Tuesday, October 21, 2014

View from above

Some final thoughts from South Africa.  The picture above from Kruger National Park is just to get your attention!

Here's the more serious photo from the Best Care Always quality summit last week.  Thabiso Bale (right), soon to earn his masters degree in nursing, was chosen to present a poster during the conference.  You see him here with Gary Kantor, BCA co-founder and Discovery Health advisor, going over his findings.

The findings were troubling and an indication of the kinds of issues facing hospitals worldwide as they seek to infuse medical treatment with a higher level of quality and safety.  Thabiso's preliminary topic was to evaluate nurses' understanding of the VAP bundle (designed to reduce the incidence of ventilator associated pneumonia for patients in ICUs.)  Not surprisingly, there were differences among the nurses that correlated to their years of experience.  The hope, though, would be that the VAP protocol would be uniformly understood and applied regardless of tenure.

More seriously, Thabiso documented that the rate of pneumonia did not correlate to the reported adherence to the VAP bundle in the ICUs.  In other words, the staff's documentation that they had carried out the bundle was inaccurate.

In my view, this kind of result is indicative of not only incomplete understanding but also incomplete buy-in by the clinical staff.  Ultimately this is derivative of a lack of leadership from "on high" in the organization.  Such a phenonemon does not only occur in Africa.  I have seen examples throughout the world, including the US.

In a comment to the post below, my regular correspondent "nonlocal MD" noted the poor safety record of some hospitals in Texas:

Interesting concept, and I am not at all surprised about Texas. It again raises the question that you and I debate, Paul - will hospitals do the right thing of their own accord or is it necessary to demand accountability from an outside source? And when you answer with the word 'leadership', I ask then, how will we find those leaders? They seem to be in short supply. 

One answer has been given by my colleague Dave Mayer, head of quality and safety at Medstar Health, who jokingly responds: "Educate the young . . .  and (when necesaary) regulate the old."

Humor aside, Dave may have the right thought.  While trying to infuse quality and safety training into the curriculum of young doctors and nurses, there is likely a need for oversight from regulators or other outside bodies--if for no other reason, than to get the attention of the senior admininstrative and clinical leadership.  That being said, unless those senior leaders truly believe in the need for process improvement and act on that belief every day, the horrendous status quo with regard to unnecessary deaths and harm documented by Michael Millenson will continue.

A new look at "safe seats"

Michael Millenson, President, Health Quality Advisors, writes:
Working with data analytics colleagues, I've produced a report on safest Congressional districts looking not at political safety (whose seat is secure) but the physical safety of constituents getting care at hospitals in that district. 

We used 20 different measures to rank each district, seven of which were measures of infection control or prevention and divided districts into good, fair and poor. Using the most conservative and evidence-based estimates, we translated those results to the political environment. We found that 59 House districts were less safe than the norm and 114 districts were safer, with measurable consequences. (I also took a look at the home districts of Obama, Biden, McConnell and Reid, plus House leadership.)

In each Congressional district ranked “poor” on safety, preventable medical errors cause an average of 553 deaths and 4,148 injuries annually; in “fair” districts, the average toll of preventable harm is 469 deaths and 3,518 injuries each year; and in “good” districts, preventable errors cause an average of 385 deaths and 2,888 injuries each year. Put differently, on average 14 more individuals die every month and 105 are injured in hospitals in districts rated “poor” on safety than in those rated “good.” Even in “good” districts, however, at least one individual dies unnecessarily every day and another eight are harmed. We also looked at Republican versus Democrat: when it comes to patient safety, there is no red America or blue America, only the United States of America: there was no difference between the parties.

You can look at the report, and your district, at www.safedistricts.com.

Separately, as you may know, there's an infection that kills up to one in five of those who contract it, costs the nation billions of dollars to treat. And yet the CDC thinks hospitals can take more than a decade to dramatically reduce it, even though a paper in the NEJM by Peter Pronovost showed what to do back in 2006. Did laxity by the Centers for Disease Control and Prevention in eliminating central-line associated bloodstream infections (CLABSIs), which are caused by hospitals, leave the way open for infection control lapses that are hurting the Ebola fight?

See my analysis at Forbes.comhttp://t.co/3a7Ao7vbG3. Retweeting appreciated.

Oh: the Congressional district in which Texas Health Presbyterian Hospital is located scored "poor." In addition, the only two districts of 436 (including DC) we could not rate, because their hospitals did not report enough information, were in Texas.

Both of these, by the way, are anchored in the medical literature, although the blog post has links, not footnotes. :-)

Hope you find this useful in your own good works.

Friday, October 17, 2014

Rainbow nation

"Rainbow nation" was the term coined by Archbishop Desmond Tutu to describe post-apartheid South Africa, after the country's first fully democratic election in 1994.  I was privileged to participate with a number of people this past week who ably represent the hopes and dreams of the country in trying to improve its health care system. They came from all parts of the country, included a variety of clinical and administrative specialties, and represented all racial and ethnic backgrounds.  Best Care Always was the predominant theme of the conference held by the Hospital Association of South Africa, with support from Discovery Health (the country's major private insurance funder), the country's private hospital firms, and various other organizations involved in clinical care, medical education, and health care policy.

And how fitting to receive the above going-away gift as I drove along the highway after leaving this exemplary meeting!

Thursday, October 16, 2014

New word: "maieutikos"

Among the joys of teaching Lean process improvement with people like the Lean Institute Africa's Norman Faull are the unexpected language lessons. Today at a Best Care Always workshop in Johannesburg, Norman posted the slide seen above.


