Quality

QUALITY: What It's Really Like to Try to Make Sure Your Mom Is Taken Care of -- Even in the Hospital Where You Work

Joanne Kenen — Fri, 16 May 2008 16:56:00 -0400

We often talk about lack of coordination of care for people with chronic diseases or complex conditions. Here's a too vivid example—and keep in mind that the author of this letter, the adult daughter of a patient with a brain tumor, worked at the hospital, a fine hospital that is at the forefront of the move to improve care quality:

Another issue is communication between specialties. My mom was part of the Neurology Service. She started on Stroke, moved to Epilepsy, then to Neuro. Oncology, then back to Epilepsy and now is back on Neuro. Onc. Did you follow that? I have come to learn that Neurologists are highly specialized. You can't ask a Neuro Oncologist about your mom's seizure meds. You have to go to her Epilepsy Neurologist. Depending on what floor you are on, the quarterback varies. My mom was transferred from one floor to another and she ended up with a whole new attending that I had never met. What made it worse was she had one for the weekend and then a new one starting the following Monday because it was a new month. Again, I work here so I knew who to call, but imagine the 80 year old man trying to take care of his wife. Lack of information is so frustrating. There needs to be a better way to communicate with families and patients.

The author of this letter, which Boston's Beth Israel president Paul Levy published in full on his blog, goes on to describe other hassles and heartbreaks ranging from someone forgetting to order food for the patient for two days to an unnecessarily curt conversation about hospice. It isn't just about convenience and inconvenience and waiting and logistics—it's also about medication errors, inadequate case management, and the quality of care. Levy is unusual in that he posts letters like this for the world to see, and then follows up with solutions, like the simple fix his staff designed a few weeks ago about where to store pulse oximeters. We'd like to hear more about how Beth Israel follows up on the suggestions this family made because, as the woman who wrote this letter pointed out, if she as an educated hospital employee has to fight this hard on her mother's behalf, what about the 80-year-old man taking care of his ailing wife, or the family with limited English, or someone without the education and training to know that someone has written into the discharge orders not one, not two, but three wrong medications.

QUALITY: Baylor Receives National Quality Healthcare Award

Tom Emswiler — Thu, 15 May 2008 16:01:00 -0400

There's a big story (subscription required) in this week's Modern Healthcare magazine describing the great care being delivered by the Baylor Health Care System in Dallas. The article is inspired by the National Quality Healthcare Award that Baylor will receive tonight from the National Quality Forum, Modern Healthcare, and the Studer Group.

The article states that through devotion to data transparency and analysis, Baylor is able to identify preventable adverse events including falls, medication errors, and surgical site infections, and analyze not only the degree to which they can be prevented, but also specific actions (such as a malfunctioning safety device or poor communication) as well as inactions. They also provide quality and performance data on their intranet so that physicians and staff can track their performance.

But my favorite anecdote is this:

Inpatients at Baylor Health Care System in Dallas don't have to wait until they're in crisis to get a visit from a rapid response team.

The team, made up of a nurse, a respiratory therapist and sometimes a hospitalist or intensivist, is available whenever a nurse feels she needs extra help or a second set of eyes and hands with a struggling patient, or when a patient's physician calls in and needs an immediate assessment. Even family members can summon the RRT if their loved one just isn't looking right. Instituted in 2006, the teams have contributed to a 12% drop in inpatient mortality.

You read that right. Just by being more responsive to a nurse, physician, or family member's uneasiness, Baylor is able to save lots of lives. Dr. Carl Couch, co-Chair of Baylor's Best Care Committee and Dr. Don Kennerly, their Chief Patient Safety Officer, both told us that a few years ago the Baylor culture didn't have a tolerance for false alarms, but now allows for and even rewards those who call the RRT over something that turns out to be nothing. It's okay to not be right 100 percent of the time. That way, no one is afraid to make the call. The results are nothing short of impressive.

Dr. Guy Clifton, my colleague on the health policy team here at New America, and I had the pleasure of visiting Baylor last month, and we (with Len Nichols) are currently writing a case study that the Commonwealth Fund will publish later this year. Baylor is doing truly remarkable things—this is only the tip of the iceberg.

