The Most Commonsensical And Hopeless Reform Idea Ever

The way that Michael Long and Sandeep Green Vaswami want to change hospital care may well rank as both the most commonsensical and most hopeless health reform proposal ever. The real question is whether they can show the same tenacity in pursuing their goal as an elderly Jewish woman from Munster, Ind., who has invested nearly two decades in a similar effort.

What the two men are advocating is simple: hospitals should offer the same level of professional staffing and patient care on weekends as during the rest of the week. They should do this, the two men write in the Health Affairs blog, because trying to cram seven days of care into five leads to a cascade of problems that harm and even kill patients. It also costs a lot of money.

That’s the commonsense part. The hopeless part is that Long and Vaswami, both affiliated with the Institute for Healthcare Optimization, seem to believe that doctors, nurses and hospital execs will read their article and then spontaneously volunteer to work the weekend shift.

American hospitals are complex entities, but at heart they remain the doctor’s workshop, dependent upon the goodwill of physicians who admit and care for patients. Maintaining that goodwill requires treading carefully. For instance, telling a neurosurgeon, “You’re working Wednesday through Sunday this week” would rank high on the list of what a friend of mine calls a “career-limiting event.”

Long and Vaswami are aware they’re tampering with long-standing tradition, but as justification they offer a disturbing catalog of the effect of care controlled by the calendar.

To begin with, bunching scheduled admissions in midweek often overwhelms the staff, leading to “significant” increased risk of patient death or admission to the Intensive Care Unit. Filled beds force emergency rooms to discharge patients to “inappropriate care locations,” with the hospital relying on specialized teams to ride to the rescue “when patients deteriorate because of inadequate care.” At the same time, “medically appropriate transfers … may also be delayed or rejected.”

And that’s when hospitals are operating normally. Patients admitted over the weekend face an increased risk “because critical diagnostic or therapeutic modalities are not available,” while patients staying over the weekend experience “delays at best and deterioration in clinical condition at worst.”

Finally, peak-and-valley scheduling is inefficient, causing hospitals to build expensive new facilities instead of efficiently using existing capacity. With an aging population and new access to health insurance, that approach will cost “billions of dollars.”

For all their indignation, however, Long and Vaswami pull their punches on both causation and remediation. So, for instance, in a 1,000-word essay backed by citations from The New England Journal of Medicine and similar sources, they never once use the words “doctor” or “physician” when referring to those whose behavior needs to change. Indeed, Long, an anesthesiologist, and Vaswami, an MBA, seem to run away from the implications of their own words. Avoiding either practical recommendations or moral outrage, they conclude: “Health care professionals have no choice but to carefully consider [emphasis added] whether weekends off are more important to us than the quality and cost of care we provide to our patients.”

I’m surprised they didn’t just write, “Take a few days off to think about it.”

Of course, the two men understand they are opening a Pandora’s box. The kind of compromises hospitals make to keep the medical staff happy is not a topic anyone wants to openly discuss. Let’s look at a few examples.

In a just-released survey by the American Association of Critical Care Nurses nearly nine of 10 nurses said they’ve seen doctors make mistakes or take dangerous shortcuts. Yet only four in 10 nurses felt empowered to speak up. In a similar vein, 3 to 5 percent of hospital physicians are estimated to be outright disruptive, with a strong correlationbetween their misbehavior and problems ranging from nurse turnover to outright errors. Researchers bemoan the unwillingness of doctors to discipline colleagues or hospitals to risk alienating big admitters.

In that kind of environment, it takes a special person to question who the hospital is really set up to serve. Myra Rosenbloom, the elderly lady I mentioned earlier, is that kind of person.

Myra first called me back in 1993. Jack Rosenbloom, her husband of 45 years and her partner in a kosher catering business, had been admitted to a local hospital the previous September after suffering a heart attack. Jack was in stable condition when Myra visited him on Saturday evening but then started suffering chest pains. The hospital declared a code-blue emergency, but on a weekend night no doctor was available. Jack died that night in the ICU.

That’s when Myra discovered that in Indiana, as elsewhere, no law required a doctor to be on duty, only that one be available within a certain time. (Typically, that’s 15 to 30 minutes.)

Myra initiated a one-woman crusade to require hospitals over 100 beds to have a doctor other than the one in the emergency room on duty at all times. During Indiana’s 1994 legislative session, she slept for five cold nights on a hard wooden bench inside the Capitol before the legislature passed a watered-down bill requiring a doctor, but letting an ER doc count towards the requirement. An ER physician was on duty at the hospital where Jack died, but he’d been too busy with other patients to answer the code-blue call.

Facing tenacious opposition from hospital groups that said her idea would cause them economic hardship, Myra has since then failed to win approval of a tougher law in Indiana, failed to pass a law in Illinois and failed to win even a hearing on similar federal legislation called the Physician Availability Act. It was first introduced in Congress in 1976, was reintroduced for a few years, vanished and then resurfaced in 2009 with the backing of Rep. Jan Schakowsky, a Democrat from suburban Chicago. At the time, Myra was 85 years old.

I called Myra the other day, and she said Schakowsky wants her to find some Republican co-sponsors so Schakowsky can reintroduce the bill. “I won’t give up till the day I die,” Myra told me with the same spirit as when we first spoke 18 years ago.

Perhaps if the nascent specialty called “nocturnists” had existed back in the early 1990s, there would have been someone to save Jack Rosenbloom that Saturday night. But the larger point made by Long and Vaswami remains. The distortions caused by giving provider convenience a greater priority than clinical necessity is exacting a fearful and avoidable toll of deaths, injuries and expense that far outweighs the cost of addressing the problem.

