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Tag: Patient Safety

#MomInHospital

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By Bob Wachter, MD

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

First a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.

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Aligning Physician Incentives Doesn’t Do It

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By Michael Painter, MD

My wife Mary and I recently got a series of early morning calls alerting us to the declining health of Mary’s mom, who was in her 90s. She died later that week. We were stricken and so sad, but took comfort that she died with dignity and good care on her own terms, and at her home in San Francisco.

Ten years ago, we received a very different early morning call, about my father.  An otherwise healthy and vigorous 72-year-old, Dad had fallen at home. Presuming he’d had a stroke, paramedics took him to a hospital with a neurosurgery speciality rather than to the university trauma center. That decision proved fatal.

A physician in Seattle at the time, I arrived the next day to find Dad in the intensive care unit on a ventilator. Dad’s head CT revealed a massive intracranial hemorrhage. Dad also had a large, obvious contusion on his forehead.

The following day, the physicians asked to remove Dad from the ventilator.  He died that night. We were profoundly devastated by his death and upset with the care he’d received.

Our family wasn’t interested in blame or lawsuits. We did, however, want answers:  Why hadn’t Dad been treated for a traumatic injury from a fall? Shouldn’t he have had timely surgery to relieve pressure from bleeding? What went wrong?

I’ve spent the last decade searching for answers, for myself and countless others, to questions about how to improve health care.  I’ve had the honor of working with many people pushing health care toward high value, at the Robert Wood Johnson Foundation(RWJF) and elsewhere.

We’ve worked hard to find solutions.  We all get it:  The health care problem is a big, complex one without silver bullet answers. Still, we’ve made incredible progress with efforts like RWJF’s Aligning Forces for Quality Initiative in which community alliances work to improve the value of their health care.

We’re searching for ways to help us all make smarter health care decisions.  We’re helping health care professionals improve and patients and families be more proactive.  We’re exploring the price and cost of care, and ways to automate health care information with technology.

And importantly, we’re working to align the incentives that health care professionals need to support and deliver great care.  We strongly believe that unless we reward great results, we won’t get them.  That means payment reform, with a focus on financial incentives for those who hunt for waste, resolve safety problems, sustain improvement, and, most of all, innovate to save more lives.

But do financial incentives to promote and reward behavior work?

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Criminal Charges for Providers Won’t Fix the NHS, Dr. Berwick

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By John Tingle

One of US President Barack Obama’s key health advisers has just published a review in the aftermath of the Mid Staffordshire hospital scandal. Don Berwick’s review is both thoughtful and reflective but one of his key recommendations – to create criminal sanctions against health staff – will not make the NHS safer for patients.

Many patients, particularly elderly ones, suffered unnecessary indignities and avoidable harm at Mid Staffordshire.

The Francis report into the crisis concluded that patients were routinely neglected by a health trust more preoccupied with cutting costs and meeting targets rather than its responsibility to provide safe care. Patients’ calls for help to use the bathroom were ignored and some were left lying in soiled sheeting or sitting on commodes for hours. Events and failings there will probably go down in history as the blackest and bleakest moment for the NHS.

When the report was published in February, the government committed to appointing a advisory group of patients to consider the various accounts of what happened and the recommendations made by Robert Francis and others. The idea was that they would distill for the government and the NHS what lessons should be learned and what changes needed to be made.

Don Berwick, who worked on the long fought for Obamacare provisions in the US, is director and co-founder of the Institute for Healthcare Improvement in Boston. He was called in by the government to reflect on the Francis report and on patient safety.

Berwick’s review makes ten recommendations including that sufficient staff are available to meet the NHS’s needs now and in the future – staff should be well-supported and able to ensure safe care at all times; quality and safety sciences and practices should be a part of the initial preparation and lifelong education of all health care professionals, including managers and executives; and leaders should create and support learning and subsequently change, at scale, within the NHS.

