Wednesday, December 26, 2007

Culture Change

How would you like to be the head of a hospital that got written up nationally because of three cases in which its neurosurgeons operated on the wrong side of the patient’s head?

Well, the CEO of Rhode Island Hospital just had that experience. The story was reported by Michelle R. Smith of the Associated Press. I read it earlier this month in The Arizona Republic.

“Wrong-site surgery” is what is now called a “never event.” A “never event” is an event that is never supposed to happen and there are established procedures, including checklists, to prevent it. In the Rhode Island Hospital cases, those procedures were in place, but not followed.

As was stated by one of the experts interviewed for the story, this is a cultural issue. Traditionally, the authority of the surgeon in the operating room has been absolute, not to be questioned by anybody. Now the never-event prevention protocol includes authorizing nurses to stop the surgery if established procedures are not being followed and holding them accountable if they fail to do so. You have to be an old hand in health care to understand what a big deal that is.

Culture change is painful, but it is what real health care reform is all about and the Rhode Island Hospital story is a salient case in point.

Tuesday, December 11, 2007

Rationing Health Care

Discussions about rationing health care almost always treat it pejoratively, ignoring the fact that it is done all the time. For example, giving everyone a brain scan every month would probably produce a measurable reduction in deaths from brain tumors. But the cost would be so outrageously out of proportion with the benefits that we would never consider it.

That is an extreme example but cost/benefit judgments – a form of rationing - get made every day in health care. The question is, who should make those judgments and in what circumstances?

On that subject, friend and erstwhile colleague Jeff Ackerman recently sent me an article from the Jerusalem Post discussing Israel’s 2008 budget for the state-subsidized basket of health services. It quoted advocates who are urging an increase larger than the 1% allocated by the national Treasury. It also included several stories of people described as being in dire need of drugs not yet included in the basket. Rationing is being done by government and people are objecting to the decisions being made.

Then last Sunday’s Boston Globe included a letter from Mitch Rabkin, long-time CEO of Boston’s Beth Israel Hospital, now retired. Commenting on an earlier article on the subject of health care costs, Rabkin stated as follows:

“Staff model HMOs and Medicare’s diagnosis-related group hospital payment arrangements, two effective cost-containment initiatives, show that transforming insurance risk to providers is fundamental to making the system efficient and effective.”

Staff model HMOs hire their own doctors and are paid a fixed monthly premium to provide care to their subscribers. Kaiser of California is probably the best-known example.

Medicare’s diagnosis-related group hospital payment system pays the hospital a pre-determined lump sum per admission based on the diagnosis.

Whereas the fee-for-service system gives providers an incentive to do more, these two approaches reward them for doing less (i.e., rationing) and, importantly, for being more efficient. As Rabkin suggests, they have proved effective in controlling cost. I would add that there is no evidence that they have on balance been harmful to patients.

Rationing being unavoidable, would you rather have it done by government or by providers? I side with Rabkin. Let the providers do it.

Monday, December 10, 2007

What Ails Healthcare

Anyone who wants to understand what ails our system of healthcare ought to get hold of a copy of the December 10, 2007 issue of the New Yorker magazine and read the article by surgeon Atul Gawande titled The Checklist.

In summary, the article is about how the use of checklists saves lives (and money) in hospital Intensive Care Units.

It is also about Dr. Peter Pronovost, a intensive care physician at Johns Hopkins Hospital in Baltimore and his pioneering work in the development and use of checklists.

The Checklist is a well written article about an interesting subject. But what brought me up short was the following that appeared near the end of the article:

“I [Gawande] asked him [Pronovost] how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care). ‘At the current rate, it will never happen,’ he said.”

When we fix that, we will have gone a long way towards reforming health care.

Wednesday, December 05, 2007

Policing Medicine

By now, nearly everyone has heard the question; “What do they call the person who graduated at the bottom of his medical school class?” and the answer; “Doctor.”

In other words, not all doctors are of equal competence and, being human beings, a few of them are incompetent – even dangerous. Because of the power they have over the lives of their patients, it is important that there be some protection against them.

