Has AUPHA Failed?

By John Griffith, MBA, FACHE posted 01-31-2017 10:44




This paper, by a team at Boston Consulting was published recently in PLOS ONE:

Quantifying Geographic Variation in Health Care Outcomes in the United States before and after Risk-Adjustment, Barry L. Rosenberg, Joshua A. Kellar, Anna Labno, et al. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166762

It documents that our industry, healthcare delivery, is a chaotic mess. From the abstract:

We compared outcome variation at state, hospital referral region, hospital service area, county, and hospital levels. Risk-adjusted outcomes were calculated after adjusting for population factors, co-morbidities, and health system factors. Even after risk-adjustment, there exists large geographical variation in outcomes. The variation in healthcare outcomes exceeds the well publicized variation in US healthcare costs. On average, we observed a 2.1-fold difference in risk-adjusted mortality outcomes between top- and bottom-decile hospitals. For example, we observed a 2.3-fold difference for risk-adjusted acute myocardial infarction inpatient mortality. On average a 10.2-fold difference in risk-adjusted patient safety outcomes exists between top and bottom-decile hospitals, including an 18.3-fold difference for risk-adjusted Central Venous Catheter Bloodstream Infection rates. A 3.0-fold difference in prevention outcomes exists between top- and bottom-decile counties on average; including a 2.2-fold difference for risk-adjusted congestive heart failure admission rates.

 Such a state of disorder could not prevail in manufacturing, airlines, or food supplies. The paper is far from the first lament about the ineffectiveness of healthcare providers, but it’s the most rigorously quantified. The usual excuses (Our patients are sicker; we are not paid enough; we are short of nurses, etc.) won’t work.

 The results the BCG authors describe are more than an OFI. Another way to state them is, “More than half the hospitals in the U.S. do a lousy job, and most of them are downright dangerous.” The findings could be viewed as an indictment of our graduates, and by extension, AUPHA and CAHME. AUPHA has been around for 70 years. Its mission, “fosters excellence and innovation in health management and policy education, and scholarship.”  This is not “excellence.”

 The article has received little attention, although it was noted by the New York Times.1 That gives us a chance to re-establish our credentials and document our commitment. To do that, both AUPHA and CAHME must make clear that:

  1. There is documented, evidence-based best practice to run hospitals and related care organizations.
  2. We know what it is.
  3. We promulgate it strongly, continuously, and effectively.

CAHME’s move to competencies was a valuable start. Should we make it real, by showing that our students not only know best practice, they know how to apply it and make it work?

I think we can and we should. The documented best practice is the performance of winners of the Baldrige Quality Award in Healthcare, who routinely achieve top quartile, and often top decile, not only in mortality and safety, but also in patient satisfaction, worker satisfaction, and financial performance. Their methods are clearly described and systematically audited. They are not simple. They require fundamental changes in both the culture and the work practices of healthcare organizations, but once achieved they are stable and transportable. There is no comparable source. (I would welcome challenges to this paragraph. It’s essential that we get consensus and get it right. My documentation is in an article that has passed peer review and is pending publication in JHM. Advance copies available to AUPHA members only, email jrg@umich.edu.2)

If we treat this as a crisis and fix it, we have a chance. If we ignore it, we join the losers.

  1.  Abelson R. Hospital Choice May Be a Matter of Life or Death. New York Times. December 14, 2016:B4.
  2. Also in Kovner A, D’Aunno T. Evidence-Based Management in Healthcare- 2 Ed. Chicago, IL: Health Administration Press; 2016, pp. 47-63.






02-14-2017 10:01

Jim, thanks for your comments. We aren't the only guilty parties. But the problem remains, and our students must address it,  I haven't checked the numbers, but yes, if all our hospitals performed at Baldrige levels, we still wouldn't be world leaders. We would be better than our current ranking. And a lot of pain would have been avoided. A very large number of people would not have wound infections, CLABSI, CAUTI, wrong site surgery, falls, diabetic complications, dehydration, and unnecessary hospitalizations. I wouldn't wish those things on my worst enemy!  I signed up to keep them from happening; I hope my students all did the same. And the Baldrige model remains the only proven path to improvement.

02-11-2017 14:13

Thanks for the cite, a good resource for class. I see more upstream causes for the failures of the hospital system, embedded in an economic, political, and social context that rewards fragmentation, acute care, and volume and is disinterested in prevention. Getting all our hospitals to Baldrige quality is a worthwhile goal and may reduce variation, but won't do much for global rankings of our health outcomes.