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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.

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