Saturday, March 24, 2007
Sure but Slow
The venerated Massachusetts General Hospital (MGH) has long enjoyed the reputation of being the greatest hospital in the world.
How shocking, then, to read in last Saturday’s Boston Globe that it had been severely taken to task on quality issues by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the chief national accrediting agency for health care institutions. The headline read “Surprise check faults MGH quality of care.”
Not so long ago, JCAHO began to conduct its inspections unannounced. Before that, they were scheduled, giving hospitals a chance to get ready. Also, JCAHO inspections now focus on actual patient care rather than on matters of structure and process, as was previously the case.
So when JCAHO popped in on MGH late last year, it came up with a lengthy list of “requirements for improvement.” The number was eventually whittled down to ten. If it had been 14, the hospital would have gotten “conditional accreditation;” i.e., something like probation.
The article didn’t list all of the infractions, but mentioned four - failure to wash hands between patients, failure to complete medical records, failure to record the extent to which pain relievers were relieving pain, and failure to find out what drugs patients were taking before being hospitalized.
The Globe followed up on the subsequent Tuesday with a rather rambling editorial. It lauded unannounced inspections and called for government mandated hospital “report cards.” It treated MGH gently, saying that the problems found “are easily corrected” – which they are not - and noting that “hospital caregivers do make mistakes” – ignoring the system failures which more likely are the cause.
Apparently, people do not yet want to accept how pervasive and deep-seated are the issues of quality and safety in health care, even in the most prestigious hospitals. But the truth will finally out, surely if slowly.
The venerated Massachusetts General Hospital (MGH) has long enjoyed the reputation of being the greatest hospital in the world.
How shocking, then, to read in last Saturday’s Boston Globe that it had been severely taken to task on quality issues by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the chief national accrediting agency for health care institutions. The headline read “Surprise check faults MGH quality of care.”
Not so long ago, JCAHO began to conduct its inspections unannounced. Before that, they were scheduled, giving hospitals a chance to get ready. Also, JCAHO inspections now focus on actual patient care rather than on matters of structure and process, as was previously the case.
So when JCAHO popped in on MGH late last year, it came up with a lengthy list of “requirements for improvement.” The number was eventually whittled down to ten. If it had been 14, the hospital would have gotten “conditional accreditation;” i.e., something like probation.
The article didn’t list all of the infractions, but mentioned four - failure to wash hands between patients, failure to complete medical records, failure to record the extent to which pain relievers were relieving pain, and failure to find out what drugs patients were taking before being hospitalized.
The Globe followed up on the subsequent Tuesday with a rather rambling editorial. It lauded unannounced inspections and called for government mandated hospital “report cards.” It treated MGH gently, saying that the problems found “are easily corrected” – which they are not - and noting that “hospital caregivers do make mistakes” – ignoring the system failures which more likely are the cause.
Apparently, people do not yet want to accept how pervasive and deep-seated are the issues of quality and safety in health care, even in the most prestigious hospitals. But the truth will finally out, surely if slowly.
Thursday, March 22, 2007
Problems and Solutions
Early in my career, it occurred to me that there were many problems in this world and many solutions. The challenge was to match them up correctly.
I was reminded of that by an Op-Ed column that appeared in the March 4 issue of The Sunday Journal in Albuquerque, NM, a copy of which was kindly sent to me by long-time friend Bill Busby.
The piece was authored by Jim Hinton, CEO of Presbyterian Health Services, the major health care provider system in the city. The title was Getting Everyone Health Care Will Improve It. He called for “A transformation in health care in which quality and access to care accelerate while costs stabilize and ultimately decrease.” He went on to suggest the strategy for achieving these goals in New Mexico would be for the state to “look to a universal coverage model in which government is the facilitator but not the single payer.”
Hinton made a valiant effort to connect his solution to the problem. He talked about the current need to shift the cost of caring for the uninsured to the insured. He mentioned the different models of universal coverage being considered. He spoke of crisis care and emergency room overcrowding. He mentioned the Internet as a source of health information and the importance of rewarding providers for quality. He referred to preventable medical errors.
But just how achieving universal coverage would improve safety, quality and cost was never quite clear – at least to me.
My own conclusion is that universal coverage is a solution for the problem of the uninsured, but it has little relevance to these other issues and is being used as a smoke screen to distract attention from the failure of the provider community to address problems it could do something about if it would.
Early in my career, it occurred to me that there were many problems in this world and many solutions. The challenge was to match them up correctly.