If Long, Vaswami and colleagues are serious about how hospitals operate, they would do well to act seriously. They could start by showing even a smattering of Myra Rosenbloom’s persistence and courage.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.

This post first appeared on Kaiser Health News.

13 replies »

  1. Many of our hospitals are not running at capacity, do we really think that adding full services over the weekend will help our economic situation? I realize the argument is about clinical improvement (or increased safety), but the adage, “No Money, No Mission” comes to mind. I agree with Determined MD on this one. As a pharmacy director for a region of hospitals, we staff the pharmacy to match patient volumes, and we do have significant staff on the weekends if volumes remain high.

  2. Even though larger hospitals are generally staffed equally over the weekends, anyone who had the misfortune to be checked in a Friday night knows that not all tests can be done on a weekend. More unusual or specific tests requiring certain staff members my not be available until Monday or Tuesday. So an overnight observation, turns in to a 3 day stay.

  3. Like bees to honey. Perhaps the Doc and Administrator purposely remained vague to prevent being perceived as arrogant. As highlighted; creating an environment where teamwork across disciplines is welcomed is very difficult. One hopes that results based interventions create the urgency needed to change how healthcare professionals – clinical and non – communicate.

  4. I would have to agree in most hospitals, staffing is scaled down some on the weekends. But overall, larger hospitals still provide diagnostic services on the weekends. Nurses, as a whole, work 24 hours a day/ 7 days a week. Physicians are scheduled to be on-call or someone else is on-call and responsible for their patients. Regardless, a physician sees the patient on the weekend. And in between, nurses know how to reach a physician by phone if the patient’s condition changes. There are hospitalist who are in and out of the hospital 24 hrs a day.

    I realize as a nation we still have patients who fall through the cracks but I believe every step we take towards improving how and when we deliver health care will positively impact our patients care and outcomes. Providing health care to such a large, diverse population is not an exact science. Every patient responds differently to care. Whereas one patient may respond exactly as planned to treatment and medications; the next patient may have serious detrimental responses to the exact same treatment and care.

  5. I thought about that and I could imagine that something like this could be pushed through w/o extra funding (e.g. in EMTALA manner). One could make the argument that docs are high earners and that it is part of their availability requirements. On the other hand, there will be a physician shortage, and many docs would just opt out of hospital care (or opt out of medicine) … and moreover, I am not sure how big the problem to be solved really is. In the large academic community hospital where I work, many services are offered throughout the weekend, and for the rest, the techs or teams can be called in (and that works). There is little reason to do joint replacements or routine gallbladders during weekends and take away family days from MDs, RNs, techs and support staff.

  6. I agree. Can’t imagine that hospital administrators haven’t considered this option.
    Maybe Paul Levy, if he is reading this, could speak to it better…..

  7. I think 7 days a week would be great, but who has the money to pay for it? Where will they get the budget? It’s time and a half for overtime, and double time for weekends. These academics need to think.

  8. Working WITH a doctor does not make one a peer equivalent.

    I spend time when my plumber comes to the house and ask for pearls and tips, but would NEVER start dictating how he does his job.

    And yet, that is how a lot of writers here come across. And yes, the intrusions into health care’s current status is threatening. Threatening to ruin it to a point where people will not know who to trust, who to go to for real assistance. And my dumbass colleagues who just stay silent, who believe “rocking the boat” will cause more problems, well, I just reply with “I know where the life boats are, you just keep your eyes on that growing iceberg dead ahead!”

  9. I agree with every statement that you have made in the post and I really appreciate your effort in gathering up the information. Thanks for it.

  10. Amazing it is almost always a non clinician who is the most vocal critic of how health care should be provided, yet, if any of these people spent even a month doing health care in a hospital, one is either humbled at the level of committment we take, or, psychosis takes hold and they run out screaming and flailing away!!!

  11. One of the authors is a clinician and the other worked in a hospital as the Director of Analysis & Planning. They aren’t strangers to what goes on from a first-hand perspective.

    Using your logic: since physicians are not trained to be managers or efficiency experts, you cannot critize insights from those who have been trained in management, efficiency or quality improvement at an institutional level.

    Everyone has part of the picture, but like the blind men and the elephant, none of us has the complete picture. We can all learn and take advice from outside our profession. Judgment consists in knowing what advice to take, not rejecting any of it that you find threatening.

  12. I am glad someone else commented first, as the author’s credentials at the end quote his book, “Demanding Medical Excellence: Doctors and Accountability in the Information Age”, is as loud a shot over the bow of the ship of physician care I have read in some time.

    Amazing it is almost always a non clinician who is the most vocal critic of how health care should be provided, yet, if any of these people spent even a month doing health care in a hospital, one is either humbled at the level of committment we take, or, psychosis takes hold and they run out screaming and flailing away!!!

    Hmmm, I never have written a book about how to run a business or manage other peoples’ monies, because, how ironic, I do not have an expertise in these areas. But, I guess being in the business field somehow allows an equivalency in defining how health care is provided.

    Again, will keep challenging the lies so unbiased and objective readers see there are other points to the ‘discussion’.

  13. “Finally, peak-and-valley scheduling is inefficient, causing hospitals to build expensive new facilities instead of efficiently using existing capacity. ”

    I know that this isn’t the main point of the text, but this statement is so asinine, I can hardly believe it, and I could barely carry on to read the rest of the OP. If there is any empirical data supporting it, please name the source.