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Tag: Quality

Wachter: Three Stories

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By ROBERT WACHTERPicture 62, MD

In my travels, I frequently hear short stories that help illuminate my work and world. Here are three recent examples; think of them as little health policy tapas.

I recently spoke in a session with Peter Pronovost, the Johns Hopkins intensivist who is the world’s top researcher in safety and quality. We were talking about why engaging physicians in this work – so called “adaptive change” – is sometimes so difficult. Peter recalled a story about his son, who at age 6 came home and told his parents that he was terrified to enter the school bathroom. “There are monsters in there,” he said. His parents reassured him that there weren’t, but the next day he returned, wide-eyed and still panicked. Peter called the school to see if they had any explanation for his son’s sudden bathroom phobia. “Oh, we put in automatic flush toilets last week, and I guess we didn’t explain it to the kids,” said the teacher.

Peter’s point was that we often ask physicians (and others in healthcare) to absorb a tremendous amount of change without giving them the background and tools they need to understand these “monsters.” It’s a lesson worth remembering.

At the same conference, I went to a terrific session given by one of my UCSF colleagues, Adams Dudley, another critical care physician and one of the nation’s experts on the impact of transparency and pay-for-performance strategies on quality. Adams was discussing his observation that physicians often feel that they – unlike every other soul on the planet – are not influenced by monetary incentives. He told this story:

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The Health Reform (Almost) Everyone Loves

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By MICHAEL MILLENSON Michael Millenson

Come with me to the land of happy health reform. It is a place where Republicans and Democrats find common ground, a place where physicians, hospitals and health insurers sit together as partners, a place where criticism is respectful, not rancorous. It is the world of Accountable Care Organizations (ACOs).

What are ACOs, and why have they escaped the general onslaught of opprobrium from Obamacare opponents?

The term Accountable Care Organization was originated by Elliott Fisher of the Dartmouth Center for the Evaluative Clinical Sciences, picked up by the Medicare Payment Advisory Commission and then enshrined in Section 3022 of the Patient Protection and Affordable Care Act (otherwise known as health care reform). The language is explicitly designed to use financial incentives to change the health care delivery system.

ACOs are defined less by form than by function. A group of physicians, possibly with a hospital, agrees to manage the full spectrum of care for a defined population of at least 5,000 Medicare beneficiaries for a minimum of three years. If the ACO meets certain targets for quality and cost-effectiveness, it gets to keep part of the savings.

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Hospitalists as Extensivists

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By PAUL LEVY Paul Levy 1

I had heard something about this, but couldn’t find it. A colleague here finally tracked it down. The story is about Caremore, a California based organization. Hospitalists generally are internal medicine doctors based in the hospital; but here they care for frail elderly members at high risk of hospital admission or readmission in skilled nursing facilities and in outpatient settings both before and after a hospital stay. Here’s an article on the AHRQ Innovations Exchange website.

An excerpt:

A Medicare Advantage plan expanded the role of its employed hospitalists, using them to continue following and caring for recently discharged members until their condition stabilizes, as well as other members at high risk of a hospital admission. Known as “extensivists” and supported by sophisticated information technology (IT) systems, these physicians generally split their time between the hospital, where they round on a small group of members each day, and an outpatient clinic, where they see recently discharged members and other members at high risk of an admission. Once or twice a week, these physicians also see members in SNFs.

The results:

The program reduced readmission rates and has led to low LOS (lengths of stay) and to below-average inpatient utilization in a high-acuity population.

Is this worth considering more broadly? What are the conditions for success? I welcome your thoughts.

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

Physician Report Cards: Don’t Shoot the Messenger

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By JOHN R. MORROWJohn Morrow

There is a BIG difference between the popular consumer/physician matching Websites such as: Vitals.com, RateMDs, Angies List, Healthgrades, Zagat and UCompareHealthcare (a NYTimes property), and the other initiatives in place to monitor physician performance as driven by hospitals, government and other payers and health plans. Soon, these differences will be merging with the more complex score cards from hospitals joining forces with the consumer tools.

OPPE (Ongoing Practice Performance Evaluation) and FPPE (focused Practice Performance Evaluation) are initiatives set in place by The Joint Commission (TJC), an arm of the American Hospital Association that accredits health care organizations. These initiatives are coming main stream to provide structured and frequent review of a hospital’s physician personnel. There is nothing new about these initiatives, (TJC has always been a follower in health care business intelligence), but soon ongoing reporting will be required by all and supplied by a variety of experienced commercial firms.