QUALITY: New Initiative Aims to Eliminate Preventable Birth Injuries

Tom Emswiler — Thu, 15 May 2008 14:24:00 -0400

Premier Hospitals are best known in health policy circles for their innovative and successful Pay-for-Performance initiative, as well as winning a Baldrige Award in 2006. This week they unveiled a new program aimed at eliminating preventable birth injuries at 16 participating hospitals.

According to their presentation, three birth-related injuries occur per 1,000 deliveries, and most of the time the specific causes can be identified. Participating hospitals will implement a 21-month collaborative using care bundles (more on that below), identify best practices and measure the cost and quality associated with those practices, and share outcomes to help other hospitals improve. It runs from April 2008 to December 2009.

Approximately 115,000 babies will be delivered at these six hospitals during the nearly two-year program; that means as many as 345 injuries could be prevented, including birth asphyxia (little or no breathing by the infant), cerebral palsy, permanent disability, and death.

The slides from the presentation state that five occurrences are responsible for most adverse perinatal events:

Failure to recognize fetal distress
Failure to proceed with a timely cesarean birth
Failure to properly resuscitate an unresponsive baby
Inappropriate use of labor-inducing drugs
Inappropriate use of vacuum/forceps

The 16 hospitals will begin by implementing the following three care bundles; each bundle has four or five required steps (steps can be skipped only for specific medical reasons). The bundles were developed by Premier, the Institute for Healthcare Improvement, and Ascension Health (two are described in detail in this paper):

Elective Induction Bundle—Four steps to determine whether it is safe for mother and baby to have labor induced via medication

Augmentation Induction Bundle—Four steps to determine whether it is safe for mother and baby to increase the frequency and strength of contractions via medication

Vacuum/Forceps Bundle—Five steps to determine whether it is safe for mother and baby to have delivery assisted via vacuum extractor or forceps

The participating hospitals are also using certain teamwork and communication tools to help implement the three bundles.

Frank Perez, CEO of Kettering Health Network, was on hand to discuss their work in recent years implementing the bundles at Kettering Medical Center. He said that by posting bundle-completion data by physician name in the hospital (unblinded!), compliance went from 40 percent to 90 percent in just one year. Nothing like a little peer pressure.

Amy Hailey, a certified registered nurse and Director of Women's Services at both Texas Health Harris Methodist Fort Worth Hospital and Texas Health Presbyterian Hospital of Dallas, was on hand to discuss their involvement at 2 of the 16 hospitals. Dr. Hal C. Lawrence, III from the American College of Obstetricians and Gynecologists shared the dangers of late preterm deliveries (35 to 37 weeks gestation) that are not medically necessary, including higher incidences of sudden infant death syndrome and learning disabilities.

USA Today writes this morning on the project here. We look forward to the results of this collaborative, and we'll be sure to post related news as it becomes available.

QUALITY: "Lucky 13" Policy Wonks Map Out Path to Health Quality

Julie Barnes — Tue, 13 May 2008 14:23:00 -0400

A lucky 13 top-notch health policy wonks outlined concrete and achievable stops to improve quality, reduce cost, and repair our health care system in the May/June issue of Health Affairs. For instance, beyond the common refrain for increased use of "evidence-based" medicine, the "Quality Crossroads Group" called on Congress to immediately create a national center to support effectiveness research so we can at least get started on examining what treatments work best and when to administer them.

We also liked the call by the authors, including New America's Len Nichols, to replace the fee-for-service payment model with systems that reward clinically effective and efficient population health management--like bundled chronic care episode payments and paying for population health performance.

As we continually say in this space and elsewhere, successful reform must address coverage, costs and quality at the same time. This Quality Crossroads Group outlines better and more succinctly than most how quality improvement, cost containment, and coverage expansion are inextricably linked. Ultimately, the group offered five ways to achieve a high-performance health system:

Create a national center for effectiveness research.
Develop models of accountable health care entities capable of providing integrated and coordinated care.
Develop payment models to reward high-value care.
Develop a national strategy for performance measurement.
Pursue a multistakeholder approach to improving population health.