I'll let you read the slide to get the meaning and context.  Your homework assignment is to now use it in a sentence during the next 24 hours!

Beyond that item, Norman related a conversation he once had with John Shook, of the Lean Enterprise Institute.  John speaks Japanese and Norman was confirming with him that gemba means the place (e.g., the factory floor) where work is done and value is created for the consumer.

John said, that while true, in Japan gemba is often used to mean "crime scene."  In that sense, going to gemba is equivalent to investigating the crime, trying to put the pattern together.  Think of Columbo, the TV detective, visiting a crime scene and slowly and persistently teasing out the evidence to find the guilty party.

Your Lean task, in going to gemba, is to discern the pattern of evidence about a flawed production or service process.  You then divine from that investigation possible experiments that will help solve the riddle of your next step of process improvement.

Wednesday, October 15, 2014

For want of a nail . . . the battle was lost

The Health Minister of South Africa, Dr. Aaron Motsoaledi joined the HASA and Best Care . . . Always quality improvement summit and gave a thoughtful overview of the challenges facing this country. Hearing one of his remarks took me back to a public hospital visit I made earlier in the week.

Here was his comment:

We have an extremely under-resourced public health care system that is serving 78% of the population, struggling to meet quality standards.

You may recall my praise for the work of several staff members at Charlotte Maxeke Johannesburg Academic Hospital.  Their focus has been on reducing ventilator associated pneumonia in the neuro-ICU.

One aspect of the VAP bundle implemented by Phindi and her staff is too enage in "closed suctioning" of the ventilator to remove biological material in which infections can breed.  This is accomplished with the kind of apparatus seen here.  It simply attaches to a port on the tracheal ventilator tube.

If the closed suction equipment is not used, an "open suction" approach is used, which requires removal of portions of the ventilator.  While the literature suggests that both approaches are equally efficiacious, experience in this hosptial suggests otherwise.  Simply put, in this hospital's environment, it is difficult to respect general precautions in the sanitary-epidemiological regime and barrier nursing techniques.

Accordingly, the staff at Charlotte Maxeke hospital have concluded that the closed suction approach is preferable.

Here's the rub.  A closed suction device of the sort shown above costs 150 rand (about $15).  After a certain amount of time during the budget year, the hospital runs out of them and cannot afford to buy more.  The rate of VAP seen by Phindi and her staff correspondingly rises.  This is the case notwithstanding that the avoidance of VAP brings financial benefits to the hospital well in excess of that price (reduced length of stay, avoiding antibiotics, and so on)--but the budget decisions for these supplies are centralized in a purchasing agency that is subject to other pressures.

So here's a concrete example of Dr. Motsoaledi's remark, "an extremely under-resourced public health care system . . . struggling to meet quality standards."


My headline reference quotes Benjamin Franklin:

For the want of a nail the shoe was lost,
For the want of a shoe the horse was lost,
For the want of a horse the rider was lost,
For the want of a rider the battle was lost,
For the want of a battle the kingdom was lost,
And all for the want of a horseshoe-nail.

Tuesday, October 14, 2014

I felt like I was back home

While I made presentation at a quality summit sponsored by Discovery Health, as usual I learned more than I imparted.  The similarities between the South Africa health care environment and that of the US are remarkable.

Jonathan Broomberg, Discovery CEO, led off with a description of the challenges facing the South African private health care system (which operates in parallel to the public system).  He noted that medical costs are growing at a rate exceeding overall inflation; that there is a rising burden of noncommunicable (i.e, lifestyle) diseases; and that there is high variability in the quality and value of care to patients.

Later, he provided examples of this variability. Looking at the treatment data from 139 hospitals, Discovery has found that in-patient (case-mix adjusted) antibiotic defined daily dosages vary from 39 to 177 per 100 bed days.  There is also a significant variation in the cost of end-of-life care among the country's regions.

Jonny noted that medical inflation costs are not largely driven by the units costs of care.  Rather it is the growing volume of services that is the critical cost driver.  He noted that insurance premiums rose at an average rate of 11.5% between 2009 and 2013.  Of that, 7.05% (or just 0.3% above inflation) was attributable to tariff increases, but 4.5% was attributable to utilization.

The supply-side drivers, he posited, are a fee-for-service physician payment environment; fragmentation of care along the spectrum of care; the construction of new hospitals; and new technologies and procedures.  He singled out the use of the daVinci surgical robot, noting its increased cost over traditional prostate removal techniques.  "It takes the premiums from 10,000 healthy members to fund 400 prostate cases" using the surgical robot, he noted.

Demand-side drivers come from an aging population; an increased disease burden; and adverse selection. The last item occurs because there is no individual mandate for insurance coverage.  Therefore, a large percentage of young adults between age 20 and 30 choose not to buy insurance--until or unless they need it.  If insurance were mandatory, premiums could be reduced by 15%, he pointed out.

Jonny summarized that a sustainable solution requires an equilibrium with no trade-offs among access, quality, and costs, but that a key aspect of the solution must be an effort to educate and empower patients.  Even among the well educated and relatively prosperous South Africans who purchase private medical insurance, there is virtually complete disempowerment in clinical settings.

After I presented a complementary talk on reduction of harm in hospitals and approaches to process improvement, a panel discussion ensued with representatives from a number of health care sectors, including two of the large private hospital chains (left).  There was remarkable consensus among the panelists as they riffed off of the earlier themes and addressed the questions posed by the moderator (below).