Private enterprise has been helping hospitals benchmark, profile and rate physicians on a broad spectrum of metrics relevant to specific acute service lines for decades. Of course mortality, length of stay, risk-adjusted complications rates, patient safety events and indicators, patient satisfaction, and a long list of Core Process Measures have all been part of that analysis. Progressive hospitals have been sharing this information with physicians, and for the most part physicians have accepted that the profiling analytics have done a good job of educating them on their performance. Medical Evaluation Committees have their hands full with information to help credential and reappoint physicians to hospital privileges, and a more informed dialog has been fostered.

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Accountability, Accountable Care Organizations, and Human Mindsets

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By KENT BOTTLES, MD

“Great companies have high cultures of accountability, it comes with this culture of criticism I was talking about before, and I think our culture is strong on that.” – Steve Ballmer

“I am responsible. Although I may not be able to prevent the worst from happening, I am responsible for my attitude toward the inevitable misfortunes that darken life. Bad things do happen; how I respond to them defines my character and the quality of my life. I can choose to sit in perpetual sadness, immobilized by the gravity of my loss, or I can choose to rise from the pain and treasure the most precious gift I have – life itself.”
– Walter Anderson

“When it comes to privacy and accountability, people always demand the former for themselves and the latter for everyone else.” – David Brin

Accountable care organizations (ACOs) are all the rage as the perfect tool to achieve our most important goal in present day American health care: decreasing per-capita cost and increasing quality at the same time. Just this week I am presenting on ACOs at a law firm conference co-sponsored by two state hospital associations and the MGMA in Minneapolis and at a hospital system board retreat in Pennsylvania. Everybody wants to know how to implement ACOs.

An essential ingredient in ACOs is accountability, and yet human beings are not always comfortable with being held accountable. The two blog posts  I wrote on physician report cards generated a lot of comments both in favor and opposed to personal accountability. And yet we know that hospitals and physicians are going to have to change the way they utilize medical resources if we are to indeed decrease per-capita cost and increase quality. Hospitals account for 40% of the rise in health care costs. Physicians account for only 20% of total health care expenditures, but when they treat patients they control the use of hospitals, drugs, medical devices, and laboratory tests.

If we are to control health care costs, hospital admissions will have to go down and physicians will have to order fewer and less expensive tests and treatments than they do today.

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NYC Train Station Bathroom Yields Cleaner Hands than Hospitals

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By MICHAEL L. MILLENSONMichael Millenson

Who can forget last year’s celebration of Global Handwashing Day, when it turned out that Brits wash their hands after using a gas station bathroom about as often as your doctor washes his hands before examining you? And that’s not a good thing.

OK, British researchers didn’t exactly come to that conclusion: I did, in this blog, after comparing what they found about motorists to what the academic literature says about doctors.

Now comes a survey of public bathroom hygiene in the US of A, and the good news is that even America’s worst washers are far more likely to have washed their hands than British drivers. The bad news is that the guy who just used the toilet at Grand Central Station is also way more likely to have clean hands than the guy walking up to your bed at the local hospital.

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Not all Ratings Are Equal: Part II

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By JOHN R. MORROW Read Part I here.

Why are all ratings not equal? Because they are designed for different purposes!
Herein lay the underlying truth to the many objections posed by organizations being rated. Rightfully so, the Three R’s (ratings, rankings and reviews) of providers must be kept in the context of overall purpose. This is one of the challenges to getting The Three R’s accepted and to making report cards right.

Health care is a big industry to rate and it is going to take more than one blog entry to develop a clearer picture of how best to move forward and embrace ratings systems, but let’s put down some context and history, as it is important to our current day objections and it is instructive to our future direction.

In the Beginning… in a fee-for-service market, before we had enough data to understand the enormous variability of clinical care, and before HCFA first contemplated releasing mortality data, performance measurement was all about financial performance measures. The ratings and rankings were quite simply all about financial and operating ratios, and hospitals were the institutional providers who were the rated with the CFO taking the bullet. Thanks to the public debt markets of the municipal bond industry, the hospital industry’s bricks, mortar and technology were mostly financed by long-term tax-exempt municipal bonds. Like most all other financial instruments these bonds are purchased and sold in the secondary markets long after the initial raising of capital, in some case decades. Being a predominantly not-for-profit industry, there exists no statutory reporting of a hospital’s financial results, and thus the Bloomberg terminals used by traders were void of hospital performance data, and the secondary bond market and the portfolio surveillance by large bond funds and bond insurers was a real challenge! No current data, no timely ratios, no real-time analysis…plenty of risk for those trading bonds. Sound familiar?

