There have been disturbing reports of hospitals firing doctors and nurses for speaking up about inadequate PPE. The most famous case was at the PeaceHealth St. Joseph hospital in Washington, where Dr. Ming Lin was let go from his position as an ER physician after he used social media to publicize suggestions for protecting patients and staff. At Northwestern Memorial Hospital in Chicago, a nurse, Lauri Mazurkiewicz warned colleagues that the hospital’s standard face masks were not safe and brought her own N95 mask. She was fired by the hospital. These examples violate a culture of safety and endanger the lives of both patients and staff. Measures that prevent healthcare workers from speaking out to protect themselves and their patients violate safety culture. Healthcare workers should be expected to voice their safety concerns, and hospital executives should be actively seeking feedback from frontline healthcare workers on how to improve their institution’s Covid-19 response.
Share power with frontline workers
According to the Institute for Healthcare Improvement, it is common for organizations facing a crisis to assume a power grab in order to maintain control. As such, it is not surprising that some hospitals are implementing draconian policies to prevent hospital staff from speaking out. While strong leadership is important in a crisis, it must be balanced by sharing and even ceding power to frontline workers. All hospitals want to provide a safe environment for their staff and high-quality care for their patients. However, in a public health emergency where resources are scarce and guidelines change daily, it’s important that hospitals have a systematic approach to keep up.
According to Gallup surveys, four of five Americans believe the quality of care they receive is good or excellent, and the majority think it is the best available in the world. Surveys by Roper, Harris Interactive, Kaiser Family Foundation, Harvard’s Chan School of Public Health, and others show similar findings. And the public’s view hasn’t changed in two decades despite an avalanche of report cards about its performance, a testy national debate about health reform and persistent media attention to its shortcomings and errors. But is the public’s confidence in the quality of the care we provide based on an informed view or something else? It’s an important distinction.
Two considerations are useful for context:
Measuring quality of care objectively in the U.S. system is a relatively new focus. And we’re learning we’re not as good as they think we are. Historically, the public’s view about “quality of care” has been anchored in two strong beliefs: 1-the U.S. system has the latest technologies and drugs, the world’s best trained clinicians and most modern facilities, so it must be the best and 2-the care “I receive” from my physicians and caregivers is excellent because they’re all well-trained and smart.
Data is not always the path to identifying good medicine. Quality and cost measures should not be perceived as “scores,” because the health care process is neither simplistic nor deterministic; it involves as much art and perception as science—and never is this more the case than in the first step of that process, making a diagnosis.
I share the following story to illustrate this lesson: we should stop behaving as if good quality can be delineated by data alone. Instead, we should be using that data to ask questions. We need to know more about exactly what we are measuring, how we can capture both the physician and patient inputs to care decisions, and how and why there are variations among different physicians.
A Tale of Two Doctors
“As soon as I start swimming, my chest feels heavy and I have trouble breathing. It is a dull pain. It is scary. I swim about a lap of the pool, and, thankfully, the pain goes away. This is happening every time I go to work out in the pool”.
Her primary physician listened intently. With more than 40 years of experience, the physician, a stalwart in the medical community, loved by all, who scored high on the “physician compare” web site listing, stopped the interview after the description and announced, with concern, that she needed to have a cardiac stress test. The stress test would require walking on a “treadmill” to monitor her heart and would include, additionally, an echocardiogram test to see if her heart was being compromised from a lack of blood flow.
“But, I have had three echocardiogram tests in the last year as part of my treatment for breast cancer and each was normal. Why would I need another”?
“Well, I understand your concern about more tests, but the echocardiograms were done without having your heart stressed by exercise. The echo tests may be normal under those circumstances, but be abnormal when you are on the treadmill. You still need the test, unfortunately. I want to order the test today and you should get it done in the next week”.
In an age where big data is king and doctors are urged to treat populations, the journey of one man still has much to tell us. This is a tale of a man named Joe.
Joseph Carrigan was a bear of a man – though his wife would say he was more teddy than bear. He loved guitar playing, and camp horror movies. Those who knew him well said he had a kind heart, a quick wit and loved cats.