As I listened to it all, the conversation seemed quite similar to those I have heard in the US over the last decade: Well-intentioned people who understand they have a high degree of interdependency.  As in the US, the question will be whether the various stakeholders will decide that their differences separate them or or whether those differences offer the potential for trades that satisfy individual corporate and sectoral interests and create value for society as a whole.

Monday, October 13, 2014

Not so different after all

I'm so pleased to be in Johnannesburg to present some sessions in association with the Hospital Association of South Africa at a quality improvement summit hosted by Best Care . . . Always!

As summarized on their website:

BCA campaign supports South(ern) African healthcare organisations as they implement specific, internationally recognised, evidence-based interventions that enhance patient safety and constitute current best practice in hospital care. BCA is inclusive and enrolls hospitals from both private and public sectors. There is no fee to join. Participating hospitals should be willing to make evidence-based changes at a faster pace, share ideas with others, measure results and report on progress.

In preparation for the event, I had a chance to tour two local hospitals, Wits Donald Gordon Medical Center and Charlotte Maxeke Johannesburg Academic Hospital.  They are just this far apart, 1.2 kilometers, physically:

But institutionally, they exemplify different worlds, as Gordon is a private hospital with under 200 beds, running profitably with payments from individuals and private insurance companies. Under national law, the doctors are not permitted to be employees of the hospital.  Maxeke is a large public tertiary hospital with over 1000 beds and 4000 admissions per month, with tight finances supported by government funding. The doctors are public employees.

But I discovered a hidden commonality between the two places.  First I met these two women at Gordon, Winnie and Ronel. They are part of a cadre of folks who have implemented quality and safety protocols, training, and documentation in several wards and units in the hospital.  They have focused on reducing the incidence of central line infections, ventilator associated pneumonia, catheter-associated urinary tract infections, and other such issues.  Although they are quick to point out they still have a lot of room for improvement, the results are clearly showing.

The team employs a "Welsh cross" as a visual cue to their staff as to progress.  Every month, the cross is posted in a highly visible location showing on which days an infection has occurred.  (In this case, for example, there was one blood stream infection on August 24, and 2 respiratory tract infections on August 12 and 14, and one other infection on August 25.)   The cross acts as a reminder of the need to be vigilant but is also a way to provide positive feedback to the staff about the efficacy of their actions.  The women noted, "We're not satisfied unless every day is green!"

Meanwhile, less than two kilometers away in the Maxeke public hospital, these two women work.  They are Constance and Phindi.  They, too, have started a program in quality improvement, focusing first on reducing VAP in the neuro-intensive care unit.  Following the same bundle of care used at Gordon, there has been a substantial reduction in pneumonia cases.  And, lo and behold, look at what's posted on the wall of their ICU! The women noted, "We're not satisfied unless every day is green!"

Coincidence? Well, no, because BCA has been holding training sessions for hospital folks--public and private--across the country. They offer advice on protocols, staff training, and the kind of institutional infrastructure and tools need to support patient quality and safety programs.

But these four women have never met one another.  While they are separated by a short distance, they live in two different worlds of patient care.  Yet, in a way, if they traded places tomorrow, they would all feel at home with the sense of purpose and passion inherent in their clinical improvement work.

Sunday, October 12, 2014

Maura Healey bobs and weaves off the court, while John Miller takes a shot

Maura Healey is a thoughtful and serious candidate for Massachusetts Attorney General, offering years of legal experience.  One thing she likes to mention is that part of her biography includes a stint as a point guard on a professional basketball team.

Well, there's a problem when a candidate brings her sports abilities to a serious economic and legal issue.  Watch this performance at a recent debate at Stonehill College (from minutes 13:50 to 21:20.)

Under direct questions from one of the reporters, Republican candidate John Miller gives a direct answer: No, he does not believe the deal between the incumbent AG and Partners Healthcare System should be approved.  He offers a cogent legal theory in support of his answer.

Healey, in contrast, offers no answer to the questions, and instead bobs and weaves all around the issue.  She then says she doesn't have enough information to have an opinion on the matter.  That is hard to fathom given this summary from the same biography:

For seven years, Maura helped lead the Attorney General’s Office, ultimately overseeing more than half of the office’s 500 employees. She began as Chief of the Civil Rights Division and went on to direct two of the office’s most prominent divisions: the Public Protection & Advocacy Bureau and the Business & Labor Bureau. She knows firsthand how important the Attorney General's work is for Massachusetts families and businesses. 

What's in the Public Protection & Advocacy Bureau?  Here's the summary from the state government website:

The Public Protection and Advocacy Bureau uses investigation, litigation, and other advocacy to enforce laws protecting the Commonwealth. The Bureau works towards meaningful economic recovery for Massachusetts by tackling the economic and mortgage foreclosure crisis with a multifaceted and aggressive strategy. The Bureau works to protect consumers from unfair and deception activity, enforces state and federal civil rights laws, ensuring access and equal opportunity for all residents, advocates for protection of our environmental resources, pursues complex insurance and finance cases on behalf of residents or government entities, works towards affordable, high-quality health care for all, and enforces antitrust laws.  The Bureau is supported by a team of skilled civil investigators.

Divisions within the Public Protection and Advocacy Bureau include: 
Oh, health care and antitrust, with consumer protection thrown in for good measure.