Historically, that has been considered a part of medicine’s professional responsibility. It was expected that doctors as a group would identify those among them whose performance was unacceptable and do something about it.

That expectation took a hard hit in a survey recently reported in the Annals of Internal Medicine (The Boston Globe, December 4). Of the physicians who responded to the survey, 45% “Had direct personal knowledge of a physician in your hospital, group, or practice who was impaired or incompetent, and did not always report the physician.”

Dr. David Bates, chief of general internal medicine at Brigham and Women’s Hospital was quoted as saying he was surprised by the result. He shouldn’t have been. Every hospital administrator knows better than to count on medical staff support when dealing with a problem physician.

It has been that way for as long as I can remember. What is new is public concern about safety in health care and recognition of the important role of physicians.

Which raises the question; if the medical profession cannot police itself, who should do it?

I can imagine only two candidates. One is the medical licensure agency of the state and the other is hospitals.

Most state licensure agencies are trying, but their procedures, being legal in nature, are time-consuming and cumbersome. Dangerous physicians need to be dealt with now, not at the end of a tedious legal procedure.

Which leaves hospitals.

Tuesday, December 04, 2007

On Picking a Doctor

Riding home to Massachusetts from Iowa the other day, I was thumbing through Sky, the Delta Airlines magazine, and came across a page titled The Best Doctors in New York.

It reminded me of the common – if no longer necessarily valid - notion that the way to be assured of the best medical care is to pick the best doctor

It also reminded me of my last job, which was at Methodist Hospital in Houston – home base of the famous heart surgeon, Michael DeBakey. It occurred to me while working there that while we all believed that Dr. DeBakey was a good heart surgeon – even the best - we had no data to support that conclusion. It was entirely possible that some heart surgeon working in obscurity somewhere had better outcomes, but there was no evidence for that, either.

That is changing now that data on safety and outcomes are becoming available. To a large extent that data relates to hospitals, although there is also information about individual physicians.

The other factor to consider is the growing evidence showing that the quality of modern health care depends less and less on individuals and more and more on systems and processes that depend upon institutional support.

In light of all that, my own view is that the best way to be assured of good care is to first pick a good hospital and then get the hospital to recommend a doctor from its staff. For one thing, the hospital will know more about the doctor than can ever be learned from published data. For another, the hospital, by making a recommendation, assumes some responsibility for certifying the doctor’s competence.

That is what our household did the last two times a surgeon was needed and it worked for us.

Saturday, December 01, 2007

Half Way There

It is my distinct impression (though I can’t know for sure) that when the Institute for Healthcare Improvement was founded in 1991, its then and current CEO Don Berwick believed that if doctors and hospitals were taught how to improve the quality and safety of care, they would do it.

The intervening years of frustratingly slow progress have apparently convinced him otherwise. Together with colleague Steven Spear of the MIT faculty, Berwick authored an op-ed piece in the November 23, 2007 issue of the Boston Globe, titled “A new design for healthcare delivery.” It points out that the structure of healthcare delivery as it evolved over 50 years ago is based on professional specialty, with resulting “silos” of surgeons, nurses, cardiologists, pharmacists, etc. That arrangement served the needs of its time, but is no longer suitable now that effective health care depends less on individuals and more on the systems and processes that cross specialty lines and that have been found so difficult to manage.

They give examples of spectacular results achieved by hospitals that have made serious efforts to manage care. They put the onus of responsibility for undertaking such efforts where it belongs – on institutions; i.e., hospitals, nursing homes, dialysis units, ambulatory surgery centers, and physicians’ offices, as well as on programs of education in the health professions. Significantly, they make no mention of the medical profession as such (which has historically had jurisdiction over matters of quality) and deprecate the usefulness of “dramatic legislative, regulatory, and fiscal flourishes.”

They recognize that, instead, improvement requires “diffuse work” at the local level and leaders willing to get into the “nitty-gritty of patient care” and confront “professional norms.”

Perhaps in a future article they will address some of the cultural and practical barriers that stand in the way of carrying out their recommendations.

That would be good, but if it is true that you can’t solve a problem until you recognize it, we can at least take some comfort now from being halfway there.

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