I knew none of these things when I met Joe in the Emergency Department on a Sunday afternoon. I had been called because of an abnormal electrocardiogram – the ER team was worried he could be having a heart attack. Not able to make sense of the story on the phone, I was in to try to sort it out. Joe was gruff, short with his answers – but clearly something just wasn’t right. He was only 54 but had more problems than the average 50 year old. Progressive calcification of his aortic valve some years ago had caused intolerable shortness of breath resulting in replacement with an artificial valve. Longstanding diabetes had resulted in kidney failure and dialysis, and most recently abnormal liver tests had revealed the presence of the early stages of cirrhosis from hepatitis C. Yet Joe continued to live an active life – with only a tight circle of family and friends aware of the illnesses beneath the surface.Continue reading…
HarvardX is offering a free online course, Improving Global Health: Focusing on Quality and Safety, starting on June 27 on edX.org. Participants in this 8-week course will engage with top experts in the field of public health as they grapple with the nature of high-quality healthcare: What is quality? How do we define it? How is it measured? And most importantly, how can we make it better? Whether you’re a healthcare provider; student of medicine, public health, or health policy; or a patient who simply cares about getting good care—this course is for you. The course is taught by Ashish K. Jha, MD, MPH, director for the Harvard Global Health Institute.
How much does it matter which hospital you go to? Of course, it matters a lot – hospitals vary enormously on quality of care, and choosing the right hospital can mean the difference between life and death. The problem is that it’s hard for most people to know how to choose. Useful data on patient outcomes remain hard to find, and even though Medicare provides data on patient mortality for select conditions on their Hospital Compare website, those mortality rates are calculated and reported in ways that make nearly every hospital look average.
Some people select to receive their care at teaching hospitals. Studies in the 1990s and early 2000s found that teaching hospitalsperformed better, but there was also evidence that they were more expensive. As “quality” metrics exploded, teaching hospitals often found themselves on the wrong end of the performance stick with more hospital-acquired conditions and more readmissions. In nearly every national pay-for-performance scheme, they seemed to be doing worse than average, not better. In an era focused on high-value care, the narrative has increasingly become that teaching hospitals are not any better – just moreexpensive.
But is this true? On the one measure that matters most to patients when it comes to hospital care – whether you live or die – are teaching hospitals truly no better or possibly worse? About a year ago, that was the conversation I had with a brilliant junior colleague, Laura Burke. When we scoured the literature, we found that there had been no recent, broad-based examination of patient outcomes at teaching versus non-teaching hospitals. So we decided to take this on.
One of the main goals of the Affordable Care Act (ACA), perhaps second only to improving access, was to improve the quality of care in our health system. Now several years out, we are at a point where we can ask some difficult questions as they relate to value and equity. Did the ACA improve quality of care in the ways it intended to? Did it do so for some people, or hospitals, more than others?
How did the ACA Attempt to Improve Quality?
Three particular programs created by the ACA are worthy to note in this regard. The Hospital Acquired Condition Reduction Program (HACRP) took effect on October 1, 2014 and was created to penalize hospitals scoring in the worst quartile for rates of hospital-acquired conditions outlined by the CMS. The Hospital Readmissions Reduction Program (HRRP), which began for patients discharged on October 1, 2012, required CMS to reduce payments to short-term, acute-care hospitals for readmissions within 30 days for specific conditions, including acute myocardial infarction, pneumonia, and heart failure.The Medicare Hospital Value-Based Purchasing Program (HVBP) started in FY2013, was built to improve quality of care for Medicare patients by rewarding acute-care hospitals with incentive payments for improvements on a number of established quality measures related to clinical processes and outcomes, efficiency, safety, and patient experience.
In 1978, the Institute of Medicine published A Manpower Policy for Primary Health Care: Report of a Study (IOM, 1978) where they defined primary care as “integrated, accessible services by clinicians accountable for addressing a majority of heath care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” The four main features of “good” primary care based on this definition are: 1. First-contact access for new medical issues, 2. Long-term and patient (not disease)-focused care, 3. Comprehensive in scope for most medical issues, and 4. Care coordination when specialty referral is required. These metrics ring as true today as they did many years ago.
Estimates suggest that a primary care physician would spend 21.7 hours per day to provide all recommended acute, chronic, and preventive care for a panel of 2,500 patients. An average workday of 8 hours extrapolates to an ideal panel of 909 patients; let us make it an even 1000 to simplify. A primary care physician could easily meet acute, chronic, and preventative needs of 1000 patients, thereby improving access. Our panels are much larger due to the shortage of available primary care physicians and poor reimbursement which keeps us enslaved. Pay us what we are worth and then utilize this “first-access” metric to judge our “quality.”
A few weeks ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”
Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.
Nevertheless, doctors were expected to greet the news with cheers. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”
Indeed, we all deserve uniform quality measures. Equality in quality!