Sunday, December 28, 2003

Saluting the Unsung Heroes of Health Care Reform

In its December 15, 2003 issue, Modern Healthcare announced its this year’s Spirit of Excellence Awards, co-sponsored by Sodexho, the hospital support services giant.

There were four Winners and four Honorable Mentions. All were praiseworthy, but my attention was drawn to one in particular. The Columbus (Ind.) Regional Hospital won an award for reducing from 25 days to 2 days the waiting time between an abnormal mammogram and a diagnosis.

My first response was that there should have been a To Heck with Patients award that the hospital could have received when the waiting time was 25 days. There could also have been an Exploiting Profession Freedom for Personal Benefit prize for the physicians and radiologists who “had resisted changing their scheduling routines” and who balked over “spending time at an outside facility, which complicated staffing.”

How about an Acute Insensitivity trophy for the surgeon who is quoted as having said “This is a slow-growing disease. It [the wait] doesn’t matter”? Or perhaps there could have been a Pocketbook Over Patient Care recognition for the primary care doctors who were said to “resent the self referrals.”

Making sport of the situation is both fun and easy, but chances are good that the situation at Columbus Regional during the 25-day-wait period was more typical than most of us would like to admit.

Thus, you have to admire the courage of radiologist Martha Dwenger and surgeon Rick Shedd who “took up the cause as ‘physician champions,’” thereby risking the ire of their physician colleagues.

Then there was the tantalizing remark by hospital CEO Doug Leonard that “member turnover on the hospital’s board brought in more sympathetic ears.” One wonders what that was all about.

We like to think of the halls of congress as the source of health care system reform. What government does is important – sometimes essential - but what really matter are the improvements hammered out at the interface of providers and patients.

So let us salute Martha Dwenger, Rick Shedd, Doug Leonard, the unnamed new Trustees, and the other unsung heroes at Columbus Regional who found themselves faced with a scandalous, if all too common, situation and did something about it.

Saturday, December 27, 2003

Using Technology to Reduce the Cost of Health Care in Massachusetts

On October 16, 2003, the Massachusetts Technology Collaborative, in cooperation with the New England Healthcare Institute, released a report claiming that proper use of seven technologies could save $2.48 billion in health care costs in Massachusetts alone. Hardly a trifling sum.

The technologies are:

· Electronic Patient-Physician Communication
· Electronic Prescribing
· Ambulatory Computerized Physician Order Entry
· Inpatient Computerized Physician Order Entry
· Disease Management Tools
· Regional Data Sharing
· Remote ICU Monitoring

Several Adoption Barriers and Challenges were identified:

· Lack of information about the true costs, benefits, and experience
· High costs versus competing needs
· Benefits don’t accrue to the user-purchaser
· Cultural resistance and inertia
· Vendor product immaturity
· Legal/regulatory barriers
· Required infrastructure and lack of standards
· The need for training and education

An Action Plan was laid out:

· Create a statewide task force(s) to oversee implementation
· Convene a statewide summit
· Implement bonus incentives
· Reimburse physicians for using technology
· Develop collaborative relationships between payers and providers
· Seek private foundation and grant funding
· Seek sources of public funding
· Provide low-cost or no-cost loans
· Share technology resources
· Establish a “trusted third party” to report on progress

The report could appropriately be labeled “blue ribbon.” Everybody who is anybody in healthcare in Massachusetts was somehow involved in it, including employers and payers.

Anybody who is interested in the full 72-pate report and has Acrobat Reader (which can be downloaded free of charge) can see it at:


The effort behind the report is laudable, to say the least, and it is sincerely to be hoped that something will come of it.

But those of us who have been hardened by experience will be sobered by the following statement that appears at the end of the section about barriers:

“Just adding technology won’t be enough. Other elements are necessary since the change required will be systemic. Leadership, culture, and mindset change, and reengineering of process are often essential.”

In other words, providers have to be willing and able to do it – something that will happen only when the pain of not doing it gets to be greater than the pain of doing it. Unfortunately, the study didn’t offer any suggestions on how to bring that condition about.

Tuesday, December 23, 2003

Culture Change at Children’s – Bottom-Up is Not Enough

This morning’s Boston Globe carried an article following up on developments at Children’s Hospital following the death there last May of a 5-year old - attributed to an epileptic seizure treated improperly due to confusion about which doctor was in charge. The confusion was traced, in turn, to the autonomy of clinical departments in teaching hospitals like Children’s.

The article began by reciting a more recent anecdote about a nurse who had to call three doctors before getting one to consult on a child having an allergic reaction in the middle of the night. The doctors involved reportedly were summoned to a staff meeting and told by their chief “The first thing out of your mouth should be, ‘Do you think somebody needs to see this child now?’” The implication was that such a thing wouldn’t have happened a year ago.

Institutional leaders commonly show their determination to address a problem by telling how much money they are spending on it. Children’s’ CEO Dr. James Mandell, no exception, said that the hospital “will spend several million dollars to improve accountability and communication, ensuring that senior doctors are available in the intensive care units around the clock and requiring specialists to share responsibility for children with difficult health problems.”

The articles writers (Anne Barnard and Scott Allen) were not taken in. Their response was that “the hospital’s overarching goal is less tangible: to change a culture common in academic medical institutions in which specialists often operate autonomously and in which medical trainees sometimes feel discouraged from asking superiors for help.”

Barnard and Allen pointed out that the hospital had had similar problems before and had made similar promises to change. However, they quoted Dr. Anthony Whittemore of next-door Brigham and Women’s as saying that the hospital had now made “a clear commitment to cultural change. That’s a little different than the last time they were in the press.”

Dr. Lock, cardiology chief at Children’s, pointed out that culture change would take time. He said, “I can’t just write a memo.” “It has to be a bottom-up event and it has to permeate the institution.”

Lock put his finger directly on the issue. Bottom-up is not enough. Until the Trustees and Administrators at Children’s take ownership of the problem and exercise some authority over the medical staff, not much is going to happen. One hopes that not too many more kids will have to die first.

Saturday, December 20, 2003

Is Public Tolerance of Poor Performance Inexhaustible?

After a couple of weeks of travel, I returned home earlier this week to find in my accumulated mail the December 1, 2003 issue of Modern Healthcare, in which the lead story featured a federal waiver obtained by the New Jersey Hospital Association (NJHA) to run a demonstration project in gainsharing.

Gainsharing is the term that has been invented for paying cash bonuses to physicians who modify their practice in such a way as to reduce hospital costs. The assumption is that patients are staying in hospitals longer than necessary and are being subjected to more tests and procedures than they need. Since these are things that doctors control, the idea is to give them a financial incentive to eliminate, or at least reduce, these excesses.

“Controversial” is one of the adjectives the author of the article applied to the project. CMS Administrator Tom Scully was described as being unenthusiastic, preferring his pay-for-performance experiment that is directed towards hospitals. (CMS is the federal agency that administers Medicare and Medicaid.) Representative Pete Stark (author of the self-referral legislation that had to be waived for the NJHA project) suggested with more than a little cynicism that doctors just be paid 25% to tell their patients to take an aspirin and make an appointment at the mortuary.

Neither hits directly on what seems to me to be the main point. Gainsharing, as generally conceived, does not reward performance over and above the call of duty, or devising better ways of providing care. Instead, it proposes to pay doctors bonuses for doing what any minimal standard of performance would require them to do already.

Anywhere else, such a proposal would be considered ludicrous. It would be like giving the gas station attendant a bonus for remembering to put the gas cap back on after filling the tank. Or giving a secretary extra pay for showing up for work on time.

The public’s willingness to tolerate the poor performance of the health care provider community is a source of continuing amazement and is not duplicated in any other field of endeavor that I can think of. So long as that remains the case, redesigning the system will not do much good. No design will work if the people in it can’t be held to some minimum performance level without having to pay them extra.

Friday, December 05, 2003

It’s Time for Hospitals to Pull up Their Socks
The December 2, 2003 release of AHA News Now reported that more than 40 national medical and health care organizations, including the AHA, had announced their endorsement of the Joint Commission on Accreditation of Healthcare Organizations' universal protocol for eliminating wrong site, wrong patient and wrong procedure surgeries. According to the report, the protocol has three elements: a pre-operative verification and document review process, marking of the operative site, and a "time-out" immediately preceding the procedure to conduct a final verification and resolve any remaining questions or concerns. At news conference on the subject, Nancy Foster, AHA senior associate director of policy, pointed out that wrong site, wrong patient and wrong procedure surgeries were rare but "100% preventable."

This development, however commendable, raises the question of why it should have been necessary in the first place. Given the seriousness of the issue and the simplicity of the prescribed solution, one wonders why every respectable hospital had not implemented it on its own long ago.

The answer speaks volumes about the level of discipline in our hospitals. The health care system may need redesign, but a lot of its problems would be solved if hospitals would just pull up their socks and pay attention to business.

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