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Computer Error or Patient-Centered Care?

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By HERBERT MATHEWSON, MD
Hub

The saga continues, but morphs from a discussion of computer error into patient-centered care (1).

In my last two posts I tell my story of trying to speed up a six-hour infusion of intravenous medication by correcting a “computer error”; a “failure to update reference information” in the computer available to the nurses. My first clue was the discrepancy between the medication’s package insert and the computer information. Discussion with the infusion nurses and a call to the Hospital’s chief pharmacist caused a review of the computer info, the package insert, and the hospital’s Pharmacy and Therapeutics Committee minutes.

The package insert stated that “after the initial 30 minutes without a side-effect the infusion rate could be gradually increased to the maximum rate.” The infusion nurses’ interpretation of “gradually” was a infusion rate step-up every 30 minutes resulting in a six-hour infusion. My preference was for a two hour infusion. I looked diligently, and in vain, for the manufacturer’s definition of “gradually”, so I called its 800 number . A very knowledgeable and accommodating RN in the Professional Services Department ( I identified myself as a physician) explained that they did not define “gradually”  because they wished “not to be too proscribing, realized that individual patients varied, and respected each facility’s responsibility to set their own protocols.” It sounded like pretty good risk management (avoidance of increased liability) to me.  She went on to say that many facilities had used a rate step-up schedule of 15 minutes rather than 30 minutes without increased side-effects and offered to send us the articles describing this.

Going to a step-up rate 0f every 15 minutes rather than 30 minutes would result in a four and a half hour infusion instead of a six hour one; still longer than my initially hoped-for two hours. Could the change in duration be labeled a triumph of “patient-centered care”? If so, was it worth all the time and effort?Continue reading…

Trust Me I’m a Doctor vs. Physician Quality Report Cards

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By KENT BOTTLES, MD

In Quality Measures and the Individual Physician, Danielle Ofri, MD, PhD, questions the usefulness of feedback report cards for individual providers. She states, “Only 33% of my patients with diabetes have glycated hemoglobin levels that are at goal. Only 44% have cholesterol levels at goal. A measly 26% have blood pressure at goal. All my grades are well below my institution’s targets.” (http://danielleofri.com/?p=1169)

It would be better for Dr. Ofri’s patients if these numbers were higher. I think even Dr. Ofri would agree with that assessment. And yet Dr. Ofri’s response to these low scores is that “the overwhelming majority of health care workers are in the profession to help patients and doing a decent job.” And more upsetting is Dr. Ofri’s conclusion where “I don’t even bother checking the results anymore. I just quietly push the reports under my pile of unread journals, phone messages, insurance forms, and prior authorizations.” (http://danielleofri.com/?p=1169)

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The Yellow Stickie Ain’t Dead Yet

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By HERBERT MATHEWSON, MDHUB's LIST

I’m sure that many of us “old timers” can remember the early days of computer implementation in our hospitals. At that time you couldn’t help but notice the dozens (or more) Yellow Stickies plastering the nurses’ station computers, usually around the monitor’s edges, filled with keywords, short cuts, new jargon, and other information helpful to them as they strived to give up their dependence on paper. Well, thirty years later, the Yellow Stickie ain’t gone just yet.

I had to go into my hospital last week to get an intravenous infusion to help me with the effects of a neuropathy. The receiving desk at the IV Infusion Center had three computer monitors with two people sitting at them. My physician’s orders were already printed out and were attached to my computer printout encounter form. After receiving my computer generated ID bracelet with bar code, I was lead into a room with four chairs, each one next to a computerized infusion pump with blinking lights and various sounds to convey different messages to the nurses caring for me. Each pump had touch-screen data entry and a multiple color display combined, was capable of at least three distinct alert sounds, and was neatly packaged to fit on a standard IV pole. The combination of four such poles, two automatic blood pressure machines with their display screens and alert sounds, the usual wall of oxygen, suction, electrical outlets, and signal lights, a R2D2-size mobile air conditioning unit standing in the middle of the floor with its coiled, white PVC exhaust duct winding to the wall, and four brand new baby blue Barca Loungers made me think that this is what a passenger cabin on a space ship would look like.Continue reading…