Hospitals

QUALITY: On-the-Job Training Lowers Turnover Rate of Nurses

Health Policy — Tue, 17 Feb 2009 19:15:00 -0500

After decades of letting newly-licensed nurses sink-or-swim on the job, some hospitals are finally tossing their new nurses a life preserver. The goal is both better quality care—-and fewer newly-minted nurses who quit.

According to the Los Angeles Times, a recent national study found that one in five newly licensed nurses quit within their first year of work. This is not what we need given our nursing shortage. Peter Buerhaus, of the Vanderbilt University Medical Center, told the LA paper that we could have a shortage of 500,000 nurses by 2025, due to increasing rates of retirement and the demands of the aging baby-boom generation. This shortage too comes at a time when nurses may actually have a larger role to play in a reformed health where we place more emphasis on primary care, care coordination, and management of chronic diseases.

Many nurses point to stress, lack of supervision, and poor on-the-job training as their reasons for leaving the field. Unlike medical school graduates, nurses have no formal residency in which they can get comfortable with their jobs, practice their skills, and gradually take on more responsibility for patient care. Most nurses are simply left to figure everything out on their own, a practice which strains their ability to deliver patient care.

In 2004, Childrens Hospital in Los Angeles started a program to help train new nurses and combat the high turnover rates. The Versant RN Residency, which has now spread to more than 70 hospitals across the U.S., pairs up new nurses with more experienced nurses. At first, the new nurse will just observe as she completes a lengthy checklist of competence in vital skills, but by the end of the 18-week partnership, the new nurse will be doing hands-on patient care work while the more senior nurse supervises.

Even though programs such as Versant cost about $5,000 per resident, the cost of replacing a nurse, including recruiting, training, and covering for a short-handed staff, will usually cost about 10 times as much. The Versant program in particular has been successful for many hospitals; the Baptist Health South Florida in Miami reports that the nurse turnover rate has dropped from 22 to only 10 percent since the program was implemented a year and half ago.

We sometimes fail to appreciate the vital role nurses play, both in the direct care they provide for patients as well as their insights into how to improve care systems. For any new care model to be successful, the cooperation and support of nurses is necessary. They are playing a big role in programs to help ease patients from hospital to home. Nurses are very close to the day-to-day work of a hospital, giving them an excellent vantage point for spotting problems in care delivery and innovating solutions. So nurse retention is good economics, and good medicine.

COST: Hospitals and the Economic Crash

Joanne Kenen — Wed, 07 Jan 2009 18:55:00 -0500

There's a strain of conventional wisdom that the health sector is recession-proof but it's not so clear that it's true when a recession is this broad and deep. Many people who are losing their jobs also are losing their insurance, and there's ample data to remind us that the uninsured and the underinsured skimp on care, which in turn affects hospitals and other providers. Even the insured are watching their health care pennies. PBS's NewsHour, in the first of a three-part series this week, profiled a husband and wife paying $800 a month for a family health insurance policy but their out-of-pocket expenses were still so high (and his mortgage-industry income nicked because of the real estate crash) that they had to choose between treating her gall bladder problems or his lung infection.

The American Hospital Association, in a bid to secure hospitals a share of the upcoming stimulus package, started running ads noting that community hospitals directly employ more than 5 million people, and hospitals support a tenth of all US private sector jobs. In 2007 45 percent of all new private sector jobs were in health care. But income is down as patients delay getting care and the demand for uncompensated care rises. Many hospitals are feeling the pinch.

Health blogger Jane Sarasohn-Kahn, whose Healthpopuli blog often addresses hospital finances, writes that hospitals reported an 8 percent increase in uncompensated care between the third quarter of 2007 and third quarter of 2008. AHA says admissions are down, elective surgeries are down, investment income is down, access to capital has shrunk. The only thing that's up is unpaid bills and bad debt. These conditions, Sarasohn-Kahn says "will no doubt erode the very heart of too many American hospitals" this year.

The NewsHour interviewed a hospital exec in Nashville who made the same point:

BETTY ANN BOWSER: Everything costs more, including health care. Doctors here at the city's Baptist Hospital are seeing dramatic evidence of what happens when health care costs continue to rise in an economic downturn.

In the past few months, there's been a 40 percent increase in the number of patients who've cancelled appointments with the hospital's cardiology practice, many of whom are insured.

CEO Charlie Powell says these are people who have serious heart conditions.

CHARLIE POWELL, CEO, St. Thomas Heart Baptist Hospital: The longer you put off preventive care, the more likely you are to end up in the emergency room and come much closer to a situation where death could be the result of a serious cardiac condition.

BETTY ANN BOWSER: So these people are literally flirting with death?

CHARLIE POWELL: Absolutely. What we're now seeing is those people with insurance making these decisions, as well.

A glance at newspapers around the country (assuming that newspapers survive their own economic meltdown but don't get us started) shows some hospitals are already in crisis:

The Atlanta Journal-Constitution reports that Clayton County's only hospital will stay open and employees will keep their jobs after the county commission voted at the last minute to back a $40.2 million bond for Southern Regional Health System. That means the 331-bed hospital will not default on its loan.

