Wednesday, October 25, 2006

Practice before Principle

Early in my career I learned that people are often willing to do in practice what they would never agree to in principle.

I thought of that when I noticed an insert in last Sunday’s New York Times (October 22, 2006) titled National Hospital Guide. It was a special advertising section “designed to help you better manage your health care needs.” It listed, briefly described, and gave contact information for 34 leading hospitals. The group included the “usual suspects,” from the Massachusetts General Hospital in Boston to the University of California at San Francisco Medical Center.

I don’t know how much it cost each hospital to get included – I suspect quite a lot – but that is not what captured my attention.

What I noted was the implicit assumption that the way to seek the best medical care was by picking the right hospital. The six individuals featured were not star-quality physicians. Four were non-M.D. CEOs, one an M.D. CEO, and one an M.D. physician-in-chief.

In principle, we want to think that seeking good care means finding the right doctor. But in practice that is ever so gradually changing – as it must - to relying on hospitals, as shown by the NYT insert.

The next step is for CEOs and Trustees to accept the responsibility they are being given.

Monday, October 23, 2006

A Cultural Barrier to Improvement

Perhaps no example more clearly illustrates what ails our system of health care than that of stroke treatment.

I was reminded of this by an article on the subject that appeared in the October 20, 2006 issue of the Boston Globe. The article began by pointing out that during the past two years Massachusetts hospitals had increased significantly the number of stroke patients who get the potentially life-saving, “clot busting” drug tissue plasminogen activator (TPA). The two-year period began in 2004 when the state set quality standards for hospitals providing stroke care.

The article went on to point out, however, that during the first half of 2006 only about half of the patients eligible for the treatment actually got it. Later on, and buried deep in the article, was it reported that while the recommended standard calls for stroke patients to get a CT scan within 25 minutes of arriving in the Emergency Room, that standard was met only less than a fourth of the time, and that performance during the first half of 2006 was no better than it had been in 2005.

TPA only works if given within three hours of the onset of the stroke. But before the drug can be given, a CT scan is necessary to prove that the stroke was caused by a clot (called an ischemic stroke), not by an aneurism (ruptured blood vessel). Giving TPA to an already bleeding aneurism just makes the situation worse.

So time is of the essence. The problem is that the process involves three separate sections of the Medical Staff. First, the patient must be seen by an Emergency physician. Then the CT scan must be done by the X-Ray department, which is controlled by Radiologists. Then the findings must be confirmed by a Neurologist. Once the stroke is confirmed to be ischemic, PTA can be given.

Making all that happen within the prescribed period requires management and discipline. But any prudent hospital CEO will think long and hard before simultaneously engaging three separate branches of the medical staff, all or some of which are likely to believe that stroke treatment is a clinical matter that administrators ought to stay out of.

Until that cultural barrier is overcome, performance improvement in health care will continue to be agonizingly slow.

Friday, October 20, 2006

What are you doing, MGH?

Some years ago the notion that hospitals should be striving for something called “healthy communities” was popular.

In more recent times, there has been concern over whether non-profit hospitals are providing enough “community benefit” to warrant their tax exemption.

Well, I have come across something that perhaps they should look into.

The October 18, 2006 issue of The Boston Globe reported the results of a study of harmful reactions to prescription drugs that resulted in visits to hospital emergency rooms. The study was developed by the federal Centers for Disease Control and Prevention, the Food and Drug Administration, and the US Consumer Product Safety Commission.

The study included 63 hospitals that reported 21,298 such incidents during a one year period ending in 2005. Extrapolated nationally, those figures result in an estimate of over 700,000 emergency visits for adverse drug reactions per year.

There are about 956,000 hospital beds in the U.S. By my calculation, that means that hospitals experience on average about 0.73 drug reaction visits to their emergency visits per bed per year.

The Massachusetts General Hospital, commonly considered one of the best hospitals in the country, has about 900 beds. So it must on average see about two such patients per day. (For a variety of reasons, it seems reasonable to assume that the number is probably higher.)