I was reminded of that by an Op-Ed column that appeared in the March 4 issue of The Sunday Journal in Albuquerque, NM, a copy of which was kindly sent to me by long-time friend Bill Busby.
The piece was authored by Jim Hinton, CEO of Presbyterian Health Services, the major health care provider system in the city. The title was Getting Everyone Health Care Will Improve It. He called for “A transformation in health care in which quality and access to care accelerate while costs stabilize and ultimately decrease.” He went on to suggest the strategy for achieving these goals in New Mexico would be for the state to “look to a universal coverage model in which government is the facilitator but not the single payer.”
Hinton made a valiant effort to connect his solution to the problem. He talked about the current need to shift the cost of caring for the uninsured to the insured. He mentioned the different models of universal coverage being considered. He spoke of crisis care and emergency room overcrowding. He mentioned the Internet as a source of health information and the importance of rewarding providers for quality. He referred to preventable medical errors.
But just how achieving universal coverage would improve safety, quality and cost was never quite clear – at least to me.
My own conclusion is that universal coverage is a solution for the problem of the uninsured, but it has little relevance to these other issues and is being used as a smoke screen to distract attention from the failure of the provider community to address problems it could do something about if it would.
Problems and Solutions
Early in my career, it occurred to me that there were many problems in this world and many solutions. The challenge was to match them up correctly.
I was reminded of that by an Op-Ed column that appeared in the March 4 issue of The Sunday Journal in Albuquerque, NM, a copy of which was kindly sent to me by long-time friend Bill Busby.
The piece was authored by Jim Hinton, CEO of Presbyterian Health Services, the major health care provider system in the city. The title was Getting Everyone Health Care Will Improve It. He called for “A transformation in health care in which quality and access to care accelerate while costs stabilize and ultimately decrease.” He went on to suggest the strategy for achieving these goals in New Mexico would be for the state to “look to a universal coverage model in which government is the facilitator but not the single payer.”
Hinton made a valiant effort to connect his solution to the problem. He talked about the current need to shift the cost of caring for the uninsured to the insured. He mentioned the different models of universal coverage being considered. He spoke of crisis care and emergency room overcrowding. He mentioned the Internet as a source of health information and the importance of rewarding providers for quality. He referred to preventable medical errors.
But just how achieving universal coverage would improve safety, quality and cost was never quite clear – at least to me.
My own conclusion is that universal coverage is a solution for the problem of the uninsured, but it has little relevance to these other issues and is being used as a smoke screen to distract attention from the failure of the provider community to address problems it could do something about if it would.
Early in my career, it occurred to me that there were many problems in this world and many solutions. The challenge was to match them up correctly.
I was reminded of that by an Op-Ed column that appeared in the March 4 issue of The Sunday Journal in Albuquerque, NM, a copy of which was kindly sent to me by long-time friend Bill Busby.
The piece was authored by Jim Hinton, CEO of Presbyterian Health Services, the major health care provider system in the city. The title was Getting Everyone Health Care Will Improve It. He called for “A transformation in health care in which quality and access to care accelerate while costs stabilize and ultimately decrease.” He went on to suggest the strategy for achieving these goals in New Mexico would be for the state to “look to a universal coverage model in which government is the facilitator but not the single payer.”
Hinton made a valiant effort to connect his solution to the problem. He talked about the current need to shift the cost of caring for the uninsured to the insured. He mentioned the different models of universal coverage being considered. He spoke of crisis care and emergency room overcrowding. He mentioned the Internet as a source of health information and the importance of rewarding providers for quality. He referred to preventable medical errors.
But just how achieving universal coverage would improve safety, quality and cost was never quite clear – at least to me.
My own conclusion is that universal coverage is a solution for the problem of the uninsured, but it has little relevance to these other issues and is being used as a smoke screen to distract attention from the failure of the provider community to address problems it could do something about if it would.
Tuesday, March 13, 2007
Encouraging News
Occasionally, landmark developments pass by unnoticed.
One such may have been reported last week. The March 5, 2007 issue of The Boston Globe carried an article by Christopher Rowland, veteran medical reporter, about the increasing attention hospital trustees are giving to patient safety; i.e., “preventing errors that lead to patient injuries and deaths.”
It has long been a firm tenet of the culture of health care that matters relating to the practice of medicine and surgery were to be dealt with by the medical staff and not to be “interfered in” by managers or trustees. This same tenet is behind the statement, popular among politicians, that “medical decisions ought to be in the hands of doctors and patients.”