It is a sad state of affairs when such an able person--who had policy oversight of these divisions for an extended period of time--feels she can not offer a direct answer about the most important health care and economic case pending before the Court.

But perhaps we should believe her.  If Healey really feels she doesn't know enough to have an opinion on the matter, she should immediately ask the incumbent AG to request a delay of the proceeding from the scheduled November 10 session to sometime after the inauguration of the new AG in January.  Maybe, by then, she would have time to form an opinion on the case.

Thursday, October 09, 2014

Lazarus lives again in Massachusetts, but at what cost?

There was a lot of coverage last year about the glitches and extra costs associated with the federal government's health care exchange website.  Must less was said about the problems faced by Massachusetts in its execution of the state portal.  In fact, Trudy Lieberman at the Columbia Journalism Review wrote an article about the paucity of local coverage of this issue.

Much of the public exposure on the delays and cost overruns has been produced by a local policy think tank, the Pioneer Institute.  It has assiduously outlined flaws in the project management and has provided the press and the public with material that raised serious questions about the competence of the state administration in this arena.

Bruce Mohl at Commonwealth Magazine offers an excellent summary of the issue here.  The Governor's folks are claiming that the costs are one number, but Pioneer folks remind him that it is not right to leave out the additional federal costs associated with the mess-up.  As Mohl writes:

Stergios urged the Patrick administration not to focus just on the state costs associated with the failed website but to also incorporate federal expenses into the mix, just as officials did with cost overruns on the Big Dig.

"The media and public did not divide that important project's costs into 'the state share' and 'the federal share.' The case of the Health Connector should be viewed through the same big picture lens, especially since the Commonwealth could easily have opted to join healthcare.gov at little or no cost to the state, or to stick with a somewhat modified version of the original website, which was working well pre-Affordable Care Act," Stergios wrote. 

Mohl's piece is well worth reading in its entirety, from the starting sentence on:

The state's health care exchange website is about to return from the dead, but the cost of resuscitation remains far from clear.

Wednesday, October 08, 2014

Mental health in hospitals on WIHI

Madge Kaplan writes about some of my most favorite people from Contra Costa!

The next WIHI broadcast — Mental Health Care in the Hospital: Preventing Harm, Promoting Safety — will take place on Thursday, October 9, from 2 to 3 PM ET, and I hope you'll tune in.
Our guests will include:
  • Kelly McCutcheon Adams, LICSW, Director, Institute for Healthcare Improvement
  • Anna Roth, RN, MS, MPH, CEO, Contra Costa Regional Medical Center & Health Centers
  • Teresa Pasquini, Mom/Advocate, Chair, Behavioral Healthcare Partnership, Contra Costa Regional Medical Center and Health Centers
  • James F. O’Dea, PhD, MBA, Regional Director, Hartford Healthcare Behavioral Health Network
  • Richard Wohl, MSW, MBA, President, Princeton House Behavioral Health; Senior Vice President, Princeton Healthcare System
Enroll Now
With all the discussion going on about the integration of behavioral health with primary care in the outpatient setting, we don’t want to ignore what’s happening in the hospital for patients with psychiatric conditions and needs. Safety has been one of the major issues identified in recent years… safety for individuals in crisis, for the staff caring for them, and for family members. Those who’ve identified effective improvements are often the patients themselves.

We’re going to venture into the acute care setting for the October 9, 2014, WIHI: Mental Health Care in the Hospital: Preventing Harm, Promoting Safety. IHI’s Kelly McCutcheon Adams is going to set the scene for a terrific panel of guests who are working hard on partnering with patients and families to improve their overall experience in the hospital; the prevention of patient harm and staff injuries; the redesign of physical environments; better management of medications; and heading off crises in the making.

Contra Costa’s Anna Roth and parent Teresa Pasquini have a powerful story to share about collaboration, starting with transforming the experience of the psychiatric emergency. Richard Wohl from Princeton House Behavioral Health wants to share what goes into creating a state of the art, safe, inpatient facility and environment for patients in need of psychiatric hospitalization. The features and attributes will resonate with many. James O’Dea from Hartford Healthcare Behavioral Health Network will tell us about “the three-legged stool” that frames his team’s improvement work, and new efforts to get further upstream with patients to help avoid the need for sudden trips to the ED and the hospital.

I'm looking forward to learning from our guests and from you, our listeners. See you on October 9. You can enroll for the broadcast here.

Tuesday, October 07, 2014

An expanded view of a pediatrican's role

Budd Shenkin, looking at some of the recent NFL news, offers an interesting perspective on the role of pediatricians.  I had never considered this aspect of the profession and offer it for your consideration.

He starts:

So much starts at the beginning. As a pediatrician I'm used to looking at the long curve of life, and trying to help people adjust that curve for their kids at the beginning. We promote physical health – exercise! – and we prevent physical disease – immunize! But beyond the body, we try to promote and prevent with behaviors as well as physical health.

We try to direct our parents and their kids to positive interactions, to positive child rearing, to verbal self defense and explanation.

P4P: The bureaucracy of documentation

Way back in 2010, I raised serious doubts about the efficacy of the pay for performance metrics that were being imposed on hospitals by private and public payers.  After listing the multitude of such metrics, I asked:

If you were in a management position and were trying to direct quality and safety improvement efforts, how would these guide your behavior? If your were a nurse or doctor and were trying to be responsive in focusing on quality and safety improvements, what would this variety of measures tell you?

