Wednesday, July 28, 2004

Fragmenting the Patient

Responding to the posting on the article by Porter and Teisberg in the Harvard Business Review (advocating that the health care market concentrate competition around particular treatments), Don Arwine continues to be concerned about the movement to specialty hospitals.  Here is his comment:

I too would like to see some discussion and a distillation of the flaws.  I think there are some serious negative implications.    The more we divvy up the body in a delivery system the more the whole patient disappears.

Monday, July 26, 2004

Should I Laugh or Cry?
An earlier posting made reference to some adverse publicity incurred recently by the Emergency Room of South Shore Hospital in suburban Boston.  Prominent was the story of the lady whose appendix burst during her six-hour wait for care.

Whether for that or some other reason, the Hospital has of late embarked on an aggressive public relations campaign, part of which takes the form of open letters from senior doctors.  A recent one was on the subject of patient safety and signed by Dr. Marvin Lipschutz, Senior Vice President, Clinical Affairs.  It appeared in the July 18, 2004 edition of the Sunday Boston Globe and took up about 2/3 of a page.

To summarize, Dr. Lipschutz claimed that the hospital guarded patient safety by:

Having only well qualified doctors on its staff.
Having physicians in key specialties on site 24/7.
Maintaining a staff of 1,150 well-qualified nurses.
Partnering with leading academic medical centers.
Standardizing care and minimizing variations.
Participating in national programs of tracking best practices.
Fostering teamwork among caregivers.
Making use of modern technology.

Those who follow such things will recognize that standardizing care and minimizing variations (which got two sentences in the middle of the piece and shared a paragraph with tracking best practices) were the only measures that directly addressed the safety issue in its contemporary manifestation.  They will also be aware that the health care delivery system has been very slow to implement them.

So I don’t know whether I should be sad because they got so little attention, or happy because they were mentioned at all.

Sunday, July 25, 2004

On Reducing Errors and Improving Quality
The following on medical errors and quality in health care comes from Dr. Claus Curdt-Christiansen, Chief Medical Officer of the International Civil Aviation Organization, a United Nations agency based in Montreal.

Many years ago some major Civil Aviation Authorities (e.g., the CAA of the United Kingdom) introduced a reporting system of aeronautical errors and mistakes of all possible kinds where the point was to find out what went wrong and why but NOT to blame anyone for whatever went wrong. This has been a success and has led to a better understanding of the human factor's role in most incidents and accidents - and, more to the point, has helped reduce the number of annual aviation accidents in spite of increasing air travel.

If a similar system were to be introduced in the hospital world so that a doctor or a nurse could self-report any mistake he/she had made without risking any kind of repercussion, a data base of knowledge would soon be established from where we could draw on actual experience to suggest changes in practices and procedures aimed at improving health care quality.


Saturday, July 24, 2004

Fee-for-Service – Increasingly Ridiculous
Yesterday we received additional evidence of how ridiculous the fee-for-service system has become.

As previously reported, Mrs. Wittrup (Marilyn) had a damaged rotator cuff surgically repaired last April.  The operation took a little more than two hours and she returned home on the same day.

In yesterday’s mail we received the report from our Medicare supplementary insurance, summarizing the surgeon’s bill and how it was settled.

Details are as follows:

Billing code   Amount billed    Medicare paid   Supplementary paid   We paid

29827             5,500.00                     1,187.07         237.41                                    0
29826             1,850.00                        368.70           73.74                                    0
29823             1,000.00                          83.32           16.66                                    0

Totals              8,350.00                     1,639.09         327.81                                    0

One wonders how long a system so outlandish can survive. 

Surely we ought to be thinking seriously about what will happen when it collapses.

Wednesday, July 14, 2004

IT in Health Care – More Talk than Do

Information technology in health care continues to be a popular topic.

The June 28, 2004 issue of AHA News, the weekly hard copy bulletin of the American Hospital Association, featured an article by Scott Wallace, President and CEO of the National Alliance for Health Information Technology. Wallace reported with enthusiasm the various pronouncements and studies attributable to his organization during the past year.

Just after seeing that, I happened to pick up the May 24, 2004 issue of Modern Healthcare, which included an article on the same general subject. The article reported the result of a survey of 73 CIO’s belonging to the Ann Arbor, MI based College of Healthcare Information Management Executives. The group was asked to indicate the “most prevalent” reasons for “not generating value from IT.”

The results were as follows:

Lack of process and IT alignment; inadequate process change (51%)
Lack of executive ownership and accountability (49%)
Lack of understanding of expected business benefits (41%)
Communication breakdown or failure (28%)
Bad business objectives (24%)
Lack of outcome measurements (24%)
Lack of strong of adequate project governance (23%)
Failure to align business vision/goals with IT (22%)
Lack of understanding of what computer users really needed (20%)
Volatile situation: Organization’s needs changed ((18%)
Poor project management (17%)
Costs exceeded benefits (16%)
Nothing significantly improved (14%)
Users did not want the IT solution (12%)
Poor performance by vendor or consultant (9%)
A problem of timing: The opportunity was lost (5%)
Technical failure of software or hardware (0%)

When it comes to operational achievements, the health care field has long been notorious for more talk than do. The subject of IT seems to fit right into the pattern.

Monday, July 12, 2004

Clinical Performance – a Hospital Responsibility?

The July 2, 2004 issue of AHA News Now, a daily e-mail news digest published by the American Hospital Association, reported that the New Jersey Department of Health and Senior Services had issued the state’s first annual hospital quality report, rating hospital’s performance on eight measures of care for heart attack and pneumonia.

In his comments on the report, Gary Carter, President and CEO of the New Jersey Hospital Association, referred to a number of quality initiatives under way and concluded by saying "We encourage health care consumers to build upon their knowledge by learning all they can about the quality of care delivered at New Jersey hospitals."

A short twenty-five years ago, such a statement might well have gotten Carter fired. At that time, only doctors were considered qualified to make judgments about the quality of care. Anyone from the lay side of the health care establishment who attempted to meddle in quality of clinical care issues would likely have found it a career limiting experience.

As the New Jersey announcement shows, that is changing. Not only has the medical profession lost its monopoly on quality judgments, but now it is the “hospital’s performance” that is being judged, not the doctors’ performance only.

What remains is for hospitals to recognize and accept the responsibility that society is assigning to them.

Saturday, July 03, 2004

Is Government Abetting Corporate Practice?

The June 29, 2004 issue of The Boston Globe reported that the Massachusetts Department of Health will be requiring that hospitals treating stroke patients meet strict new quality standards. Under the plan, “ambulances will take suspected stroke victims only to hospitals that can prove that they will give prompt care to stroke victims and provide around-the-clock availability of brain-scanning equipment with radiologists and neurologists available to read the scans.”

I find this noteworthy, not only because it is a long-overdue effort to bring the care of stroke patients up to well-known standards, but also because the program is directed at hospitals – not at the medical profession.

In fact, one sentence in the article begins “Massachusetts hospitals that want to continue treating stroke patients must be able to quickly evaluate whether a patient should get [the drug] t-PA….”

I don’t know if that amounts to “corporate practice” or not, but to me it sounds awfully close.

(For the benefit of those who don’t follow such things, “corporate practice” has to do with physicians engaging in the practice of medicine as representatives of corporations rather than as independent professionals, something that the medical profession has long opposed. Some states have laws against it.)

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