Those who pay attention to such things remember the Institute of Medicine report of 1999 which stunned the world of health care by reporting that as many as 90,000+ Americans were being killed each year by medical errors. As became clear both in the report and in subsequent discussion, many if not most of these errors could be traced not to unavoidable accidents or careless individuals but to flawed systems. An example would be the prescription of a drug by one doctor who did not know that the patient was on an incompatible drug that had been prescribed by another – or a patient given the wrong drug or dosage because the prescription was misread.
These system issues are not confined to either the professional or institutional components of health care; i.e., doctors or hospitals, and so remedies have to deal with both.
Correcting flawed systems is not something that doctors are organized to do, and so hospitals have to do it. But the traditional and deeply entrenched separation of institutional and professional roles in the culture of health care has made them reluctant to take on that responsibility. Progress in responding to the Institute of Medicine report has been slow accordingly.
Rowland’s report suggests that hospital trustees are beginning to recognize and accept the necessary role of hospitals in guaranteeing patient safety. That is encouraging news.
Occasionally, landmark developments pass by unnoticed.
One such may have been reported last week. The March 5, 2007 issue of The Boston Globe carried an article by Christopher Rowland, veteran medical reporter, about the increasing attention hospital trustees are giving to patient safety; i.e., “preventing errors that lead to patient injuries and deaths.”
It has long been a firm tenet of the culture of health care that matters relating to the practice of medicine and surgery were to be dealt with by the medical staff and not to be “interfered in” by managers or trustees. This same tenet is behind the statement, popular among politicians, that “medical decisions ought to be in the hands of doctors and patients.”
Those who pay attention to such things remember the Institute of Medicine report of 1999 which stunned the world of health care by reporting that as many as 90,000+ Americans were being killed each year by medical errors. As became clear both in the report and in subsequent discussion, many if not most of these errors could be traced not to unavoidable accidents or careless individuals but to flawed systems. An example would be the prescription of a drug by one doctor who did not know that the patient was on an incompatible drug that had been prescribed by another – or a patient given the wrong drug or dosage because the prescription was misread.
These system issues are not confined to either the professional or institutional components of health care; i.e., doctors or hospitals, and so remedies have to deal with both.
Correcting flawed systems is not something that doctors are organized to do, and so hospitals have to do it. But the traditional and deeply entrenched separation of institutional and professional roles in the culture of health care has made them reluctant to take on that responsibility. Progress in responding to the Institute of Medicine report has been slow accordingly.
Rowland’s report suggests that hospital trustees are beginning to recognize and accept the necessary role of hospitals in guaranteeing patient safety. That is encouraging news.
Sunday, March 11, 2007
Thoughts from McNulty
Tom McNulty, friend, erstwhile colleague, and retired CFO of Henry Ford Health System in Detroit has been reading these postings and has some thoughts to share:
…………………
The answer to the health care crisis in the United States does not exist.
The major issue is simply demand vs. who should pay for it.
The path to the solution has to start with the realization that the possible answers cannot be solved with bureaucratic process. A majority of our confusion is centered in the 30 percent of the cost of the programs being vested in the administrative and federally mandated regulated requirements.
Creating a simple process, such as vouchers (first suggested by the Brooking institute during the Carter administration and managed by professional non-governmental agencies) might have some appeal.
We continue to create legacy annuities for consultants, administrators and professional bureaucrats.
Maybe the answer is being simple and let the forces of the need select the direction.
Tom McNulty, friend, erstwhile colleague, and retired CFO of Henry Ford Health System in Detroit has been reading these postings and has some thoughts to share:
…………………
The answer to the health care crisis in the United States does not exist.
The major issue is simply demand vs. who should pay for it.
The path to the solution has to start with the realization that the possible answers cannot be solved with bureaucratic process. A majority of our confusion is centered in the 30 percent of the cost of the programs being vested in the administrative and federally mandated regulated requirements.
Creating a simple process, such as vouchers (first suggested by the Brooking institute during the Carter administration and managed by professional non-governmental agencies) might have some appeal.
We continue to create legacy annuities for consultants, administrators and professional bureaucrats.
Maybe the answer is being simple and let the forces of the need select the direction.
Friday, March 09, 2007
Mugglie on Walter Reed
Minnesota Social Worker Cindy Mugglie has the following comment regarding the Walter Reed military hospital situation:
……………………
The situation at Walter Reed is disturbing but not surprising; it sounds like another case of what I like to call the Vegas Syndrome. What happens in Vegas stays in Vegas, and what happens in our institutions stays in our institutions, at least until the problems become large enough to catch the attention of the media.