Let me jump to the answers: The large number of overlapping measures, often with different definitions among payers, can cause confusion rather than offer guidance to hospitals in directing improvement efforts. That is especially the case because many of the items are "roll-ups" of several metrics in themselves.

In this respect, P4P measures are not always the most useful management tools by which to focus attention on the fundamental elements of process improvement: reduction in variation, redesign of work, and communication in clinical settings -- all in collaboration with patients and families. 

Well, a new JAMA report reaches conclusions that are even more strikingly set forth.  The commentary notes:

The findings of a study presented in this issue of JAMA Internal Medicine reinforce concerns about the unintended consequences of public reporting and pay for performance and also suggest a gap between quality improvement activities and patient care. Lindenauer et al surveyed hospital leaders (chief executive officers and executives responsible for quality) about publicly reported quality measures required by the CMS. Although most respondents said that they used the measures extensively, more than half were concerned that the measures encouraged teaching to the test, and almost half reported trying to maximize performance primarily through changes in documentation and coding. Also important is that half or more believed that the CMS measures did not meaningfully distinguish among hospitals or accurately reflect quality of care, even for conditions specifically targeted by the measures. In short, the study findings suggest that many hospital leaders doubt the clinical relevance of these measures. This skepticism is consistent with national data: studies of public reporting and pay-for-performance programs in the United States have failed to demonstrate a clear connection to improved quality.

Indeed, as you see from this excerpt, there is concern that P4P metrics actually distract the hospital and doctors from the things that matter, by focusing on the bureaucracy of documentation.

Where does this leave us?  Well, we need to go back to the underlying values that motivate doctors and nurses, a desire to alleviate human suffering caused by disease.  As I concluded back then:

People who have studied how to achieve change in organizations point to the need for an overarching, audacious set of goals that are highly motivational.

In our case, the most important established goal is to eliminate preventable harm, one endorsed by our Board of Directors. This goal is combined with a strong commitment to transparency, so we hold ourselves accountable to the standard we have set. So, while we will always do our best to meet P4P requirements . . . we do so within an overall context that is meant to transform the organization. 

Monday, October 06, 2014

CFOs join surgeons in quest for robots

This analyst's report from BTIG tells you all that is wrong with health care in some US academic medical centers today.  An excerpt, with emphasis added:

Subject: Hospital CFO Dinner Takeaways: Two NYC-area Academic Centers Highlight What They're Willing to Spend On, and Where They're Cutting Back

Robotics, imaging, personalized medicine and smart tools are areas of investment, while reducing inpatient care offers savings.

  *   Overall, both hospital CFOs seemed much more positive than a few years ago. One noted his center is running at a 9% operating margin this year and both noted HC reform has not had a major negative impact this year as many had previously feared.

  *   Robotics: These administrators have found that ISRG's (BTIG Neutral Rated) robot helps extend the careers of older surgeons (who may be losing hand steadiness) while helping younger surgeons improve more quickly. They noted that minimally invasive robotic procedures save costs with faster discharge. Both CFOs said their centers profit from robotic surgery and both now have credentialing programs in place. Both seemed more open to additional adoption than a few years ago.

  *   The robot is currently used for urology, gynecology, and cardiology procedures, but surgeons are asking to use it for general surgery. One CFO would like to see more profitable reimbursement rates. This particular center's robots are at capacity, so a new robot would need to be purchased for use in general surgery. A request for an Xi is being evaluated. The other CFO noted that they are in the process of buying four new robots for a new center.

Sunday, October 05, 2014

Something the MA Attorney General should read

She won't, of course. But maybe the two candidates for Attorney General, John Miller and Maura Healey, will.  Speaking of which, when is some reporter in Massachusetts going to ask them the following questions--and insist on "yes" or "no" as the answers--so we can see where each stands on the major economic and health care issue facing the state:

1) Do you believe the Court should approve the settlement deal offered by the Attorney General with regard to Partners Healthcare System's acquisition of new hospitals?

2) If you are elected on November 4, will you request the incumbent AG to ask for a delay in the Nov. 10 hearing on this matter, to give you a chance to review it and have input before the Court?

Now to the article. Suzanne Delbanco has been a keen observer of healthcare issues for many years.  In this latest column at the Wall Street Journal, she summarizes the adverse impact of industry consolidation.  Excerpts:

Health-care costs are going up, and there's a lot of debate about why. Is it the high cost of drugs or our aging population? Is it Americans' insistence on having the newest, most high-tech care? Each of these may contribute to rising costs. But a close look at the data reveals that one factor is increasing costs in recent years more than anything else: consolidation among hospitals and doctors.

Consolidation means many things, from the merger of two hospitals or health systems to an acquisition of a physician group by a hospital. Generally, however, when providers consolidate, private insurers end up paying more for services. Nationwide, payments to hospitals on behalf of the privately insured are an estimated 3% higher as a result of consolidation, according to a 2012 report by my organization, Catalyst for Payment Reform. That may sound small, but 3% of the almost $900 billion the U.S. spends on hospital care each year is a hefty chunk of change. 

Yet many doctors and hospitals argue that health-care reform, with its emphasis on care coordination, compels them to consolidate. After all, new models under the Affordable Care Act for delivering care, such as accountable-care organizations, require doctors and hospitals to work together to coordinate and improve patient care and reduce spending. Some providers contend that mergers let them achieve economies of scale and improve efficiency, enabling them to decrease costs and improve care. 

