“Sunshine Is the Best Disinfectant”

June 2017 Vol 10, No 4 - Editorial
David B. Nash, MD, MBA
Editor-in-Chief
American Health & Drug Benefits
Founding Dean
Jefferson College of Population Health
Philadelphia, PA
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Just last year, the Pennsylvania Health Care Cost Containment Council, known as PHC4, celebrated its 30th anniversary. This watershed event went largely unnoticed at the national level, because PHC4 is a relatively unheralded organization. Yet its impact, and its 3 decades of accomplishments, are increasingly apparent during this transition period in healthcare reform. In short, the public accountability for outcomes will continue to be central to the pending changes in the care delivery system. I had the privilege of addressing many past and current leaders of PHC4, along with members of the state legislature and other dignitaries, at a celebratory conference in Harrisburg, PA, to publicly recognize this important anniversary.

What follows is an abbreviated version of my celebratory comments, with a special emphasis on the role of public accountability on the quality and safety of the care that we deliver. For nearly 20 years, I have chaired the Technical Advisory Group (TAG) for PHC4. The TAG is comprised of statewide experts who perform an important function by giving advice to the staff and leadership at PHC4, and whose guidance has been central to the success of the agency in its mission to promote “sunshine as the best disinfectant.”

Drawing on the work of Steven D. Findlay in a 2016 article in Health Affairs, I mirrored the 3-decade timeline of public reporting that he created.1 The history of PHC4 aligns in an uncanny, positive way with the timeline created by Mr Findlay. Please let me explain.

PHC4 was created in 1986 by an Act of the Pennsylvania State Legislature. The year 1986 stands as the veritable beginning of the accountability movement. Barely a year later, Medicare, known then as the Health Care Financing Administration, released the first-ever hospital-specific mortality data. By 1991, the New York State Department of Health published the first-ever hospital-specific, surgeon-specific mortality report for coronary artery bypass graft (CABG) surgery. In August of that year, my former colleagues from the University of Pennsylvania and I published what has become a landmark article in the Journal of the American Medical Association (JAMA) that describes the differences in mortality from CABG surgery between 5 teaching hospitals in Philadelphia, PA.2

In 1991, the New England Journal of Medicine refused to publish our findings, because the editor thought that the public disclosure of mortality rates on an individual hospital level (although the hospitals were labeled A-E) was potentially libelous. George Lundberg, the courageous editor of JAMA at that time, thought differently and published our article, along with an article from O’Connor and colleagues at the Northern New England Cooperative Cardiovascular Disease Study Group at Dartmouth3—yes, a bit of almost ancient history reaching back to 1991 as the jumping-off point for the movement toward public accountability. By 1995, PHC4 joined New York State in publishing only the second publicly available CABG outcomes report. Yours truly was selected to be the local hospital spokesperson at a raucous press conference, wherein the hospitals simply were unprepared to deal with an unprecedented level of interest in the data by the lay press.

For an article in the Joint Commission Journal on Quality Improvement,4 my former colleague, the late Marvin Bentley, and I researched the impact of the public reporting of CABG outcomes, and the response of hospitals across Pennsylvania. Not surprising, our results showed that the hospitals paid close attention to the report, whereas the public and employers, as well as multiple insurance companies, paid slight-to-no attention at that time. We were among the first to argue that although report cards, regrettably, may not influence public opinion, hospitals surely were paying avid attention to them.

In 2006, PHC4 played a central role in a nationally evolving story. At a press conference at the venerable National Press Club in Washington, DC, PHC4 debuted the first-ever statewide hospital-acquired infection report. Mind you, no state had ever assembled the data regarding hospital-acquired infection, and in fact, that lexicon was not yet in regular use. In other words, most informed individuals had never heard of the term “hospital-acquired infection” or “hospital-acquired condition” back then. A November 2006 press conference resulted in a front-page breakthrough story in USA TODAY, which was, in turn, widely cited.5 I’m proud to say that we, in turn, published the results of the press conference and several key investigations in a special issue of the American Journal of Medical Quality in November 2006.6 Thus began the 15-year conversation on the role of hospital-acquired conditions and their deep connection to the quality and safety of care that we deliver at the bedside. Sunshine is indeed the best disinfectant.