Minnesota Social Worker Cindy Mugglie has the following comment regarding the Walter Reed military hospital situation:
……………………
The situation at Walter Reed is disturbing but not surprising; it sounds like another case of what I like to call the Vegas Syndrome. What happens in Vegas stays in Vegas, and what happens in our institutions stays in our institutions, at least until the problems become large enough to catch the attention of the media.
Thursday, March 08, 2007
Questions
Ed Ablard is on my blog list because of a conversation during coffee hour at my church. He has some questions:
……………………….
My stepmother (87) recently renewed her membership in National Committee to Preserve etc. Their recent push is to close the hole in the prescription doughnut, to make Medicare the price arbiter of drugs and set the price, and make Medicare a provider along with insurers. Can you spark some dialogue from your readers about these items?
Second, I am starting a study of best practices for screening school age kids. Would you encourage your readers to find out what the local schools are doing about making sure kids can see in school and get glasses as needed around their neighborhoods and post a reply?
The Academy of Opthalmology guidelines are silent after about 5 yrs. What is the standard for screening equipment? Still the eyechart or some electronic gizmo like Titmus or other?
Ed Ablard is on my blog list because of a conversation during coffee hour at my church. He has some questions:
……………………….
My stepmother (87) recently renewed her membership in National Committee to Preserve etc. Their recent push is to close the hole in the prescription doughnut, to make Medicare the price arbiter of drugs and set the price, and make Medicare a provider along with insurers. Can you spark some dialogue from your readers about these items?
Second, I am starting a study of best practices for screening school age kids. Would you encourage your readers to find out what the local schools are doing about making sure kids can see in school and get glasses as needed around their neighborhoods and post a reply?
The Academy of Opthalmology guidelines are silent after about 5 yrs. What is the standard for screening equipment? Still the eyechart or some electronic gizmo like Titmus or other?
Monday, March 05, 2007
Walter Reed
I can imagine what happened.
Three things we know for sure:
The problem was focused in the outpatient programs.
The problem has been known about for some time but only recently became a public issue.
Defense Department authorities have been careful to exonerate the physicians and other caregivers at Walter Reed.
Here is my theory:
1. The ideology that governed the Defense Department in its conduct of the Iraq War did not permit preparation for the number of soldiers and marines who would require treatment and the severity of their injuries.
2. As the war became more costly and lengthier than anticipated, budgetary pressures within the Defense Department became severe. Combat operations took priority. Stateside operations, including medical, were short-changed.
3. The senior military officers in charge of the medical programs, being good soldiers, tried to make the best of it. Realizing that people would listen if the in-patient oriented senior physicians complained publicly, they supported inpatient programs at the expense of outpatient, where complaints were less likely to be heeded.
The strategy worked for two or three years and if the war had ended in a timely way it might have been successful. But it didn’t and the situation finally blew up.
What will happen now is like what happened in the Catholic sex scandals. The generals, like the bishops, who were doing what was expected of them will be sacrificed. More lucky generals will be allowed to fix the problem, the new Secretary of Defense will look like a hero, and the public’s attention will be drawn elsewhere.
I can imagine what happened.
Three things we know for sure:
The problem was focused in the outpatient programs.
The problem has been known about for some time but only recently became a public issue.
Defense Department authorities have been careful to exonerate the physicians and other caregivers at Walter Reed.
Here is my theory:
1. The ideology that governed the Defense Department in its conduct of the Iraq War did not permit preparation for the number of soldiers and marines who would require treatment and the severity of their injuries.
2. As the war became more costly and lengthier than anticipated, budgetary pressures within the Defense Department became severe. Combat operations took priority. Stateside operations, including medical, were short-changed.
3. The senior military officers in charge of the medical programs, being good soldiers, tried to make the best of it. Realizing that people would listen if the in-patient oriented senior physicians complained publicly, they supported inpatient programs at the expense of outpatient, where complaints were less likely to be heeded.
The strategy worked for two or three years and if the war had ended in a timely way it might have been successful. But it didn’t and the situation finally blew up.
What will happen now is like what happened in the Catholic sex scandals. The generals, like the bishops, who were doing what was expected of them will be sacrificed. More lucky generals will be allowed to fix the problem, the new Secretary of Defense will look like a hero, and the public’s attention will be drawn elsewhere.