The Philadelphia Inquirer reports that the Hospital and Healthsystem Association of Pennsylvania has released results of a December survey showing that tight credit, ailing stocks, and financially strapped patients are hurting the state's hospitals. Forty-two percent reported a moderate to significant effect on their day-to-day financial operations, and three-quarters are forecasting a moderate to significant effect on their financial stability this year.

The Tennesseean reported that credit crunch derailed the planned sale of and HCA hospital in Pensacola, Fla. The locally owned not-for-profit health care system that sought to buy West Florida Hospital couldn't secure financing.

And back in Atlanta, health advocates criticized beleaguered Grady Memorial Hospital for proposing to raise costs for some uninsured patients, saying hospital leaders were being insensitive to poor people who use Grady as their health center of last resort. Grady CEO Michael Young said the hospital wants "to make sure that people who can afford to pay something will pay something" but will not deny care to those in need.

So if hospitals are a strong sector, we'd hate to think about what's happening to the weak sectors. (Never mind, we already know.)

COST: The Slump's Impact on the Health Care Sector

Joanne Kenen — Mon, 24 Nov 2008 17:46:00 -0500

Health care is usually deemed more or less recession proof. Maybe not this time, according to a recent Chicago Tribune article that analyzed several Moody’s Investor Service reports on sectors including hospitals, medical devices and insurance companies. Bottom line: Moody's revised the health care industry’s 12- to 18-month outlook from "stable" to "negative."

The analysts expected more uninsured people, because of growing joblessness, and postponement of nonemergency surgeries. Nonprofit hospitals are also expected to feel the pinch of less access to financing through the tax-exempt debt market. A survey by the American Hospital Association (hat tip to Jane Sarasohn-Kahn at Health Populi) found that 40 percent of US hospitals have seen a drop in inpatient admissions, in the third quarter of this year compared to the same time period in 2007. Meanwhile, uncompensated care rose, and it got harder to borrow money. (Health Populi also speculated, however, that people with employer-sponsored insurance who are worried about losing their job might speed up discretionary health spending while they are still covered, despite the much higher deductibles workers now face—$1000 is now not uncommon for an individual.)

"The current uncertainty surrounding political solutions with respect to health care at both the state and federal levels hinders insurers' ability to develop focused strategic plans," the Tribune quoted Moody's Vice President Stephen Zaharuk as saying. "More urgently, reimbursement cuts to insurers for Medicare Advantage programs and pressure on state budgets for Medicaid spending are threatening the growth and profitability of these segments."

Democrats have long complained of the extra costs to the government from payments to Medicare Advantage (privately-operated managed care plans for seniors.) Today’s New York Times reports on two new studies appearing in Health Affairs that show that the plans are increasing Medicare’s costs and complexities without improving care of the elderly. President-elect Barack Obama and Congressional Democrats are already expected to consider cutting MA payments.

HEALTH REFORM: The Health Agenda of a Hockey Mom

Joanne Kenen — Fri, 05 Sep 2008 19:02:00 -0400

We just posted an item about how health played at the conventions. Now for those of you who want to learn something about Gov. Sarah Palin's health reform history, here's some recommended reading.

The Washington Post and the Wall Street Journal both look at her record on health care in Alaska, and find it's fairly slim. Her focus was naturally in keeping with her free market philosophy. She pushed for more transparent information for consumers, and waged an unsuccessful fight to end the state's certificate of need rules, even after an expert panel she appointed recommended that the CoN law remain on the books.

Critics of CoN laws, Palin included, say they add another layer of government regulation that impedes competition and keep prices artificially high. Backers say they encourage overutilization and high prices. Hospital sometimes argue that they will be hurt if smaller clinics are allowed to compete for profitable services like MRIs but not pick up the less profitable or money-losing services, like caring for the uninsured. Good blog posts on this topic (which explain more about what Certificate of Need means and does) include Bob Laszewski's here and Joe Paduda's here.

CULTURE BEAT: "HOSPITAL" Takes Us Inside Culturally Complex Brooklyn Hospital

Joanne Kenen — Mon, 19 May 2008 15:19:00 -0400

Picture an urban hospital where 67 languages are spoken, the Chinese food is glatt kosher, and the most exotic ethnic species is a blond Nebraskan surfer named Davey doing his medical residency in the E.R. Welcome to Maimonides Medical Center, in Borough Park, Brooklyn.

In HOSPITAL: Man Woman Birth Death Infinity Plus Red Tape Bad Behavior Money God and Diversity on Steroids author Julie Salamon gives rare insight into one year in the life of a large, complex, urban hospital (Read Jackie Judd's interview with Salamon about her new book here). In 2003, Maimonides admitted 38,667 patients, 127,319 were seen in its outpatient clinics, and 81,190 passed through the Emergency Department. More than 6,000 babies were born; more than 1,000 people died.

