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Tag: Quality

When Will UPMC Explain the Whole Story?

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By PAUL LEVY

The UPMC kidney transplant story continues to develop.  This was the one where a doctor and nurse were disciplined in a matter that clearly reflected some systemic problems, more than personnel problems regarding those two people.

Now UPI reports:

A report by a federal agency on a kidney transplant at the University of Pittsburgh Medical Center suggests more problems than the hospital has acknowledged.

The Centers for Medicare and Medicaid Services said its investigation found the nephrologist should have been aware the kidney donor was infected with hepatitis C, the Pittsburgh Post-Gazette reported Tuesday. The hospital has suspended the lead surgeon and the transplant coordinator.

The CMS report said the test results were available for two months in the donor’s medical record. But none of the doctors and nurses apparently reviewed the record, and the kidney was transplanted into a man who was not infected with the virus.

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Unintended Consequences

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By STEVE SANDERS

Joe is a guy that never really cared about his health. He is overweight, according to any objective standard, and always attributes this to “bigger muscles” (it isn’t). He dutifully comes in once a year, but admittedly only because of his wife’s insistence. She worries about his lack of exercise, his growing abdominal midsection (“muscle”) and the fact that all he does on weekends is sleep. There is a strong history of heart disease in his family—his father was only a few years older than Joe, when he collapsed at the dinner table and died. Joe always turns down repeated offers for the flu vaccine with the response, “I never get sick,” and shows little interest in his lab results, even though his blood sugar and office blood pressure are always high (“I get nervous at the doctor’s office”) and his “bad” cholesterol has never been even close to normal.

At his last appointment, Joe forcefully slapped a stack of papers on the exam table and seemed agitated. “We had a health screening at work last week,” he explained, “My numbers are out of whack and I need your help.” I wasn’t surprised at the numbers, but his seemingly new interest in his own health had me intrigued until he explained. “I get $50.00 off my health premiums, if my blood pressures are normal and $150.00 for having a physical,” he said. Mystery solved—money supplied by his employer was motivating Joe to get healthy.Continue reading…

Are We Ready for Global Payments?

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By DAVID HARLOW

Massachusetts Attorney General Martha Coakley released her office’s second annual report, An Examination of Health Care Cost Trends and Drivers (PDF; see also press release), which contains a wealth of critical data analysis — and also highlights how little we know about certain things — providing some important context for the discussion of the proposed Part III of Massachusetts health reform, a bill filed by Governor Patrick which would create all-payor ACOs and a system of global payments.

At this late date, few would argue against a move a way from fee-for-service reimbursement for health care, or adding quality metrics to the mix, and tying financial rewards to providers to their performance measured against these metrics.  (Consider the Massachusetts Blue Cross Blue Shield ACQ (alternative quality contract) experience.)  The AG’s report, however, highlights the wide disparities in payments to providers based on negotiating strength, rather than quality or cost of care (as noted in last year’s AG report; check out the 2009 special commission report, too).

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Quality Like Beauty Is In the Eye Of The Beholder

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By HUMPHREY TAYLOR

For as long as I can remember we have told ourselves that the health care priorities of the American people are access, cost  and quality.  However there was never a consensus as to what exactly we meant by quality, let alone how to measure it, or pay for it.  The truth is that there are many ways of defining quality and our research shows that different players define quality very differently. Patients, physicians , employers, insurers, the I.O.M, hospital managers, drug companies, the NCQA, public health experts, demographers and policy wonks all focus on different indicators of quality.  Clearly quality,  like beauty, is in the eye of the beholder.

Patients tend to define quality as meaning affordable access to almost everything.  Naturally they care about the outcomes of their own care. They tend to believe that more care is better than less. The demeanor and bedside manner of doctors and nurses, being treated with respect and courtesy, are important. They often judge hospitals the way they judge hotels; good food and a nice atrium make a difference.  As Ian Morrison has written “good quality is being in a waiting room with people who have more money than you”.

The Institute of Medicine has equated quality with the avoidance of medical errors (adverse events) and patient safety , and the pursuit of ways to improve these.

Most Employers tend to equate quality with having happy , uncomplaining employees at the lowest possible cost.  A minority of progressive employers , such as those who participate in the NBGH and PBGH meetings, also focus on “value” and the use of sticks and carrots to influence the behavior of their employees and pay for performance incentives to influence  providers.

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The Hospitalist Field Turns 15: What The Past Says About The Future

By BOB WACHTER, MD

I just returned from the Society of Hospital Medicine’s annual meeting in Dallas. Seeing more than 2,000 hospitalists in one place is remarkable, since I remember the days when we all fit into a mid-sized conference room at a Holiday Inn.

I have clearly assumed the mantle of elder statesman at these meetings. I find this odd, since my idea of an elder statesman is UCSF’s former chair of medicine, Lloyd Hollingsworth (“Holly”) Smith, a man of unbelievable accomplishment and grace. Holly is now in his late 80s, and every year we ask him to say a few words at our department’s annual faculty dinner. Holly is the best after-dinner speaker I know – his comments, always insightful and hilarious, are increasingly peppered with “old guy” references (my recent favorite: “I’ve now reached the age of – when I reach down to tie my shoes, I ask myself, ‘Is there anything else I need to do as long as I’m down here?’ before I get up.”)

I’m not complaining: for the past decade, I’ve had the honor of giving a closing keynote address at the annual hospital medicine meeting. In this week’s talk, I reflected on the history of the hospitalist field, in the 15 years since Lee Goldman and I coined the term in the New England Journal of Medicine.