To be succinct, we agree.

HEALTH IT: Calling Sherlock Holmes

Joanne Kenen — Tue, 06 May 2008 21:01:00 -0400

We're suckers for medical mysteries like the one in today's Washington Post health section headlined "Five Doctors, Stumped." Today's medical whodunit (or more accurately who-didn't-do-it) was about the misdiagnosis of a woman named Bettie Munro, thought to have Parkinson's disease. Munro did not have Parkinson's. Instead, an upset stomach among other things had changed how her aging body was absorbing lithium, creating a toxic condition. One sentence near the end of the story particularly struck us, "One physician said he thought another had checked her (lithium) level, so he didn't bother." It made us think about the interview we just posted with Dr. Carol Diamond, an expert on health information technology at the Markle Foundation. We don't believe (and Diamond doesn't assert) that health IT will stop every medical mistake, avoid every misdiagnosis, create a perfect world of health and harmony. But we can't help wondering: if the five doctors caring for Bettie Munro—a psychiatrist, a neurologist, her internist, a gastroenterologist and her husband, a retired obstetrician—had all been reading one computerized medical record, with all her medications, all her lab work, all her symptoms, all their (legible) notes, wouldn't there have been a pretty decent chance that one of them would have figured out what was wrong? Or what needed to be done? She and her family would have suffered less. And the health care system would have saved $100,000 in tests, medicines and unnecessary hospitalizations.

HEALTH IT: Markle's Carol Diamond on Making the Connections (Part 1)

Health Policy — Tue, 06 May 2008 15:43:00 -0400

Many Washington, D.C. policymakers (including the presidential candidates) talk about the need for more health information technology. Everyone seems to agree that health IT will improve quality and can help control costs. For instance, RAND has estimated that greater use of health IT will yield an annual efficiency savings of $77 billion over 15 years. A study in JAMA showed that when doctors use computers to order medications, preventable errors drop by as much as 55 percent. Another study in the Annals of Internal Medicine showed 12 to 20 percent improvements in compliance with physician guidelines and other benefits. Despite all this agreement, we haven't quite figured out how to get from here to there. So we asked Carol Diamond, M.D., M.P.H., the Managing Director of the Health Program at the Markle Foundation in New York, to share her insight into how we can overcome the policy and technical challenges and bring 21st century tools to our paper-based health system.

Q: Health IT can be confusing. If you were at a cocktail party, how would you describe what you do?

A: Markle's work centers on the idea that emerging information and communications technologies can improve peoples' lives. That includes the health arena. We are working to accelerate the rate at which modern information technology enables consumers, and the health system that supports them, to improve health and health care.

Health lags behind other sectors in taking advantage of 21st century information tools. We know there are great benefits to modernizing the way health information is collected, shared, and analyzed. Our work takes on the challenges that have so far prevented the widespread adoption of these tools. When we can overcome these challenges, and accurate information is available to consumers and those who care for them, the result will be better and safer health care.

Q: What is Connecting for Health?

A: Connecting for Health (http://www.connectingforhealth.org/) is a public-private initiative established by Markle in 2002 that brings together a diverse group of health, policy, and technology leaders. Though each person brings a particular perspective, together, we share a single purpose: to improve health and health care for consumers by advancing use of health information technologies (HIT). Over the years, more than 100 organizations have been participating in Connecting for Health, including consumer groups, clinicians, hospitals, government entities, privacy advocates, technologists, and businesses. Together we have worked to address and define the issues that can accelerate the use of HIT.

Connecting for Health brings together leaders working toward making vital health information available when and where it's needed in a private and secure manner so the best possible care can be provided.

Connecting for Health is led and operated by the Markle Foundation and has received additional financial support from the Robert Wood Johnson Foundation. I've been honored to serve as Chair of Connecting for Health since 2002.

Q: Why is information technology so important to improving our health care system?

A: Despite unprecedented levels of health care spending and advances in medical technology, American health care remains inefficient and ineffective in many ways. National spending is 16 percent of GDP, which is much higher than other industrialized countries. But on the basis of quality, the United States is ranked #37 by the World Health Organization.. And according to the Institute of Medicine, almost 100,000 Americans die every year from medical errors in hospitals. That's the equivalent of a Boeing 747 crashing every two or three days.

