Hospital Referral Guidelines

Preamble to the Hospital Referral Guidelines

The Michigan Health and Safety Coalition (MH&SC) suggests using the Michigan Health and Safety Coalition Hospital Referral Guidelines to help improve quality of care and patient safety in Michigan. The guidelines focus on eight areas of care including Intensive Care Unit physician staffing, care for low birthweight infants and infants with congenital anomalies in Neonatal Intensive Care Units, and the following procedures: abdominal aortic aneurysm repair, carotid endarterectomy surgery, esophagectomy for cancer, open heart procedures, and percutaneous coronary interventions. These areas of care were selected for guideline development based on evidence of a relationship between particular characteristics of a hospital and patient health outcomes and significant employer interest for useful quality indicators in these areas.

Six Expert Clinical Panels (ECPs) developed the guidelines using a rigorous, facilitated review process that included an assessment of currently available scientific evidence from published, peer-reviewed health services research and expert collaborative consensus opinion. These guidelines are based on the principles of continuous quality improvement and will evolve as new evidence is identified.

Within the guidelines, the ECPs included a recommendation that statewide, collaborative databases be developed and implemented so that 1) health care quality can be monitored for continuous improvement, 2) hospital performance can be comparatively measured and shared with consumers, purchasers, and payers and 3) clinicians can participate in a protected peer review process during which they can collaborate with practitioners throughout the state to improve care. These guidelines recommend that physicians and hospitals participate in a collective learning environment for quality improvement.

The Hospital Referral Guidelines are multi-faceted and include indices that, taken as a whole, represent what the Coalition believes is the best currently available method to measure health care quality. Indices contained within the guidelines include volume of services, structural and process characteristics of facilities where services are provided, and outcomes of care such as mortality and morbidity. Use of any single indicator to gauge overall quality of care in any hospital is potentially misleading to those who may use the information to help guide their health care decisions. When all aspects of the guideline are assessed, however, a more complete and accurate picture of care in hospitals emerges. The Coalition, thus, sees use of the guidelines as one of many important variables to be considered in making decisions about healthcare services.

The MH&SC does not intend the guidelines to be "standards" for care. Actual application of the guidelines within specific geographic areas and health care institutions should be carefully considered to understand downstream impacts on quality of care, cost of care, access to care, hospital resources, funding, and other potential unintended consequences. Actual use of the guidelines, however, is outside the scope of the MH&SC. Payers, purchasers, providers and consumers will ultimately determine their use independent of the Coalition.

The Coalition will continue to work on the guidelines and the related implementation strategy. The Coalition welcomes any ideas on the best approach to implementation. As next steps, the Coalition will conduct a baseline assessment to identify where Michigan hospital practices are today compared to the guidelines and will use the assessment information to help develop implementation approaches.