Interview With Suzanne Delbanco, PhD, Executive Director of The Leapfrog Group

The goal of The Leapfrog Group is to make healthcare safer. Composed of more than 150 public and private organizations that provide healthcare benefits, The Leapfrog Group works with medical experts throughout the United States to identify problems and propose solutions to reduce medical errors. Leapfrog is aimed at mobilizing employer purchasing power to alert the healthcare industry that big leaps in patient safety and value will be recognized and rewarded. Leapfrog was founded by the Business Roundtable (BRT) and is supported by the BRT, the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality, Leapfrog members, and others. In this interview with the Journal of Nursing Care Quality, Suzanne Delbanco, PhD, Leapfrog's first executive director, talks about how system changes can improve patient safety and the initiatives of Leapfrog.

The Leapfrog Group has proposed specific best practices that healthcare systems can adopt to reduce healthcare errors (computer physician order entry, evidence-based hospital referral, and ICU physician staffing). Tell us about The Leapfrog Group's progress in helping healthcare systems adopt these practices. Do you find that health systems are beginning to use them now that Leapfrog is getting the message out to the healthcare industry?

Delbanco: It is always hard to pinpoint the single source of change, and I think there are multiple sources leading to changes to improve patient safety. Since Leapfrog's launch 3 years ago, we have seen significant growth in the proportion of hospitals using computer physician order entry systems and staffing intensive care units with intensivists. For example, when we launched Leapfrog, it was estimated that about 2% to 3% of hospitals had computerized physician order entry systems. What we are finding now based on responses to our national, voluntary online hospital survey is that about 5% of responding hospitals have fully implemented computerized physician order entry systems. But what is even more remarkable is that another 17% say that they plan to have systems fully in place by 2005. This is an important finding because we have known for a decade that this technology works to reduce medical errors.

What do you think are barriers to implementation of Leapfrog's initiatives? Is cost the main barrier?

Delbanco: I think it's hard to pinpoint a single barrier because you will hear different challenges depending on the hospital or healthcare system. I certainly think that cost is one of the major and most common challenges that hospitals face. But, there are also challenges when it comes to changing physicians' workflow and asking physicians who have been handwriting prescriptions for years to now use the computer for entering their orders. We need to think about work in a very different way.

Are you maintaining a database of best practices for patient safety?

Delbanco: No. Since Leapfrog is a coalition of employers, our expertise is not in advising hospitals how to deliver care down to the last detail. Our recommendations are based on input from our expert advisors and of course on research that links the recommendations to better outcomes for patients. When it comes to working directly with individual hospitals or documenting how individual hospitals implemented best practices for patient safety, we leave that to some of the other organizations that have strengths in those areas, such as the Institute for Healthcare Improvement.

Are you working with JCAHO (Joint Commission on Accreditation of Healthcare Organizations)?

Delbanco: Yes, we work with JCAHO in a variety of ways. Since JCAHO is one of our formal partners, when it comes to updating our recommendations each year, they provide input to us. In addition, specifically in the area of intensive care, we are working with JCAHO to develop the first national risk adjustment methodology and reporting program for ICU outcomes. The reason why this is important is that we are advocating and recommending to hospitals that patient care in ICUs be managed by intensivists. We know that there is a shortage of intensivists, and we also know that there may be other factors that could improve the care of patients in ICUs. Having a national program where hospitals can report their outcomes not only will provide the information that patients want to know (ie, how many patients survived their stay in the ICU and survived it without experiencing any complications), but it also will enable us to look backward and identify what is different about the ICUs with better outcomes. We may find that it is not only having an intensivist that makes a difference but that there are other measures that ICUs can take to improve patient care.

There are studies that have shown the effectiveness of master's prepared nurse practitioners in improving patient outcomes. Are you considering the benefits of having acute care nurse practitioners in intensive care units?

Delbanco: Not at this point. But again, having the ability to compare outcomes across different ICUs and then examining the factors that may have contributed to those different outcomes will open up a lot of opportunity to consider other aspects of care delivery. I am often asked about physicians who only see patients in the hospital but have not gone through the fellowship training to become an intensivist. However, they are in the ICU on a regular basis to oversee their patients. It may be that maintaining this constant presence is what leads to better outcomes. If so, this can be applied to other practitioners who have a lot of experience in the ICU and who maintain a constant presence looking over their patients.