Julie (we overlapped on a health reporting fellowship last year, although I knew her writing before I knew her) is a cultural critic, not a policy wonk. The narrative she tells is more about the drama and feuds and loves and losses and financial fights and towering egos of doctors, administrators and even the cleaning crews than it is about health policy. In fact, we only meet a handful of patients (most of those she focuses on were poor and dying, depending on the hospital to meet many needs beyond medical care). But she had astonishing access to the people who somehow or other—despite the shockingly abundant "bad behavior"—cared enough not only to keep serving their multiethnic community but to keep trying to do a better job:

Depending on the day or night, life in the hospital could seem full of exquisite promise or pointless despair. The system was tainted by callous disregard for decent and equitable care, by money lust, by corporate influence and by lack of political will. But a great many people who were part of the system wanted something better. Yes individual doctors and nurses behaved badly, sometimes inexcusably so. Clerks were rude to patients and to each other. People made mistakes. Yet I was constantly struck by the sense of urgency that accompanied desires for fairness, for compassionate medicine, for efficiency, for meaning—and yes, for cleaner rooms.

It's an easy read and a rich story.

INNOVATORS: Wisconsin Hospitals Trim Waste and Improve Care

Joanne Kenen — Fri, 11 Apr 2008 15:05:00 -0400

"There are two things we need to do in medicine," a hospital administrator told Guy Boulton of the Milwaukee Journal Sentinel recently. "We need to learn to see waste. And we need to see risk."

The paper wrote a thoughtful two-part series (here and here) recently documenting how ThedaCare, a four-hospital chain in Wisconsin, has used those two guiding principals not just to save money but to improve patient care. They've re-examined everything from washing sheets to heart surgery. They've saved money—and improved outcomes for patients. They've shortened waits for appointments for CT scans. And they've eliminated hundreds of forms.

One example: an uncomplicated heart bypass surgery, including the doctors' fees, cost $30,400 at a ThedaCare hospital. At some other southeastern Wisconsin hospitals, insurers pay more than double that.

A lot of the improvements can be seen in the general medicine unit at ThedaCare's Appleton Medical Center, where they've introduced a model called "Collaborative Care." The unit serves patients with infections, pneumonia, heart failure, and similar problems. The improvements have cut the amount of time patients typically stay in the hospital by 20 percent.

In this context, "Collaborative" is more than a buzzword. Doctors now make rounds with a pharmacist and a nurse. A care manager (who deals with things like insurance coverage or follow up home care) sometimes joins them. The pharmacist can chime in about the doctor's prescription choices, for instance, reducing the risk of errors or dangerous drug interactions. The collaboration also reduces the number of frantic calls to the doctors' pagers. Nurses are more involved in coordinating care; more routine aspects have been turned over to licenses practical nurses or trained aides.

By focusing on reducing waste, ThedaCare is joining a number of hospitals trying to implement Toyota's proven methods of increasing quality and reducing cost. We wrote about the similar journey of Seattle's Virginia Mason Medical Center last month.

Coincidentally, we were attending a conference about reinventing practice sponsored by the Institute of Healthcare Improvement when this article came out. ThedaCare and its culture of change has caught IHI's attention, too.

QUALITY: What If All Patients Could Go to a "Benchmark Hospital"? Part II

Tom Emswiler — Fri, 21 Mar 2008 17:10:00 -0400

Yesterday I posted on this year's "100 Top Hospitals: National Benchmarks for Success" list, released this week by Thomson Healthcare. I promised I would post today about how to get from here to there.

I bet you lost sleep with anticipation!

Again, I want to quote Steven Pearlstein's column last year on this issue, specifically the story of how Winchester Medical Center in Virginia responded to its "somewhat disappointing" report a few years ago:

Winchester Medical Center set a goal of making the Top 100 list by 2008. It hired a consultant, altered its executive compensation to put a bigger emphasis on quality and organized teams in every department to implement small changes in procedures that translate into big improvements in its quality score.

After nurses took extra time to take fuller medical histories, and body hair was clipped rather than shaved before surgery, and the timing was changed on when antibiotics were administered, for example, surgical infection rates fell by 75 percent.

And by creating special emergency teams to focus on heart attack patients as soon as they were picked up by an ambulance, Winchester reduced the time it took to get a patient to a catheterization lab to 40 minutes from an average of 120.

This is proof that hospitals can learn. While Winchester indeed learned a new way of doing things, we need to move towards a better way to disseminate health best practices, so that other hospitals can more easily learn from Winchester's hard work.

A recent paper by Thomas Bodenheimer takes a look at the "Science of Spread" - or, how dissemination in the health world differs from the non-health world. Donald Berwick's life's work is to disseminate best practices, but also has written an academic how-to manual on spreading innovations in health care in one's own organization.

Relevant and rewarding non-health dissemination works include Malcolm Gladwell's The Tipping Point and Made to Stick by Chip and Dan Heath, as well as Everett Rogers' Diffusion of Innovations, which Bodenheimer cites as the seminal work on the topic.

Here at the New America Foundation, we are trying to do our part. My boss Len Nichols and I are putting the finishing touches on a case study of the Hill Physicians Medical Group, an independent practice association in northern California that is helping its affiliated-yet-independent physicians improve the quality of care they provide by gaining their trust and then working with them as collaborators. We'll post a link on the NHD blog when it's finished.