There is no evidence to support such claims. For example, when mergers happen in already concentrated markets, price increases can exceed 20%, as 2012 research by the Federal Trade Commission's Martin Gaynor and University of Pennsylvania professor Robert Town showed. The authors also found that "physician-hospital consolidation has not led to either improved quality or reduced costs."

Friday, October 03, 2014

Don't blame the EHR!

Back to our Ebola case in Texas.  Here's a report from the Washington Post:

Thursday night, the hospital said it released him because “separate physician and nursing workflows” kept physicians from seeing his travel history, which would have shown his recent presence in Liberia and possibly triggered extra scrutiny. The statement said that the “documentation of the travel history was located in the nursing workflow portion” of the electronic health records and “would not automatically appear in the physician’s standard workflow." 

Blaming the EHR is like blaming the printer on a computer.  Someone or some group of people made a decision at some time that the nurses' notes would not be visible to doctors.

(I wonder if the doctors asked for this "feature" at some point so the nurses notes wouldn't "clutter up" their screens.)
As I said before, this case calls for a full root cause analysis, and then we need a way to send the message of what was learned throughout the country.

By the way, a friend from Toronto reports:

In Ontario since SARS “FRI Screening” – Febrile Respiratory Illness Screening is mandatory at ED triage.  The process is flexible and can easily be adjusted to add specific questions for new outbreaks, so the public health and ID experts can just tell us to ask about travel to Saudi Arabia for MERS or specific parts of West Africa for Ebola, we amend the WORD document and produce a new version of the screener, and all the nurse has to do is comply with what they always do – ask the questions on the screener and report a “failed” screen and take the indicated action.  It’s a “system” that works extraordinarily well.

Thursday, October 02, 2014

Asani offers thoughts on religious illiteracy

I'm moving off health care for this post.  Sorry to those who object, but sometimes other topics (beyond soccer!) raise issues that I like to explore with you. This one is particularly appropriate as many of us enter into a special weekend, comprising both Yom Kippur and Eid-al-Adha.  Read on if you'd like.

If you're like me, a non-Muslim living in a world in which there is a lot of news about people of that religion, it can be confusing to separate the practice of the religion from the political and nationalistic contexts in which we often view it.  Ali Asani, Professor of Indo-Muslim and Islamic Religion and Cultures, gave a short lecture this week at Harvard that I found very helpful.  It was called, The Importance of Fostering Religious Literacy: The case of Muslims in the US.”

Ali started with a provocative slide, with the simple words, "Why do they hate us?" He explained that he had often heard this sentiment from non-Muslim Americans about Muslims in the rest of the world.  He then pointed out that he had heard exactly the same question from Muslims around the world about Americans!  Clearly, there is a lack of understanding going on, and he spent most of his talk addressing the reason, which he termed religious illiteracy.

He pointed out that there is global illiteracy about religion and culture.  This results in an inability to engage with the differences between us because we have a lack of tools to understand the differences.  Mutual stereotyping exists, and then ignorance means that encounters between groups ironically leads to more polarization.

He referred to Diane Moore and her book Overcoming Religious Illiteracy and presented some of her main points as follows:

Ali listed some manifestations of religious illiteracy:

1)  Equation of religion with devotional practice, rites, rituals, and ceremonies.
2)  The essence of religion is perceived as located in sacred texts.
3)  Religious traditions are seen as timeless and unchanging and monolithic. (In contrast, there is a huge extent of diversity within Islam.)
4 ) Religions are seen as actors having agency; i.e., there is a tendency to personify religion, but it's just a construct, not a being.
5) The use of religion as the exclusive lens to explain the actions of an individual or a community.
6) An entire religious community is held responsible for the actions of an individual.

He then expanded on Moore's conclusions and pointed to the dangers of religious illiteracy as leading to stereotypes and dehumanization, accompanied by less respect for diversity.  Such illiteracy can also be exploited by ideologues to promote extremism and fundamentalism.  Finally, he noted that democracy cannot function if one is ignorant and afraid of one's neighbors.

In closing he urged the audience to help educate themselves and others to differentiate between devotional expression and the study of religion; to consider religions as internally diverse as opposed to uniform; to consider religion as evolving and and changing, as opposed to being ahistorical and static; and to see religious influences as being embedded in all dimensions of culture, as opposed to the assumption that religions function in discrete, isolated, "private" separable contexts.

In summary, there was plenty of food for thought from a thoughtful man who would like us to be able to celebrate our differences rather than be fearful of them.

L'shana tovah and Eid mubarak!

45 days buys you very little

While I appreciate the efforts of Defense Secretary Chuck Hagel to improve the quality of care in the Military Health System, his order directing "all health care facilities identified as outliers in categories of access, quality and safety to provide action plans for improvement within 45 days" is ill conceived.

Sure, they'll come up with plans.  After all, they have to follow orders.  But everyone working in health care facilities understands that the work processes in place in hospitals and clinics have developed over many years. Bolting on changes will not change underlying systemic problems, and may even make them worse.

The plans that will be put forward will likely make short-term incremental improvements, but then things will fall back to old (or new) levels of dysfunction after a few months.

Mr. Hagel is absolutely correct that “Our men and women in uniform and their families deserve the finest health care in the world.”  But long-term process improvement does not come from rushing to put a plan together, especially when it comes from the top down.  The Secretary might take a hint from the nuclear Navy, where principles of front-line engagement in support of process improvement have been in place for decades.

There's many a slip 'twixt the cup and the lip

"How could it happen?" is the question everyone's asking.

No, not the guy who walked into the White House past the Secret Service.