We know, today, that technology can improve efficiency, quality, and safety. By improving communication and care coordination among providers, implementing tools that offer decision support for clinicians, and enabling patients to access their health information when needed, patient safety could be enhanced while waste and inefficiencies in the system could be reduced. To illustrate, RAND has measured that if most hospitals and doctors' offices adopted health IT, the potential efficiency savings for both inpatient and outpatient care could average over $77 billion per year.

Look around to other sectors from banking to travel services to e-commerce. They are "networked." By tapping into information networks, you can pay bills, book flights, pay a stranger on eBay, etc. The U.S. health care system has yet to be transformed in similar ways. We must figure out how to share health information according to the needs and wishes of each individual so that they can receive the best possible health care and, at the same time, take great care to protect their privacy and the security of their health information.

Q. Can you give a specific example of how technology would positively affect care?

A: There are many. The complex world of modern medicine has become nearly impossible to navigate without the assistance of electronic systems. Simple advances in our ability to manage medications could have a profound impact on quality and safety. For starters, simply having a complete and accurate accounting of medications that people are taking can be an enormous step forward in terms of avoiding dangerous drug interactions. Information—such as whether you are allergic to a medication—can save your life. If that information is available, it can help those who care for you give you safer, more effective treatment and care.

But it does not stop at improving care for individual patients. It's also about learning more quickly what works and what doesn't work for whole groups of patients. Compared to paper, electronic health information can radically accelerate our ability to understand in a timely way what treatments work best, and which may present unacceptable risks. It can help us monitor the spread of disease outbreaks that may represent pubic health concerns. Information is critical to improving quality and safety for many people.

Consumers also need access to this critical information. Never have people been more engaged in using information tools to understand their own health or the health of their loved ones. Once people have access to their own information, they can take advantage of new information services to help them better manage their own health and to become better partners in their health care with their physicians and other caregivers. While simply searching for information about health conditions is the most popular reason for people to use the Internet in health, other forms of social media and social networking are taking hold. These include online forums, blogs, and live chat rooms. In many online communities, consumers are sharing their own information about their diseases, treatments and health experiences. These new streams of data, innovative tools and patient communities pave the way for new patient roles in health care research, decision-making, and information sharing.

(Check back tomorrow as Dr. Diamond talks about the challenges—and the progress.)

QUALITY: Robots, Robots, Robots

Tom Emswiler — Tue, 06 May 2008 14:38:00 -0400

The Wall Street Journal Health Blog had a witty interpretation of Sunday's New York Times business section piece on robotic surgery; specifically, the three laws of robotics in I, Robot and how they mesh with the current state of surgical robots. Although not an expert in science fiction written before my parents were born, I looked up the handy Wikipedia page on the subject and thought of one additional maxim: the Zeroth Law.

The Zeroth Law states that a robot must not merely act in the interests of individual humans, but of all humanity. (It's numbered zero because it is meant to preempt the other three laws if applicable.) With that in mind, we think that robots should be used if they increase quality, such as the case of gallbladder surgery, but should be more cautiously used where their benefit is marginal but certainly more expensive, like prostate surgery. Unless of course the patient is willing to pick up more of the tab, as to not pass it on to others in the insurance pool (or for Medicare beneficiaries, taxpayers). I think the robots would approve.

QUALITY: Mercy Health System Wins Baldrige Award

Tom Emswiler — Mon, 05 May 2008 19:30:00 -0400

The Malcolm Baldrige National Quality Award recognizes excellence in organizational strategies and results for manufacturers, service companies, small businesses, education and health care organizations, nonprofits, and government agencies. Way back in the 1990s, the Council on Competitiveness said, "More than any other program... (it's) responsible for making quality a national priority and disseminating best practices across the United States." Sounds like we should pay attention.

Five organizations recently received the Baldrige Award from President Bush and Commerce Secretary Carlos Gutierrez, including two health care systems. One is the Mercy Health System, which is a fully-integrated, three-hospital system serving southern Wisconsin and northern Illinois.