I wonder if the leaders at MGH are aware of this and what, if anything, they are doing about it.

Tuesday, October 17, 2006

It’s the System, Stupid!

We like to think that we can count on our physicians to make sure that we receive good medical care.

There seems to be more to it than that.

The October 2, 2006 issue of the Annals of Internal Medicine reported a retrospective review of 307 closed malpractice claims by a team of Harvard and University of Texas researchers.

59% of those claims were found to involved diagnostic errors that harmed patients. Of those, 30% resulted in death.

In 55% of those cases, there was a failure to order an appropriate diagnostic test. 45% of the time, a proper follow-up plan was not followed. 45% of the harmed patients did not get a proper history taken or physical exam performed. Diagnostic tests were incorrectly interpreted for 37% of them.

Factors contributing to the errors included failures in judgment (79%), vigilance or memory (59%), knowledge (48%), patient related factors (46%), and handoffs (20%).

The study concluded that diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. In other words, the chance of a good outcome in modern healthcare depends not only on the doctor, but also on the system of which the doctor is a part.

We don’t want to believe that, but the numbers speak for themselves.

Thursday, October 12, 2006

A Modest Proposal

“Public is seeking solutions to what ails the nation’s health care system.”

That was the headline of the lead article in the October 2, 2006 issue of AHA News, the weekly newsletter of the American Hospital Association.

The article summarized the findings of two reports, one by the Commonwealth Fund and the other by The Citizen’s Health Care Working Group. The Commonwealth Fund study concluded that “the nation’s health care system is doing poorly by virtually every measure.” The Working Group [surprisingly?] reported that “Americans want a health care system where everyone has access to high quality care.”

Recommendations repeated all the slogans about affordable health care, integrated community health networks, the need for a unified national health policy, and the like.

I have a modest proposal. How about a congressional hearing in which the CEOs and Board Chairmen of various hospitals from across the country are asked, one hospital at a time, to report in specific terms on what their institutions are doing to reduce both medical errors and the cost of care, and the measurable results of those efforts?

It wouldn’t be hard to do, it wouldn’t cost much and it could well cause more improvement than you might think.

Saturday, October 07, 2006

Still Nobody in Charge

Long time friend and colleague from Kentucky days Leon Hisle reports that he recently had a pacemaker installed at the University of Kentucky Medical Center. He had been going to the cardiac clinic on the second floor. The pacemaker was installed directly above on the third floor.

When he went for the pacemaker procedure, they asked for his insurance cards. He replied that they had them already since he had been coming to the clinic for years. They replied that they could not access the clinic computers so they would need the card. When he asked whether any departments within the Medical Center could access computers in other departments, the answer was no.

Leon suggested that they needed me back. (I was Administrator there from 1962, when the hospital first opened, until 1967.)

My response was that nobody was in charge when I was there, either.

Friday, October 06, 2006

Whose Good?

Thomas Menino, the Mayor of Boston, wants to make wireless Internet available throughout the city. There is discussion about who should run the system. Some cities have opted to work with one company, like Earthlink or Google. Others have given the responsibility to a team of companies.

An editorial in the October 5, 2006 issue of The Boston Globe reported that Mayor Menino wants to take a different approach. He had a task force review the options. One idea it came up with is to put the project in the hands of a nonprofit organization.

Why a nonprofit? According to the editorial, because “its mission would focus on the public good.”

That comment reminded me of the ongoing public demand that nonprofit hospitals show that they are providing enough “community benefit” to justify their tax exemptions. Why is that happening if focusing on the public good is their basic mission as nonprofit organizations? Somebody must think that they are focusing on something else.

If those somebodys are right, what are nonprofit hospitals focused on?

One answer could be the “good” of the physicians on whom they depend for patients. Perhaps there are other answers.

We ought to figure out what the right answer is.

This page is powered by Blogger. Isn't yours?

FREE counter and Web statistics from sitetracker.com