Friday, March 02, 2007
The Usefulness of Analogies
Pat Keith is a retired elementary school principal. I know her because we share grandsons. Here are her thoughts on the usefulness of analogies and their application to health care:
…………………..
As a retired educator and administrator who has no expertise in health care management, it helps me to speak to the improvement of health care in educational terms. We know there is no "easy button" for such a complicated problem; however, it is incumbent upon each of us to be responsible patients and responsible caretakers of the very young and very old. If we consider patients as "children", doctors as "teachers", advocates as "parents" and health care managers as "school administrators", we can draw analogies that make sense to us all.
For the best outcomes to be achieved, children need to do their homework, follow some basic rules, ask the right questions and engage in the learning process; supported, encouraged and supervised by their parents. Teachers must know their craft, study, consult their colleagues, treat each child with dignity and recognize individuals who may learn in a way unlike others. A sense of humor is required!
Then we have the principals who need to be out of their offices and in the classrooms, with a finger on the pulse of the building overall. They continually evaluate programs and personnel, keeping what works and discarding what doesn't. They must listen, counsel, budget creatively and make tough decisions - always putting children first.
I am confident that each reader could continue these analogies. Such requirements of the principal players in health care would be an "elementary" but strong beginning in improving the system.
Pat Keith is a retired elementary school principal. I know her because we share grandsons. Here are her thoughts on the usefulness of analogies and their application to health care:
…………………..
As a retired educator and administrator who has no expertise in health care management, it helps me to speak to the improvement of health care in educational terms. We know there is no "easy button" for such a complicated problem; however, it is incumbent upon each of us to be responsible patients and responsible caretakers of the very young and very old. If we consider patients as "children", doctors as "teachers", advocates as "parents" and health care managers as "school administrators", we can draw analogies that make sense to us all.
For the best outcomes to be achieved, children need to do their homework, follow some basic rules, ask the right questions and engage in the learning process; supported, encouraged and supervised by their parents. Teachers must know their craft, study, consult their colleagues, treat each child with dignity and recognize individuals who may learn in a way unlike others. A sense of humor is required!
Then we have the principals who need to be out of their offices and in the classrooms, with a finger on the pulse of the building overall. They continually evaluate programs and personnel, keeping what works and discarding what doesn't. They must listen, counsel, budget creatively and make tough decisions - always putting children first.
I am confident that each reader could continue these analogies. Such requirements of the principal players in health care would be an "elementary" but strong beginning in improving the system.
Thursday, March 01, 2007
A Hazard to Recognize
Last night I channel surfed onto Question Time in the British Parliament and saw Prime Minister Tony Blair and opposition leader David Cameron debating whether under Blair’s Premiership the number of hospital beds in Great Britain had increased or decreased and, in either case, whether that was good or bad. Both were making valiant efforts to make it appear that they knew what they were talking about.
It reminded me that shortly after the University of Kentucky Hospital opened in 1962, I became aware that people throughout the Medical Center were giving different answers when asked how many beds the hospital had in operation. Bill Ennis was my associate at the time and I resolved the matter by declaring that the number of beds in operation was the number that Bill Ennis said were in operation.
If individual hospitals have trouble knowing exactly how many beds they are operating at any point in time (and I assume they still do), then it seems pretty silly for high-level politicians to be debating how many beds are in operation in the entire country.
One of the hazards of large, complex organizations is the tendency of their executive heads to act like experts on subjects they know nothing about. It’s a factor worth keeping in mind as we undertake to redesign our health care system.
Last night I channel surfed onto Question Time in the British Parliament and saw Prime Minister Tony Blair and opposition leader David Cameron debating whether under Blair’s Premiership the number of hospital beds in Great Britain had increased or decreased and, in either case, whether that was good or bad. Both were making valiant efforts to make it appear that they knew what they were talking about.
It reminded me that shortly after the University of Kentucky Hospital opened in 1962, I became aware that people throughout the Medical Center were giving different answers when asked how many beds the hospital had in operation. Bill Ennis was my associate at the time and I resolved the matter by declaring that the number of beds in operation was the number that Bill Ennis said were in operation.
If individual hospitals have trouble knowing exactly how many beds they are operating at any point in time (and I assume they still do), then it seems pretty silly for high-level politicians to be debating how many beds are in operation in the entire country.
One of the hazards of large, complex organizations is the tendency of their executive heads to act like experts on subjects they know nothing about. It’s a factor worth keeping in mind as we undertake to redesign our health care system.