From 2010 through late 2016, 3 teams of investigators have attempted to assess the true impact of public report cards and the role that these report cards may play in improving the quality and safety of care. Space prohibits a deep dive into these 3 articles, but teams led by well-known investigators such as Jon B. Christianson, PhD,7 Karen E. Joynt, MD, MPH,8 and Brent Sandmeyer, MPH,9 all reached generally the same conclusion, that the public reporting of outcomes certainly influences the work done at the individual hospital level by shining a bright light on areas that need improvement. Public reporting plays a modest role from a managed care perspective, as payers seek the most efficient and effective providers with whom to contract services; yet, disappointingly, the public still is not fully engaged in the reporting of outcomes.

What about future directions for PHC4? As I noted in my celebratory plenary talk, the movement from volume to value is inexorable. As a result, in my view, one must conclude that PHC4 will continue to play a central role in this transformation of the care delivery system. This transformation will also begin to focus on work in the ambulatory arena, because so much care is delivered outside of the hospital setting.

In addition, from a governance perspective, the role of the Board of Trustees must expand as the spectrum of care from primary care to hospice care is considered. As this purview expands, the need for credible and unbiased outcomes information that is publicly available will play a central role in the transformation process.

In the conclusion of my remarks, I noted that although PHC4 has played a central role in promoting public accountability for outcomes, the private sector has joined the fray, but only very recently. Here, I referred to work at organizations such as Northwell in Long Island, NY,10 which now releases patient satisfaction scores on an individual physician basis for all current and potential consumers to review. I’m confident that my millennial children will most likely turn to familiar sources of public accountability, such as Yelp11 and other review systems, to provide information about the patient experience of care.

So the question remains, does public accountability ultimately improve the quality and safety of the care we deliver? I’m confident that the answer is in the affirmative, and one only has to look at recent tragedies, such as the deaths of 9 children at a specialty hospital in Philadelphia, for proof.12 Had it not been for the “sunshine” that dogged reporters had shone on this problem, it never would have come to light. I hope to continue in public service through my chairmanship of the TAG for as long as they will have me. I’m proud of PHC4’s work, and I am happy and grateful to have played even a small role in its maturation and national impact.

Do you believe that public reporting of outcomes improves the quality and safety of the care that we deliver? As always, I am interested in your views, and you can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..

References
1. Findlay SD. Consumers’ interest in provider ratings grows, and improved report cards and other steps could accelerate their use. Health Aff (Millwood). 2016;35:688-696.
2. Williams SV, Nash DB, Goldfarb N. Differences in mortality from coronary artery bypass graft surgery at five teaching hospitals. JAMA. 1991;266:810-815.
3. O’Connor GT, Plume SK, Olmstead EM, et al; for the Northern New England Cardiovascular Disease Study Group. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. JAMA. 1991;266:803-809.
4. Bentley JM, Nash DB. How Pennsylvania hospitals have responded to publicly released reports on coronary artery bypass graft surgery. Jt Comm J Qual Improv. 1998;24:40-49.
5. Appleby J. Pa. reveals infection rates in hospitals. USA TODAY. November 14, 2006. https://usatoday30.usatoday.com/money/industries/health/2006-11-14-infections-usat_x.htm. Accessed January 9, 2017.
6. American College of Medical Quality. Hospital-acquired infection: meeting the challenge. Am J Med Qual. 2006;21(6 suppl):5S-34S.
7. Christianson JB, Volmar KM, Alexander J, Scanlon DP. A report card on provider report cards: current status of the health care transparency movement. J Gen Intern Med. 2010;25:1235-1241.
8. Joynt KE, Orav EJ, Zheng J, Jha AK. Public reporting of mortality rates for hospitalized Medicare patients and trends in mortality for reported conditions. Ann Intern Med. 2016;165:153-160.
9. Sandmeyer B, Fraser I. New evidence on what works in effective public reporting. Health Serv Res. 2016;51(suppl 2):1159-1166.
10. Ramey C. Long Island hospital posts doctor ratings: North Shore-LIJ is the first in New York area, and among the few in the U.S., to do so. Wall Street Journal. August 26, 2015. www.wsj.com/articles/long-island-hospital-posts-doc
tor-ratings-1440635377. Accessed January 9, 2017.
11. Ranard BL, Werner RM, Antanavicius T, et al. Yelp reviews of hospital care can supplement and inform traditional surveys of the patient experience of care. Health Aff (Millwood). 2016;35:697-705.
12. Avril T, Purcell D, Fazlollah M. State: Philly hospital failed to fully investigate children’s deaths. Philadelphia Inquirer. September 24, 2016. www.philly.com/philly/health/20160925_State__Phila__hospital_failed_to_fully_investigate_children_s_deaths.html. Accessed January 9, 2017.

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