Quality

This month's issue of Healthcare Executive (subscription required) features a column by Joseph S. Bujak titled "Approaches to Influencing Physician Behavior." It's adapted from Dr. Bujak's book, Inside the Physician Mind: Finding Common Ground with Doctors. The column lists six approaches; I want to highlight two that I found especially insightful.

First, Dr. Bujak writes, encourage self-discovery and self-interest. This can be achieved if you know a physician's values—but too often these are not evident even to the physician herself. Consider asking physicians to participate in a self-assessment exercise. Once these values are known, physicians can consider changes in their behavior that allow them to better adhere to their values and thus better serve their self interest.

Americans want health reform. They want coverage expansion and insurance reform. As long as they can keep the health plan they have now, save money, and finance it all by taxing an upper income smoker. You know, like that guy on the Monopoly board.

They also want to fill the Medicare drug benefit doughnut hole, cover kids, and provide more care to our veterans. By taxing that same rich smoker.

 OK, we're exaggerating. The Kaiser Family Foundation did its traditional poll on the health care agenda for the new president and Congress. There was definitely some good news for those hoping for comprehensive health reform this year. A solid majority of Americans (61 percent) believe that during our economic meltdown "it is more important than ever to take on health reform now."

 But the poll also highlighted serious obstacles that reformers need to keep in mind. That includes deep partisanship and a huge amount of economic anxiety,  according to analysis offered at a Kaiser forum with three of our favorite health policy experts, Kaiser CEO Drew Altman, the foundation's public opinion research director Mollyann Brodie and Harvard professor Robert Blendon, who is an expert on health reform politics and public opinion. (webcast here, transcript in a few days)

We've posted a few times about safety checklists for hospitals and Dr. Peter Pronovost, and about how the World Health Organization is promoting surgical checklists (we heard about that from Dr. Atul Gawande and the Institute for Healthcare Improvement.) Now there's evidence  published in the New England Journal of Medicine that the surgical checklists are making a difference. And that finding suggests that checklists could work in other settings as well.

  As my friend and colleague Maryn McKenna notes in her Superbug blog,

"Using a simple but detailed checklist, eight hospitals in a mix of high-income and resource-poor areas were able to reduce their rates of surgical complications by one-third and their rate of death due to surgical complications by almost one-half.

We don't always have good news on the health care quality/innovation front, so this is encouraging. Read the rest of Maryn's post here.

Would red carpets and massage chairs convince you to purse a career known for red tape and wheel chairs?

Recruiters struggling to fill our nation's nursing shortage hope so. The AP has a story today detailing some of the creative methods recruiters are using to attract new nurses and convince former nurses to come back to the field. (We blogged a few months ago about attempts to recruit and retain nurses by giving them greater autonomy.)

As the article notes, despite reasonably high salaries—registered nurses made an average of $62,480 in 2007—and that nursing is one of the few growing job sectors in our economy, it's not been an easy job to fill. Several factors are at play. A lack of qualified instructors limits the number of nurses who can be trained each year. Nurse who are qualified to teach often find they can make up to 20 percent more at a hospital.

When I was at the IHI conference in Nashville a few weeks ago, I sat in on a half-day "learning lab" called, "What Does it Take to Transform Healthcare?" Taught by three physicians with vastly different backgrounds—private practice in Oregon, an Alaska native medical system (which I'll post about separately soon), and a Swedish county health system—the session didn't really strive to answer the big questions so much as to encourage participants to go home and think hard about them. Who should make decisions about our health care system? What are the goals of reform? Who sets them and do they reflect the shared values of a community? Why does fixing health care take so long, and why is it so hard? I'm not going to try to sum it all up here, because it was a pretty open-ended exercise, but I wanted to touch on a few points that stuck with me and hope they aren't too disjointed out of the context of this discussion.

One was the "hype cycle." This idea (adapted from Gartner Research) isn't unique to health care quality, but we get all excited about one trend or innovation, our expectations are wildly inflated, then we crash. At some point, hope and disappointment should find some kind of equilibrium at the "plateau of productivity." But sometimes we just move on to the next big thing—consumer-directed health care, pay for performance, electronic medical records, patient-centered medical homes or whatever. Maybe we need less of the next big thing and more of a medley of sensible middle-sized things, all tempered by more realistic expectations. (MedPAC, to its credit, has been recommending a mixture of innovations, not a magic bullet).

I want to spend a moment highlighting news that got surprisingly little attention in my favorite health policy media earlier this month.  Dr. Paul Chan and colleagues published an article in the December 3, 2008 edition of JAMA titled "Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response Team."  It reaches a conclusion about Rapid Response Teams (RRTs) that might be surprising to many in the quality community.

The Chan article describes two 20-month periods, one before and one after RRTs were deployed at Saint Luke's Hospital, a 400-bed academic medical center in Kansas City.  Although cardiac arrests, cardiac arrest mortality, and in-hospital mortality all declined, none of the changes were statically significant. 

The CBO released two long-anticipated reports on health care today: Key Issues in Analyzing Major Health Insurance Proposals and Budget Options, Volume I: Health Care. You can check out the acting CBO director Robert Sunshine’s comments here.

Well be back with more on the specifics just after we’ve had time wade through the reports’ combined 427 pages.

We quoted Dr. Elliott Fisher in our recent American Prospect piece but naturally the head Dartmouth Atlas researcher had more smart things to share than we could fit in one magazine article. The Dartmouth team has been telling us for years about the unjustifiable and often inexplicable ways that health care differs from one place to another, and how much of our health care spending doesn't make people healthier. What's exciting now is that more people are listening. So we thought we would share  more of what Dr. Fisher told us about how to create a more sustainable high-quality health care system.

Extrapolating from the Kevin Bacon theory of health care and the economy one arrives at the fortune cookie corollary of international affairs, which states that any major issue is made more interesting simply by adding the phrase, ‘In China.'

For example, fixing the economy means fixing health care. It's true in the U.S. and as a piece in the current issue of Newsweek argues, equally true in China.

With an economic crisis of increasingly global proportions, the article argues China must boost its domestic consumption to maintain a desired level of economic growth. But efforts to stimulate the Chinese economy have been stymied by the country's high rate of domestic savings. The World Bank estimates the average household savings rate to be around 25 percent in China, substantially higher than most developed countries. The disparity is even more apparent when you look at net national savings rates across the G-20 (Below. Hat tip, Alejandra and New America's Asset Building Program)

Why is China too scared to spend? The answer Newsweek argues, is health care. As Cornell professor Huang Ming tells the magazine, the "‘[Chinese] save because they are frightened of getting sick.' The costs of illness can be ruinous. A better health-care system would unleash domestic spending and thereby boost employment."

Those fears are all too familiar to Americans for whom more than half of all bankruptcies and home foreclosures are caused by the high cost of health care.

The good news is, none of you failed. The bad news is most of you did pretty terribly.

We had flashbacks to our own collegiate career when the American College of Emergency Physicians released its National Report Card on the State of Emergency Medicine this week. (Executive Summary here, overall results here.)

Overall the U.S. earned average grade of C- reflecting performance on these five categories:

• Access to Emergency Care: D-
• Quality and Patient Safety Environment: C+
• Medical Liability Environment: C-
• Public Health and Injury Prevention: C
• Disaster Preparedness: C+

The D- in access to emergency care is particularly troubling with 12 states receiving a failing grade (see map below).

ACEP summarizes the situation well, saying: