid embolism, a rare, hard-to-prove complication of childbirth.

Daniel claims that his wife — who worked in the maternity unit where she delivered her baby — died from botched medical care that failed to stop her from hemorrhaging nearly a third of the blood in her body.

“It was utter chaos,” he recalled. “I remember multiple towels and sponges like they were trying to soak up the blood … but it kept coming.”

Doctors failed to perform vital tests, to employ an obstetrical balloon — a standard device used to halt postpartum hemorrhage — and to start massive blood transfusions until too late, court documents claim.

Just four hours after the birth of her 8-pound, 7-ounce daughter, Moani Daniel was dead.

“I was in shock,” recalled Walter Daniel.

Capt. Jeffrey Bitterman, commanding officer of Naval Hospital Bremerton, said in an email that the circumstances of Moani Daniel’s death were “thoroughly examined in a quality review process.” The results of the review cannot be publicly released, he said, declining further comment because of pending litigation.

However, in a press release promoting the “Aloha Moani” 5K run organized in Daniel’s honor, Navy officials publicly said she died “due to a rare complication of childbirth.”

Walter and Moani Daniel, who met in Hawaii, had been married nearly a decade when she became pregnant in 2013. Moani Daniel had a son, Damien, now 19, from a previous marriage.

Moani Daniel loved her job, but she had submitted her resignation to the Navy months earlier and was set to leave the service in April 2014. Walter Daniel had accepted a job in Northern California, where he had moved with Damien to get him settled in school.

The day after his wife’s death, Walter Daniel returned to her empty apartment.

“She had all this stuff for the baby set up,” he recalled. “I’m like, ‘What the hell just happened?’ It was like a nightmare.’”



The Feres doctrine holds that active-duty members of the military cannot sue under the Federal Tort Claims Act for harm “incident to service.” The justices wanted to ensure that Congress would not be “burdened with private bills on behalf of military and naval personnel.”

They reasoned then that the military provides comprehensive relief for injuries or death of service members and their families — and that there’s no parallel with private liability because the relationship between the government and its armed forces is distinct. Later, the court insisted that a primary reason for barring such lawsuits is to maintain military discipline.

But the decision, particularly the definition of “incident to service,” has been debated fiercely for years by scholars and, at least twice, in bills before Congress.

The rule, however, has been interpreted to include not just military duty, but virtually any activity of an active-duty service member, said Richard Custin, a clinical professor of business law and ethics at the University of San Diego.

“It’s just grossly unfair,” he said. “Childbirth is not a military activity. It’s clearly not ‘incident to service.’”

Custin and other critics claim the Feres doctrine strips military members of a constitutional right to seek redress for grievances, while also allowing military hospitals and doctors to escape scrutiny for negligent care.

Military hospitals reported 545 so-called sentinel events — medical omissions or errors — from 2014 to 2017, according to Defense Health Agency data. In 2014, Naval Hospital Bremerton reported at least one case of postpartum hemorrhage or hysterectomy.

But such reports aren’t public, so Daniel doesn’t know whether his wife’s case was included in those records. A 2014 review of military health care found the rate of postpartum hemorrhage was consistently higher in military hospitals than the national average, Hoyal noted.

“What they do in the medical arena is no different than what civilian hospitals do and they should be held to the same standards as civilian hospitals and civilian doctors,” Hoyal said.

Officials with the Department of Defense declined interview requests regarding the Feres ruling.

In an email, however, an agency spokeswoman said that overturning the rule would “destroy the premise” of no-fault workers’ compensation available in the military and elsewhere. It would also “create an unsustainable inequity” between military members allowed to sue and others, such as those injured in combat, who couldn’t.

And, rather than improving military health care, overturning Feres would “compromise its effectiveness,” the agency said, noting: “No medical system is perfect.”

Custin, the law professor, said he sympathizes with Daniel, but isn’t optimistic that the court will view the case differently than other medical malpractice claims.

“What this attorney needs to do is somehow distinguish Daniel from the long line of victims that have been maligned by Feres,” he said.

Walter Daniel has been raising daughter Victoria as a single dad for four years. After the death of his wife, Moani, he left the Coast Guard and returned to college to study to become a high school teacher.(Heidi de Marco/KHN)

Hoyal intends to argue that the Supreme Court’s rulings regarding Feres have been inconsistent and irreconcilable. In decisions that followed Feres, the court rejected its own “parallel liability” argument, said Hoyal. And it has never ruled that medical decisions like those at stake in Daniel’s case would undermine military discipline.

“In short, the legal landscape has undergone a sea change since 1950,” Hoyal’s petition states. “Theories once central to Feres no longer matter. Rationales not considered in Feres are now central.”

Such an argument may well sway an increasingly conservative Supreme Court that now includes justices loyal to Scalia’s views — as well as progressives inclined to support workers’ rights, said Dwight Stirling, chief executive of the Center for Law and Military Policy, a Southern California think tank.

“The Feres doctrine does not divide the court members on your standard ideological grounds,” he said. “It tends to scramble the typical calculus.”

Walter Daniel hopes so. After raising Victoria as a single dad for four years, he left the Coast Guard, recently remarried and returned to college to study to become a high school teacher. Even as his life moves on, he said, he hopes Moani Daniel’s case will provide justice for others.

“It’s not about the Daniel family, it’s about those thousands of service members throughout the world who are affected by this rule,” he said. “That’s what our fight is for.”


KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.