Tag: Quality

Profits, Quality, and U.S. Hospitals

Aug 20, 2012• 8

By Ashish Jha, MD

The recent articles in the New York Times about the Hospital Corporation of America (HCA) have once again raised important questions about the role of for-profit hospitals in the U.S. healthcare system. For-profits make up about 20% of all hospitals and many of them are part of large chains (such as HCA). Critics of for-profit hospitals have argued that these institutions sacrifice good patient care in their search for better financial returns. Supporters argue that there is little evidence that their behavior differs substantially from non-profit institutions or that their care is meaningfully worse.

To me, this is essentially an empirical question. Yet, I read the through the articles, I was struck by the dearth of data provided on the quality of care at these hospitals. Based on the comments that followed the stories, it was clear that many readers came away thinking that these hospitals had sacrificed quality in order to maximize profits. Here, I thought an ounce of evidence might be helpful.

Measuring quality:

There is no perfect way to measure the quality of a hospital. However, the science of quality measurement has made huge progress over the past decade. There is increasing consensus around a set of metrics, many of which are now publicly reported by the government and even are part of pay-for-performance schemes. While one can criticize every one of these metrics as imperfect, taken together, they paint a relatively good, broad picture of the quality of care in an institution. We focused on five metrics with widespread acceptance:

To Gauge Hospital Quality, Patients Deserve More Outcome Measures

Aug 17, 2012• 13

By PETER PRONOVOST, MD

Patients, providers and the public have much to celebrate. Recently, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

The addition of bloodstream infections data is a huge step forward. These potentially lethal complications, measured using Centers for Disease Control and Prevention’s methods, are among the most accurately measured outcomes. In addition, the science of how to significantly reduce these infections is mature, and hundreds of hospitals of all types and sizes have nearly eliminated them. A program to reduce these infections that started at Johns Hopkins Hospital was spread throughout Michigan, and is now being implemented throughout the U.S., demonstrating substantial reductions.

Do You Believe Doctors Are Systems, My Friends?

Aug 15, 2012• 24

By David Shaywitz, MD

In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.

The basic premise, of course, isn’t new, and seems closely aligned with what I’ve heard articulated from a range of policy experts (such as Arnold Milstein) and management experts (such as Clayton Christensen, specifically in his book The Innovator’s Prescription).

The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.

According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.

Hospital Quality Under Scrutiny

Aug 13, 2012• 7

By E. THOMAS WOOD

Last week’s New York Times article on cardiac care at some HCA-owned hospitals yielded a chorus of comments from readers who argued that for-profit hospital care is inherently low-quality care. As it happened, in working on a history of the investor-owned hospital sector, I had just been crunching data that might either support or refute that assertion. The results are surprising, if far from decisive.

Last September, the Joint Commission released the first of what it said would be annual lists recognizing “Top Performers on Key Quality Measures™” among the nation’s accredited hospitals. The all-star roster is based on “core measure performance data” that hospitals report to the Commission. The data cover adherence to “accountability measures ” established as best practice in the eyes of the Commission – making sure to prescribe beta-blockers for heart attack patients at discharge, for example, or to discontinue prophylactic antibiotics within 24 hours after surgery.

Unlike hospital quality measures that look at results – death rates and other outcomes – this one looks at processes. In theory, then, it ought to be more fair to hospitals that tend to serve sicker or more compromised patients, such as government-run hospitals in inner cities.

EHR Adoption Alone Does Not Guarantee Quality Care

Aug 12, 2012

By Debbie Lucas, Kristi Mitchell, and Barry Dalin

Under the Health Information Technology for Economic and Clinical Health Act of 2009, healthcare providers are now offered incentives to use electronic health records (EHRs).

A recent analysis from the Centers for Disease Control and Prevention (CDC) found that by 2011, 55 percent of physicians reported they had adopted EHRs, indicating that EHR adoption is finally on the rise. Moreover, three in four adopters said their system met the Act’s criteria for meaningful use.

Healthcare providers deserve recognition for adopting EHR systems. Their journey to date has not been easy, with challenges ranging from unexpected expenses to the logistics of incorporating technology smoothly into their interactions with patients.

Adoption of an EHR in and of itself does not improve care. Having electronic access to data is just the first step. Quality is only improved when providers interpret data to connect the dots between diagnoses and treatment options.

Et tu Dr. Gupta?

Aug 5, 2012• 8

By PAUL LEVY

As well intentioned and thoughtful as he is, Sanjay Gupta nonetheless misses the point in his recent New York Times op-ed “More treatment, more mistakes.” The theme of the chief medical correspondent for the Health, Medical & Wellness unit at CNN is:

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not…. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error.

With a quick aside in admiration of Peter Pronovost’s approach to harm reduction and some other process improvements, he then says:

What may be even more important is remembering the limits of our power. More — more procedures, more testing, more treatment — is not always better.