But most controversial is his final recommendation:

We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

Berwick proposes the government creates a new general offence of “willful or reckless neglect”, applicable both to organisations and individuals. Organizational sanctions might involve removing leaders and disqualifying them from future leadership roles, public reprimand of the organization and, in extreme cases, financial sanctions – but only where that will not compromise patient care.

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Why a New Healthcare Technology Designed to Cut Costs and Increase Efficiency Probably Won’t Put Anesthesiologists Out of Work

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By Shirie Leng, MD

The Wall Street Journal recently contacted me regarding an upcoming article on Sedasys, the new gadget that is supposed to be able to infuse propofol by computer while monitoring vital signs.

If you’ve read anything I’ve written previously, you’ll know that I am NOT a big proponent of technology as a means of “improving” patient care. To me, the more technology you put between the patient and the caregiver, the less medicine you’re practicing, and the more data-entry and computer programming you’re doing.

Sedasys is designed specifically to administer propofol.  Propofol is a milk-like substance that produces a range of effects from sedation to general anesthesia.  For sedation you just use less,  for general anesthesia you use more.  Its very quick onset and very quick recovery make it great for outpatient sedation.  It has to be given in a continuous drip because its effect goes away so fast.  GI docs love it because its so effective.  I suspect they also love it because propofol comes with an anesthesiologist to give it.

The only problem is the one Michael Jackson encountered: it has this pesky side effect of causing you to stop breathing.  And you can’t tell by looking at a person how much will sedate them and how much will make them stop breathing.

A little old lady with a million health problems might sedate at, say, 40 mg and stop breathing at 60 mg, while an 19-year-old could probably take 150 mg and still be fighting you.  It’s not necessarily weight-based.

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More Work Is Needed on the Safety and Efficacy of Healthcare Information Technology

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By Stephen Soumerai & Ross Koppel

If one were writing about the improvement of gastronomy in America, one would probably not celebrate “over 300 billion hamburgers served.”  But that’s very much the type of success Dr. Ashish Jha is celebrating in last week’s piece on recent US healthcare IT sales. Unfortunately, the proliferation of Big Macs does not reflect superior cuisine, and healthcare IT (HIT) sales do not equate with better healthcare or with better health. Quantity does not equal quality of care.

To be sure, Dr. Jha acknowledges the challenges of rolling out HIT throughout US hospitals. And he should be strongly commended for his admission that HIT doesn’t capture care by many specialists and doesn’t save money. In addition, Dr. Jha points to the general inability of hospitals, outpatient physicians and laboratories to transfer data among themselves as a reason for HIT’s meager results.

But this is a circular argument and not an excuse. It is the vendors’ insistence on isolated proprietary systems (and the government’s acquiescence to the vendors) that created this lack of communication (non-interoperability) which so limits one of HIT’s most valuable benefits.

In our opinion, the major concern is that the blog post fails to answer the question we ask our PhD students:

So what? What is the outcome?

This entire effort is fueled by $29 billion in government subsidies and incentives, and by trillions of dollars spent and to be spent by hospitals, doctors and others [1].

So where is the evidence to back up the government’s and industry’s promises of lower mortality, improved health and lower health care costs?

Single studies tell us little. Sadly, as many as 90% of health IT studies fail the minimal criteria of the respected international literature syntheses conducted by the Cochrane Collaboration.

In other words, studies with weak methodology or sweetheart evaluation arrangements just don’t count as evidence.
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Can a Portable Hand Sanitizer System Reduce Hospital-Acquired Infections in America’s Hospitals?

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By Mike Miesen


Ignaz Semmelweiss was laughed out of his Viennese hospital when he suggested that physicians should wash their hands in between conducting an autopsy and delivering a baby.

150 years later, we know just how right he was, but hand sanitation compliance rates at hospitals still hover in the 30% to 50% range. This makes it easy for hospital-acquired infections (HAIs) such as MRSA and VRE to run rampant, a (literally) dirty, not-so-little, and not-so-secret reality for American patients.

A Healthbox-backed startup is trying to change that. SwipeSense, founded in 2012 by Northwestern University graduates Mert Iseri and Yuri Malina, is a system designed to improve sanitation practices in hospitals using portable hand sanitizers and wirelessly-collected data on their use.

The organization wants to help stem the tide of avoidable HAIs. Each year, about 100,000 Americans die from infections they contract during their time in the hospital – more than the number of Americans killed by guns, motor vehicles, and leukemiacombined. In addition to the direct human toll, HAIs cause patient length of stays to increase by 8.0 days in ICUs and 7.4 to 9.4days in acute care wards, taking up expensive capacity and preventing others from accessing needed hospital beds. They’re also expensive, causing an estimated $4.5 to $5.7 billion in excess costs.

Iseri and Malina were inspired to create SwipeSense by a project they did for Design for America, a student group created to catalyze social change using human-centered design (also founded by Iseri and Malina). It took them to Northwestern Memorial University Hospital in their college town of Evanston, Illinois, where they identified two salient issues with hand sanitation: convenience and compliance.

“It’s obvious it’s not the fault of the nurse or physician…it’s something wrong with the system,” Malina told me in an interview. Even though alcohol foam and soap dispensers are ubiquitous in American hospitals, they often aren’t at the immediate point of care: “medical staff need to sanitize four or five times per patient encounter,” Malina said, making proper sanitation an arduous, time-consuming, and unrealistic task. “Our philosophy at SwipeSense is that the right thing to do should be the easiest thing to do… We want to make something that people love.”

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A Time of Change at the American Board of Internal Medicine

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By Bob Wachter, MD

Yesterday was my last day as chair of the ABIM, and the end of my eight-year tenure on the Board. In this blog – a bookend to the one I wrote at the start of the year, which went near-viral – I’ll describe some of our accomplishments this year and a few of the challenges that I leave my talented successors to grapple with.

I had two very tangible tasks to accomplish during my chairmanship. First, after a decade-long tenure as CEO and President of ABIM, Chris Cassel announced her intention to step down. (Chris is now CEO of the National Quality Forum, which is increasingly crucial in a world looking for robust measures of quality, safety, and value.) After an extensive search, we selected Richard Baron to become ABIM’s new CEO, and Rich began earlier this month. Rich is one of the most impressive people I’ve met in healthcare, and a perfect choice to lead ABIM into the future. As someone who practiced general internal medicine for nearly three decades in a mid-sized Philadelphia office, he is a “doctor’s doctor.”

He is intimately familiar with the work of the Board, having served on the boards of both ABIM and the ABIM Foundation for over a decade (including a year as ABIM chair). He also has extensive policy experience, most recently as director for Seamless Care Models for the Center for Medicare & Medicaid Innovation (CMMI), where he was responsible for putting meat on the bones of concepts like the “Medical Home” and “Accountable Care Organization.” Rich is wickedly smart, a superb communicator, and a great listener with impeccable values and an unerring ethical compass. He’ll be splendid.

The second area may be a bit more Inside Baseball, but will ultimately be just as important. A couple of years ago, we began a process to redesign the ABIM’s governance. Our 28-person board was both too large and had too much on its plate for effective decision making. In work that was superbly led by then-chair Catherine Lucey, assisted by a crack committee, staff and governance expert Jamie Orlikoff, we decided to transform our governance structure. As of tomorrow, the ABIM board shrinks to 15 members – chosen for their experiences and competencies rather than because they represent a given medical subspecialty – and a new group, the ABIM Council, is formed.Continue reading…

Seven Policy Recommendations for Healthcare’s New Era

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Berenson, Pronovost & Krumholz

There is a consensus that measuring performance can be instrumental in improving value in U.S. health care. In particular clinical areas, such as cardiac and intensive care, measurement has been associated with important improvements in providers’ use of evidence-based strategies and patients’ health outcomes over the past two decades. Perhaps most important, measures have altered the culture of health care delivery for the better, with a growing acceptance that clinical practice can and should be objectively assessed.