Has Leapfrog "leaped over" nursing? How have nurses become involved in Leapfrog initiatives?

Delbanco: Leapfrog started with a narrow focus. We only have 3 recommendations out of a much, much larger universe of practices that hospitals could and should be incorporating to improve patient care, including the ability of nurses to deliver good care. When we first got started, a lot of discussion occurred about whether or not there was something that we should recommend specifically about nursing care. At the time we felt that the research was not clear enough about what our recommendation should be. It was clear not only from common sense but also from the developing research base that patient-nurse ratios were important. But we did not know the ratio to recommend nor in what situations that ratio would apply. In the future as we expand our recommendations, we are going to the National Quality Forum as a source for nationally endorsed standards, and we know that they are doing a project right now on nursing care.

So you will be working through the National Quality Forum?

Delbanco: Correct. When we got started, the National Quality Forum (NQF) was not yet in full operation, so we came up with our own recommendations. Now that the NQF exists and we are members of it, as are many, many health organizations across the country, we would rather recommend nationally endorsed, consensus-based standards than develop our own. We are turning to the NQF as our primary source of recommendations.

Many agencies are suggesting patient participation in promoting safe care such as the national "Speak Up" initiative. What is your viewpoint on patients participating in their own safety while hospitalized?

Delbanco: Leapfrog's view is that consumers have a very important role to play in not only making smarter choices for themselves when it comes to healthcare but also in helping to reshape what's offered in the healthcare system by expressing their preferences and demanding change. Whether it is participation in healthcare by making smarter choices about where to seek care or by playing a more active role in their own care, we certainly think that patients are an important piece of what is going to drive improvement.

Do you think that hospitals and other healthcare agencies have been effective in getting more active patient participation?

Delbanco: This is not something that we have been tracking so far. I have heard of some innovative programs, though, where patients are asked if they want to participate in their own care. For example, when patients come into the hospital, they are empowered, or their friend or family member is empowered, to question what physicians are doing, ask about their medications, and ask about reasons for procedures and screenings. In these programs the staff is trained to expect patients to say, "Excuse me, is that the right drug?" Or, "Is that the right dose?" "Did you wash your hands?" In these programs the dynamic is not a defensive one but instead is a collaborative one. When I hear about programs like this, I am encouraged about some of the creative ideas that people are exploring to improve patient participation.

One of our editorial board members asked this particular question: Is there a long-term goal of directing purchasers of healthcare toward hospitals with your initiatives in place or a better patient safety record?

Delbanco: Absolutely. A part of what Leapfrog is about is trying to create what I will call "reinforcement" in the healthcare market for providers that stand out for their safety and quality of care. We believe that one of the ways you can do that is by emphasizing doing business with hospitals that, for example, have implemented the practices we recommend for patients' safety. Another way is by educating our companies' employees about the importance of those practices when they are selecting a hospital for care. We certainly think that as purchasers one of the most important levers that we can use to drive change is by reshaping how we do business when it comes to actually purchasing and choosing healthcare.

What other safety agenda items, such as bar coding, are you looking at?

Delbanco: As I said before, we are now working with the NQF. The first area of expansion in terms of our recommendations is to incorporate the other 27 practices for safer healthcare that have been endorsed by the NQF as part of a bigger report that also includes our 3 recommendations. A list of 30 patient safety practices was endorsed by the NQF last spring. Leapfrog has focused on 3 of them, but there are 27 others that we have not yet brought to our initiative. We are currently in the process of receiving comments on our proposed method/weighting system.

For my last question, what else should I have asked about?

Delbanco: We have talked about quite a number of issues. The only other information that I think would be of interest to your readers is that we have hospital-specific information available free-of-charge on our Web site. Your readers may be interested in looking at which hospitals in their area have implemented the practices that we are promoting or the stage they are at in their implementation.

The Web site is http://www.leapfroggroup.org/consumer_intro1.htm.

For more information about The Leapfrog Group, visit http://www.leapfroggroup.org.