And then, remarkably, he presents M&M conferences as a remedy:

One place where I have seen these issues addressed is in Morbidity and Mortality, or M and M — a weekly gathering of doctors, off limits to the public, which serves in most hospitals as a forum for the discussion of mistakes, complications, deaths and unusual cases. It is a sort of quality-assurance conference where doctors hold one another accountable and learn from one another’s mistakes. They are some of the most candid and indelible meetings I have ever attended.

Continue reading…

The 25 Questions

Aug 4, 2012• 5

By PETER PRONOVOST, MD

Recently, I had an enlightening encounter with Horst Schulze, who led Ritz-Carlton Hotels to national awards and has since opened his own hotel chain, Capella. Hortz gave an informal presentation to members of a program that I’m taking part in, the Baldrige Executive Fellowship, and we continued to talk afterwards. Capella has five ultraluxury hotels from New York to Singapore, and all have been recognized as tops in their region. Horst spoke to us of a culture of excellence. He knows—he has built such a culture time and time again. Excellence does not occur by chance. It requires clear goals and a system.

Horst explained that to be great, everyone in the organization needs to know the goals, in order of importance. For Capella, the goals are 1) keep existing customers, 2) add new customers, and 3) optimize the spend of each customer. Every employee not only needs to know the goals, but they need to know the behaviors to achieve them. The Capella employees ensure a warm welcome, compliance with and anticipation of guests’ needs, and a fond farewell.

All employees are required to know service standards. Twenty-five of them. One of them states that you are responsible to identify and immediately correct defects before they affect a guest—for example, getting customers food when the restaurant is closed. Defect prevention is key to service excellence, just as it is to delivering safe health care. Another service standard states that when a guest encounters any difficulty, you are responsible to own it and resolve the problem to the guest’s complete satisfaction.

Capella has standard processes for everything—how to submit defects, how to resolve them. And they trained staff in the goals, the behaviors and the processes. Each hotel, every morning is required to have a huddle at which all staff attend. They review the goals for the company and read one of the behaviors, called service standards. Every day they read a different one. They cycle repeats every 25 days.

If a manager did not do this, Horst said, they would be fired.

The Destructiveness of Measures

Jul 21, 2012• 11

By Dr. Wes

A little box pops up before him asking if he asked the patient about the exercise. He mumbles something under his breath, clicks a little box beneath the question, then moves on.

This is what medicine has become: a series of computer queries and measures of clicks. It must be measurable, quantifiable, and justifiable or it didn’t happen.

Do they ask if I asked them about if they used cocaine? Of course not: too politically incorrect.

Do they ask if I really listened to their heart? Of course not – this activity is not a paid activity.

Do they ask about the myriad of phone calls and e-mails to arrange for a procedure? Nope.

Do they measure my time with the patient when I go back to see them on the same day? Nope – not paid for.

So what’s the motivation for doctors to be doctors? Are we retraining our doctors from care-givers to data providers? What are we losing in turn?

Is This Health Reform Which I See Before Me?

Jul 9, 2012• 24

By David Dranove

In a recent column, Clarence Page ridiculed Republicans who claim that they want healthcare reform but oppose programs that dramatically reduce the number of uninsured. Republicans counter that the PPACA is not true reform because it fails to contain costs. It seems that our political commentators have finally joined a long standing debate among health policy experts. More precisely, they have joined two-thirds of that debate.

The healthcare system is often described as a three-legged stool, supported by access, cost, and quality. Policy makers have usually paid attention to the most “rickety” leg, sometimes to the detriment of the others. During the 1960s and 1970s, access was the biggest problem, and government gave us Medicare, Medicaid, and the community health center movement. These programs triggered a surge in healthcare spending, and by the mid-1970s through the mid-1990s, the emphasis shifted to cost containment. When government price controls and planning laws failed, the private sector stepped in with a “competitive” solution based on HMOs and selective contracting.

Better Healthcare for Less — Even the NY Times Says: “It’s a movement!”

Jun 23, 2012• 2

By Joe Flower

I’ve been saying it for years now, it’s the theme of Healthcare Beyond Reform: Doing It Right For Half The Cost — and now it’s even hit the editorial pages of the NY Times: A June 2 editorial, “Treating You Better For Less,” trumpets the “good news” about a “grass-roots movement” using “already proven techniques” that “could transform the entire system in ways that will benefit all Americans.”

“It is a measure of how dysfunctional the system has become,” says the editorial, “that these successful experiments — based on medical sense, sound research and efficiencies — seem so revolutionary.” It goes on to describe several of the kinds of new ventures in efficiency and effectiveness that make up the core of Healthcare Beyond Reform, in different healthcare systems and health insurers across the country.

The news here is not that these things are happening, or that they are so widespread that they can be called a “grass-roots movement.” The real news here is that the movement has gained such momentum that big, mainstream media organizations outside of healthcare, well beyond the policy wonk orbit, have begun to surface what may turn out to be the biggest story of our times: The largest sector of our economy turning inside out, like some movie transformer, on the way toward providing all of us with far better care for far less than we could possibly imagine. Better healthcare for half the cost.