This kind of reflection is useful because, in a world in which we’re all drinking out of a huge information hose, it’s easy to focus on the short term and lose track of the arc of history. Self-help guru Tony Robbins had it right when he said, “Most people overestimate what they can do in a year, and underestimate what they can do in a decade.” Our 15-year history proves that.Continue reading…

Let’s Just Keep Killing and Maiming Them

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By PAUL LEVY

Old patterns die hard. Back in March 2010, I posted a chart from the ACHE that Jim Conway had sent me showing a decrease in the ranking of quality and safety among priorities reported by hospital executives.

Now comes an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled “The State of Patient Experience in American Hospitals.” Of those places surveyed, 51% were individual hospitals and 49% were hospital groups or systems. There was an even mix of urban, suburban, and rural facilities.

As in the prior ACHE survey, 69% of hospital executives rank things other than quality and patient safety as top priorities.

Any way you look at it, this is quite simply a failure of leadership and governance in American hospitals. There is a strange adherence to the view that “these things happen,” an apparent belief that a certain level of harm that occurs to patients is just the way things should be. It is as though the medical profession, hospital administrators, and hospital trustees have decided that the current amount of harm is the statistically irreducible level.Continue reading…

Did Nine Patients Have to Die?

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By MICHAEL KIRSCH, MD

Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.

What went wrong? How did an instrument of healing become death by lethal injection? What is the lesson that can emerge from this unimaginable horror?

This tragedy represents that most feared ‘never event’ that can ever occur – death by friendly fire. No survivors. Contrast this with many other medical ‘never events’ as defined by the Centers for Medicare and Medicaid Services, such as post-operative infections, development of bed sores in the hospital or wrong-site surgery. Under the ‘never events’ program, hospitals will be financially penalized if a listed event occurs. Many physicians and hospitals are concerned that there will be a ‘never events’ mission creep with new outcomes added to the list that don’t belong there. Medical complications, which are unavoidable, may soon be defined as ‘never events’.

Do we need a new category of ‘never ever ever events’ to include those that lead to fatal outcomes?

The facts of the Alabama deaths have started to emerge.  Apparently, a water faucet in the pharmacy was contaminated. Protocols and processes are violated every day in all spheres of professional life; and we usually get away with them. The absence of serious consequences breeds complacency, which is shattered by an occasional tragedy. Isn’t it after a horrible traffic accident that a local government decides to erect street lights that were requested by local residents for years? I read earlier today that the Federal Aviation Administration is requiring extensive inspections of a few hundred airplanes when small cracks were discovered in a few of them. This followed a near disaster when a 5 foot hole burst open in the roof of an airplane during flight. The plane landed and all survived. Of course, a very different outcome was possible.

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Minor League Report Cards

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By DAVID DRANOVE

I was pleased to see the Chicago Tribune carry an op-ed piece this week by my friend and colleague Michael Millenson. The gist of the piece was that information about hospital quality is readily available online and we should use that information when choosing a hospital. Michael is right — there is no shortage of places to turn to get information about hospital quality. But I think he waxes too enthusiastic.

For one thing, it is not clear whether the widespread availability of quality information is a boon or a problem. Consider Medicare’s Hospital Compare website. Look up quality information for pneumonia and you are overwhelmed with nearly 20 different measures on four different web pages. I couldn’t possibly make sense of all this information even if I used sophisticated computer software; how could the average person sort through it all? One quality measure seems to stand out – mortality. But I wonder if this should be a major concern for pneumonia patients. Are we talking about 5 percent mortality rates, or 0.05 percent? I don’t know and Medicare won’t tell me.

HealthGrades.com is much simpler – it just reports mortality. The widely respected Leapfrog Group reports mortality for pneumonia and also reports another 8 general hospital quality measures, some of which are derived from even more measures.

When reading these report cards I find that my local hospital in Highland Park scores very well on mortality in the HealthGrades and Leapfrog reports but I can’t find it anywhere at the Medicare website. And I wonder if the low mortality rate is due to the hospital or due to the demographics of the patients. Michael Millenson pointed out that these report cards are risk adjusted, but he failed to mention that the available risk are pretty lousy – mostly controls for age, sex, and a few comorbidities. (Much better risk adjustment is possible but requires data not available to Medicare, HealthGrades, or Leapfrog.) Hospitals that get poor quality scores often report that their patients are sicker than the risk adjusters give them credit for. They might be right. Hospitals that get good scores never claim that their patients are healthier. Maybe they are hiding something.Continue reading…

How the Veterans are Winning the War

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By PAUL LEVY

At a seminar last night at the Center for Public Leadership at Harvard’s Kennedy School, one of the students asked a question along the lines of, “How do you know when you have done too much with regard to transparency?” My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI’s Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)

Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton’s article this week in the Wall Street Journal — “Data Spur Changes in VA Care” — documents this in more detail. Some excerpts:

Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.

The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals’ rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients’ ages and relative frailty.

“Why would we not want our performance to be public? It’s good for VA’s leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve,” Mr. Shinseki said in an emailed statement.

At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.

Seeing the data helped, says the Salem hospital’s chief of surgery, Gary Collin, because “you can become kind of complacent.”Continue reading…

Oregon Death with Dignity Act vindicated

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To no one rational’s surprise, a study confirms that those few Oregon patients (400 over 10 years) who chose legal physician assisted suicide in case of terminal illness had a better quality of death than those who didn’t. Sadly because those attacking it aren’t rational, this won’t end the debate–but if you’re terminally ill you have better choices in Oregon (and Washington & Switzerland).