The nurse who asked the question.  CNN reports:

The first person to be diagnosed with Ebola on American soil went to the emergency room last week, but was released from the hospital even though he told staff he had traveled from Liberia.

Hospital officials have acknowledged that the patient's travel history wasn't "fully communicated" to doctors, but also said in a statement Wednesday that based on his symptoms, there was no reason to admit him when he first came to the emergency room last Thursday night.

A nurse asked the patient about his recent travels while he was in the emergency room, and the patient said he had been in Africa, said Dr. Mark Lester, executive vice president of Texas Health Resources. But that information was not "fully communicated" to the medical team, Lester said.

The man underwent basic blood tests, but not an Ebola screening, and was sent home with antibiotics, said Dr. Edward Goodman with Texas Health Presbyterian Hospital.

Three days later, the man returned to the facility, where it was determined that he probably had Ebola. He was then isolated.

There are probably several reasons. The simplest one, "the nurse messed," up might be correct, but it is also likely to be incomplete.  If a full-scale root cause analysis were conducted, we'd probably learn about any of the following: a lack of training of front-line clinical staff with regard to this disease, a series of protocols that are not attuned to this new and rare disease, and/or habitual poor communication between the triage staff and others.

Let's hope the country learns from this experience.  That's a most important task for the CDC to focus on right now.

Think how powerful a teaching tool this would be: If the nurse and MDs at Texas Health produced a 7-minute YouTube video of what went wrong and how they've changed their protocols.  That would go, er, viral within hours.

Walid offers a summary

Continuing our series on the CMS Open Payments database, I offer this chart prepared by Walid Gellad, and posted on Twitter at @walidgellad, summarizing the payments made from Intuitive Surgical to doctors and hospitals for five months in 2103.  Gellad describes himself as "Primary care physician. Health services research. Co-direct Pitt Center for Pharmaceutical Policy & Prescribing. Opinions my own."  Here's his bio.

Striking to me, as I noted below, is the number of payments and amount (over $2 million) made for "education," i.e., paying doctors to attend training sessions on the use of the daVinci robotic surgery equipment.

Wednesday, October 01, 2014

Money and trust

In my post below, I offer some information about payments made nationally by Intuitive Surgery to hospitals and doctors to support the extended use of the daVinci surgical robot.  Here, I take a look at some local examples.  As I searched through the Massachusetts listings, two names popped out as repeated recipients of cash or in-kind payments and services in amounts exceeding $2500:

Jeffrey Spillane,  Southeastern Surgical Associates, in Hyannis, who operates at Cape Cod Hospital; and James Hermenegildo, Truesdale Surgical Associates, in Fall River, who operates at Charleton Memorial and St. Anne's Hospital.

Dr. Spillane is credited as "the first thoracic surgeon to bring Robotic Assisted Thoracic surgery to Cape Cod." His practice website lists the following promotional article in the local newspaper: "A da Vinci for the modern age," Cape Cod Times.  Further, his page at SSA leads patients to this Southeastern Robotic Surgery Web Site and also to watch this Intuitive Surgical-produced video.

For the five months of 2013 data so far reported by CMS, Dr. Spillane is listed as receiving five payments of $3000 or $3500 from Intuitive for "education" along with payments $150 or $300 for food and beverage on the same dates.

Dr. Hermenegildo is credited by Southcoast Health System with introducing robotic single site surgery for gall bladder removal to the geographical area south of Boston.  (I have written about doubts that are raised by Intuitive's hope to expand the daVinci's reach into cholecystectomies.)

This surgeon's reported payments for the five months include three of $2500 each for education, six payments of $500 each for education, and two payments of $150 for food and beverage.

I don't know much about the Intuitive Surgical training program, but I am surmising that personal attendance at educational events provides doctors with the $2500-$3500 fee (along with meals), and perhaps the online modules offer a $500 fee.  Whatever those details, I don't see why it is appropriate for doctors to be paid for education programs by equipment manufacturers.

But, at this point, the issue is not about my opinion.  Neither does this post have anything to do with the technical competence of these doctors, which I assume is at the highest levels.  Instead, the CMS report raises a different type of issue, one at the heart of the doctor-patient relationship. Trust.

In sum, the most important questions can only be answered by patients being served by these two doctors and the thousands of others listed in the Open Payments database:  "Have you been informed that the manufacturer of equipment that is used in one of three possible approaches to your surgery has made payments to your doctor? Do you have any concerns as to whether your doctor's clinical approach to your care might be influenced by the (now reported) financial relationship with this manufacturer?"

Walking around money

It's been a long time since I wrote about the extremely close relationship between the University of Illinois Chicago, its surgical faculty, and Intuitive Surgical, the manufacturer of the daVinci robot.  I am drawn to do so again by the publication yesterday by CMS of the Open Payments database, showing payments from manufacturers to doctors and hospitals.  The presentation demonstrates the remarkable number of payments ISRG has made throughout the country in support of its robotic surgery devices. UIC is just one of many beneficiaries.

As noted by Charles Ornstein at Pro Publica, though, this database is by no means complete. He points out:

* The data doesn’t cover all payments.
The Physician Payment Sunshine Act, part of the 2010 Affordable Care Act, called for the first public release of this data 18 months ago. But because of delays writing detailed rules implementing the law, the first release of data will happen today and it will only cover payments for a few months, from August to December 2013.