Guided by their mission to provide "exceptional health services, resulting in healing in the broadest sense," Mercy operates according to its Culture of Excellence Four Pillars: quality, service, partnering, and cost.

Mercy calls their 4,000 employees "partners," and that includes 285 physicians who make up most of their medical staff. When hired, partners are asked to commit to the system's mission, participate in performance improvement efforts, and create a professional growth plan. In addition to paying off with low staff turnover, Mercy is listed as one of the top places to work by both AARP and Working Mother magazine.

With regard to quality, the Department of Commerce says, "Best-practice benchmarks are used (by Mercy) to measure clinical care and ensure continuous improvement and patient safety." It shows: Mercy has among the lowest risk-adjusted mortality rates in the United States, including a very low rate for pneumonia deaths. What's more, they have an electronic network that allows clinicians across the system to view patients' visit history, images, orders, and test results at the point of care.

Mercy's service pillar is exemplified by their "Take the LEAD" program, which encourages partners to turn negative patient experiences into positive ones: Listen to the customer; Empathize with the customer; Accept their perspective, Apologize, Acknowledge concern and take Action to recover; Direct to the person able to recover the situation, and Document the occurrence.

Regarding cost, Mercy encourages partners to identify ideas for growing revenue, decreasing expenses and waste, and increasing productivity and effectiveness. Their A2 bond rating has remained stable since 1996, a sign of competent financial management.

QUALITY: Domo Arigato Dr. Roboto?

Paul Testa — Fri, 02 May 2008 14:37:00 -0400

We love robots as much as the next guy, as long the next guy is our colleague Tom Emswiler. No offense to Shia Laboeuf, but Tom knows how to talk about transformative technological change and its place in health reform. His post on minimally invasive, or laparoscopic, surgery perfectly explained the link between innovation and value in medicine--a complex relation on full display in Wednesday's USA Today article on the da Vinci robot—a four-armed surgical system that is the $1.5 million Bentley of laparoscopic surgery.

As Tom writes: "Technology is valuable, even if it costs more, if it improves outcomes." But, "If a hospital spends a million dollars on a new piece of equipment that doesn't do a better job, there is no value added." This dynamic is essential to understanding that: "Comparative effectiveness is not a way to keep new innovations from patients; rather, it is a way to determine what works best, for whom, when. In this case, new technology results in better outcomes."

For the da Vinci robot, Tom's insights made us think about the good, the bad, and the crucial questions of value and cost for patient and provider. Starting with:

The Good: The doctors quoted in the USA Today article believe the da Vinci robot has the potential to greatly improve the outcomes and costs of coronary bypasses by performing the procedure without having to split open the patient's chest and stop the patient's heart. Two 100-patient studies have produced positive results, with the latest coming from the University of Maryland this week, where researchers found the da Vinci improved mortality rates, reduced complications, decreased in-patient stays and produced savings that made up for its added $8,000 in costs. Encouraging results but with such small sample sizes, they're far from definitive. An editorial last year in the Journal of Thoracic and Cardiac Surgery (subscription) was less convinced by what it called the "emperor's new clothes." Which brings us to:

The Bad: Prostatectomies accounted for 55,000 of the 85,000 da Vinci procedures last year, despite the lack of clear evidence that laparoscopic surgery produces better results for a patient than open surgery, or that prostatectomies are a better treatment for prostate cancer than other remedies. Forcing us to ask:

The Crucial Questions of Value and Cost for Patient and Provider: We all know that robots can be great dancers, maids, and even police officers. For health care, robots and medical innovation in general, must be justified in terms of value and improved outcomes. Four robotic arms may be a better option for some procedures (provided the clinical evidence is there), but they should not be just another tool to win market share in a medical arms race. Neither hospitals, nor patients can afford it.

QUALITY: At Least He's Not Smoking

Paul Testa — Wed, 30 Apr 2008 20:49:00 -0400

What else can we say about The Health Care Blog's post today: "After A Short Stay In the US, Michelangelo's David Returns To Florence," except that we hope David is covered by more than the Tribuna at the Gallery of the Accademia di Belle Arti in Florence—chronic disease is expensive.