Nevertheless, as we argue in the full-length version of this paper, substantial shortcomings in the quality of U.S. health care persist. Furthermore, the growth of performance measurement has been accompanied by increasing concerns about the scientific rigor, transparency, and limitations of available measure sets, and how measures should be used to provide proper incentives to improve performance.

The challenge is to recognize current limitations in how measures are used in order to build a much stronger infrastructure to support the goals of increased accountability, more informed patient choice, and quality improvement. In the following paper, we offer seven policy recommendations for achieving the potential of performance measurement.

1. Decisively move from measuring processes to outcomes.

There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance.

Read more.

2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short.

While working to develop a broad set of outcome measures that can be the basis for attaining the goals of public accountability and information for consumer choice, Medicare should ensure that the use of performance measures supports quality improvement efforts to address important deficiencies in how care is provided, not only to Medicare beneficiaries but to all Americans. CMS’ current focus on reducing preventable rehospitalizations within 30 days of discharge represents a timely, strategic use of performance measurement to address an evident problem where there are demonstrated approaches to achieve successful improvement [6]. Read more.

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How UCSF Is Solving the Quality, Cost and Value Equation

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By Bob Wachter, MD

I sometimes explain to medical students that they are entering a profession being transformed, like coal to diamonds, under the pressure of a new mandate. “The world is going to push us, relentlessly and without mercy, to deliver the highest quality, safest, most satisfying care at the lowest cost,” I’ll say gravely, trying to get their attention.

“What exactly were you trying to do before?” some have asked, in that wonderful way that smart students blend naiveté with blinding insight.

It is pretty amazing that healthcare has been insulated from the business pressures that everybody from Yahoo! to my father’s garment business have experienced since the days of Adam Smith. We experienced a bit of this pressure in the mid-1990s, when pundits declared healthcare inflation “unsustainable” (sound familiar?) and we invented managed care to slay it. We know how that story ended – the public and professional backlash against HMOs defanged the managed care tiger to the point that it could barely produce a “meow.” The backlash was followed by a 15-year run during which efforts to slash healthcare costs have been remarkably meager.

That run has ended.

Luckily, while we’ve been let off the hook on cost-reduction, we’ve not been given a free pass on improvement. Beginning with the Institute of Medicine reports on safety (2000) and quality (2001), we have been under growing pressure to improve the numerator of the value equation: patient safety, quality of care, and patient satisfaction. Particularly for those of us who work in hospitals, we now feel this pressure from many angles: from accreditors (more vigorous and unannounced Joint Commission inspections, residency duty hour limits), transparency (Medicare’s Hospital Compare), comparative measurement (HealthGrades, Leapfrog, Consumer Reports and many other hospital rankings), and, most recently, payment policies (no pay for “never events,” penalties for readmissions, value-based purchasing, and “Meaningful Use” standards for IT).

These initiatives have created an increasingly robust business case to improve. Hospitals everywhere have responded with new resources, committees, ways of analyzing data, educational programs, computer systems, and more.

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1. Decisively move from measuring processes to outcomes.

Berenson, Pronovost & Krumholz

There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance. We believe the operational challenges of moving to producing accurate and reliable outcome measures, though daunting, are worth the effort to overcome.

Patients, payers, policy-makers, and providers all care about the end results of care—not the technical approaches that providers may adopt to achieve desired outcomes, and may well vary across different organizations. Public reporting and rewards for outcomes rather than processes of care should cause provider organizations to engage in broader approaches to quality improvement activities, ideally relying on rapid-learning through root cause analysis and teamwork rather than taking on a few conveniently available process measures that are actionable but often explain little of the variation in outcomes that exemplifies U.S. health care.

However, given the inherent limitations of administrative data, which are used primarily for payment purposes, and even clinical information in electronic health records (EHRs), consideration should be given to developing a national, standardized system for outcome reporting [1]. A new outcome reporting system would not be simple or inexpensive, but current data systems may simply be insufficient to support accurate reporting of outcomes. An example is the National Health Care Safety Network system for reporting health care infections [2].

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