* By design, some data on research payments won't be included.
The Sunshine Act allows drug and device companies to delay the publication of data related to research of new products or, in some cases, new uses for existing products. The payments won't be made public until the product is approved by the Food and Drug Administration, or four calendar years after the payment was made, whichever comes first. It is unclear how much money is involved, but, again, just because a doctor doesn't show up as receiving a research payment doesn't mean he or she hasn't received one.

* Because of errors, additional data isn't being released.
CMS has acknowledged that one third of the payment records submitted by companies for last year had data problems that could lead to cases of mistaken identity. The names associated with those payments won't be released today. Federal officials are asking companies to recheck the data, which should be released publicly next year.

With these limitations is mind, I went to the database and filtered the entries by name of company--Intuitive Surgical--and there are thousands of entries.  I then ranked them in descending order.  Most recipients were hospitals, but some were individuals.

Many doctors and hospital received payments for "education"  or "services other than consulting, including serving as faculty or speaker at venues other than a continuing education program."  One of the top recipients in these categories is the University of California, with a total exceeding $600,000.  There were some large items, $175,000 and $100,000; but most of the 79 entries were in the range of $3000 to $6000 payments.

No doubt it is coincidental that the surgery department at UC Davis presents this website parroting unsupported assertions about robotic surgery's benefits to patients.

Another is Houston's Methodist Hospital, which received over $200,000 in the "education" category.

Again from their website, we see the misleading comparison of robotic surgery to open surgery, but no mention of the relative value of manual laparoscopic surgery.

In all, there are almost 17,000 payments from ISRG from this five-month period.  Some are pennies for reimbursements, but almost 1600 are in the range of $2000 to $10,000.  Where are the recipients?  Baltimore, Philadelphia, Tampa, Atlanta, Phoenix, Miami, New York, Loveland, Reno, Newark, Kissimmee, Lansing, Austin, Orlando, Basking Ridge, Greenville, Owensboro, Detroit, Brooklyn, Ypsilanti, Kirland, Menomee Falls, Mt. Clemens, Hialeah, Bemidji, Tulsa, Blue Ash, Sarasota, Patchogue, Jackson, Plains, Cincinnati, Columbus, Jonesboro, Oklahoma City, Novi, Minneapolis, Shelby Township, Pittsburgh, Eau Claire, Green Bay, Denver, Appleton, Jupiter, Kansas City, Las Vegas, Gainesville, Wausau, Rochester, North Little Rock, Milwaukee, and dozens more.

In the old days of politics, we would have called this "walking around money," sprinkling beneficence to engender widespread support and loyalty.

Let's get back to Illinois.  Right near the top of the CMS list was the UIC's Pier Giulianotti.  According to CMS, he received two payments of $50,000 each in cash or cash equivalents as "grants" for the Clinical Robotic Surgery Association.  What's that?  According to its website, it is a "new society devoted to the minimally invasive robotic surgery." It is registered as a not-for-profit corporation.

I couldn't find any mention of Intuitive Surgical financial support on the website, even in Dr. Giulianotti's welcoming letter, but I did find a number of testimonials for the organization from UIC faculty members.  You might remember some of these people from the full page New York Times Magazine advertisement in which the University allowed its name and reputation to be used in support of Intuitive Surgical.

Here's one person from the ad:

Robotic surgery is a constantly evolving field, CRSA website is an invaluable tool to stay up to date.  The platform is easily navigable and is very practical. Information shared on the website includes basic procedures and more complex ones making the site of unique interest for beginners and for expert robotic surgeons. The possibility to assist to entire procedures during the live events is a formidable educational  opportunity to learn from the masters without the need to travel. It's amazing to see how such a large group of surgeons from all over the world is open to share their experiences and work as a group to improve the quality of care and the quality of Surgery.
Francesco Bianco, MD, Assistant professor of Surgery
Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago.

Here's another:

The CRSA represents a common ground where pioneers of robotic surgery coming from various subspecialties work side by side with young, ambitious and promising robotic surgeons. This synergism has created a dynamic and exciting surgical community where masters of robotic surgery share on a daily basis their terrific experience in the operative theater with innovative ideas brought in by young, brilliant individuals that have the potential to be the next generation of robotic surgery innovators.

The website of the association is clearly in line with these traits as it offers a tremendous amount (835 and the number increases each month) of advanced robotic surgery videos presented in a modern looking and easy to navigate internet frame.

CRSA represents for me the ideal place to cultivate and share my passion for robotic surgery and innovation and to provide my contribution for the advancement of the field and therefore I strongly and unconditionally support this association.
Antonio Gangemi, MD, FACS, Assistant Professor of Surgery
Division of General, Minimally Invasive and Robotic Surgery University of Illinois at Chicago, IL, USA.

And another:

Having the opportunity to share the experience from international surgeons has an incredible value for our clinical and research practices. The CRSA website allows surgeons to be connected and integrated allowing to share experiences in difficlut cases.

CRSA has more than 800 videos about diverse robotic procedures, I dont know of any other portal so complete and diverse. Direct communication with other robotic surgeons dealing with similar problems is a powerful advantage of the portal as well.

For any robotic surgeon , experienced or begginer CRSA portal gives extensive material , comments and opinions that improve their clinical experience. CRSA website is also an important communication channel to be informed about upcoming meetings, trainig courses and news of the robotic world. I highly recommend the CRSA website to any surgeon around the world who wants to start a robotic practice.
Enrique Elli, MD, Assistant Professor of Surgery, Associate Director of Bariatric Surgery
Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago.