tag:blogger.com,1999:blog-32053362.post770247489430784538..comments2024-03-18T06:27:51.599-04:00Comments on Not Running a Hospital: Above averagesPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger43125tag:blogger.com,1999:blog-32053362.post-14562503936256232392007-07-20T12:50:00.000-04:002007-07-20T12:50:00.000-04:00Speaking of NY, here's another interesting facet o...Speaking of NY, here's another interesting facet of this issue from "The doctors weigh in" blog:<BR/><BR/>http://www.thedoctorweighsin.com/journal/2007/7/19/should-we-have-health-care-performance-transparency-by-whom-.html<BR/><BR/>Funny he makes his comments concerning transparency about NY, which jaz points out has been reporting on cardiac surgery for some time.<BR/><BR/>Tangentially, I think Bill McGuire (former CEO of UHC) is the most egregious example of a doctor selling out his Hippocratic oath for profit. His license should be lifted for ethics violations.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-2279815056600545032007-07-19T19:06:00.000-04:002007-07-19T19:06:00.000-04:00Thanks anon 9:28 (can't people use pseudonyms any ...Thanks anon 9:28 (can't people use pseudonyms any more? I'd much rather address a "Bob" than "THX 1138")<BR/><BR/>My first sentence was trying to answer the knee-jerk reaction that "all patients are different", these reports are built by consensus and involve specialists who make very difficult decision about who to include in the sample. They do a thankless job of trying to find a sample of comparative cases, albeit after extensive risk adjustment.<BR/><BR/>Nonetheless, yes, many patients are considered too out of bounds for comparative analysis.<BR/><BR/>New York has been reporting these numbers since 1994 or maybe 1995 if I remember correctly. Of course, the risk factors have been tweaked over time, and the criteria and risk factors are monitored constantly. None of these reports are "fire and forget", huge amounts of work go into ensuring their validity.<BR/><BR/>Pennsylvania also reports on cardiac surgery, at least ten years if not more.<BR/><BR/>New Jersey and California do pretty much the same but I don't know how long they've been publicly reporting.<BR/><BR/>There may be more, I may have missed a couple. I think the Florida state Web site has mortality rates.<BR/><BR/>All of this misses the point that every hospital, hospital association and state health department that has the data does their own reporting, just not for public consumption.<BR/><BR/>So, long story short, cardiac surgery public reporting has been around for about fifteen years.<BR/><BR/>jJazhttps://www.blogger.com/profile/06624232605595849074noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-90767284980883251002007-07-19T08:05:00.000-04:002007-07-19T08:05:00.000-04:00Dear Jaz;I am anon 9:28. While I don't exactly und...Dear Jaz;<BR/><BR/>I am anon 9:28. While I don't exactly understand your first sentence (are you saying everyone high risk has already been excluded?), I have no quibble with your general sentiment. I am not a surgeon; in fact, if anyone came under my knife, they would already be dead. (:<BR/><BR/>My point is just that all laws or incentives or rules must be examined for unintended consequences, and this is one example. I attempted to read the report you cited despte my lousy dialup connection here, and it seems there is a gold mine of data there which could be mined for additional study on such possible consequences. Why not let these reporting states serve as pilot projects for some years, and study the data instead of theorizing, or has this been done and I am not aware of it? (How long has NY been doing this, anyway?)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-36498701926347628562007-07-18T19:09:00.000-04:002007-07-18T19:09:00.000-04:00Dear Anonymous, given the exclusion criteria and v...Dear Anonymous, given the exclusion criteria and very generous number of risk factors, not to mention any second procedure dropping the patient from the sample, don't you think that leaves very few patients at risk of being considered "too" risky?<BR/><BR/>Here's a quote I find alarming and relevant:<BR/><BR/>"Surgeons became quite creative in finding ways to keep their patients out of the data sample. David Brown of SUNY–Stony Brook remembers a patient from 1999, a man in his early fifties who was athletic, a bicyclist, whom he referred to surgery for a bypass. <BR/><BR/>On paper, the man was a low-risk patient—young, healthy, with just one vessel that needed repair. For some reason, however, the man went into cardiac arrest while being put under anesthesia. If he had died, the Department of Health would have scored the death with a very high mortality and no risk adjustment. But the man survived, and a week later Brown glanced at the report and noticed that the surgeon had performed an additional procedure while the patient was on the table.<BR/><BR/>“He did a mitral annuloplasty, which is putting a little ring around the mitral valve,” Brown says. Because of this surgery, this patient no longer could be considered for the state data; he was knocked out of the sample. If the patient died, it wouldn’t affect that surgeon’s mortality rate. “I called him, and he sort of hemmed and hawed about it,” Brown remembers. “I was going to report it, because I thought it was assault. Certainly it was done strictly to manipulate the data.”"<BR/><BR/>I would happily give up all risk-assessed data in exchange for the name of any surgeon who feels it in his or her power to perform unnecessary procedures on my human body to avoid peer review. <BR/><BR/>Deaths will occur. We are mortal. Nonetheless, what I should have said instead of saying the mortality rate has plummeted, what's more important is that the variability between surgeons and hospitals has significantly declined.<BR/><BR/>If less people are getting surgery that wouldn't have kept them alive for 30 more days anyway, well, that's a debate for the health economists and utilisation experts. I'm in no position to state my desire or lack thereof for heart surgery to prolong my life 28 days, I've never been in the situation. Honestly though, I can easily imagine not wanting it. <BR/><BR/>And I stand by my personal choice to enjoy being declined service by anyone who fears their intervention will report out poorly. It's not the only reason I believe in public reporting, but it's up there on the list.<BR/><BR/>If you are so worried I won't fare well under your knife, I say pass me on.Jazhttps://www.blogger.com/profile/06624232605595849074noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-32551473135767289182007-07-18T09:28:00.000-04:002007-07-18T09:28:00.000-04:00Dear Jaz;While it is true that mortality has plumm...Dear Jaz;<BR/><BR/>While it is true that mortality has plummeted in NY state, one would have to do a study to see if the higher risk patients are now being denied surgery, as Dr. Lee et al feared. This would also result in a plummeting rate attributed to cardiac surgery - it would just be attributed to deaths from heart disease instead.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-52225082150560303882007-07-18T08:05:00.000-04:002007-07-18T08:05:00.000-04:00As a nurse who has been around for a long time (si...As a nurse who has been around for a long time (since 1978), medicine has always been a 'secret' society. It has only been recently that patients are allowed to have access to their records let alone the data concerning an MD or a hospital. Medicine I believe was probably the initial profession that utilized acronyms/abbreviations, why to keep things from non-medical people hidden. This is going way back but there actually used to be an acceptable standard acronym/abbreviation of {PIA} or {RPIA} that was actually written in patient's records. I think you can guess what that stood for, many people don't know what the 'R' stands for, it is for ROYAL. Now that would never occur and that is a good thing as it should not have been used in the first place, but it was the norm years ago. It takes a while for people to adjust to type of disclosure that is now occurring and some people can never accept it, but there will not be a choice any longer to continue to outdated thought of keeping things within a private circle of members.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-73661618977455517952007-07-17T22:16:00.000-04:002007-07-17T22:16:00.000-04:00To the doc who said "When I finish residency, if t...To the doc who said "When I finish residency, if this sort of scheme is around then quite frankly I'm not taking patients who have a good chance of dying in 30 days" I would like to thank you on behalf of myself and any of your future patients.<BR/><BR/>Speaking as a potential patient, I'd like to think that if my doctor was worried about his ability to care for me he'd refer me to someone he felt could do a better job, or at least tell me he's worried you can't do the job adequately.<BR/><BR/>However, in the absence of that, maybe these "schemes" will do some of the heavy lifting.<BR/><BR/>New York seems to have benefited greatly from cardiac surgery outcomes reporting, although the jury is out on whether the poor-performing docs stopped practicing or simply moved to a less transparent state. Either way, the statewide mortality rate post CABG has plummeted.<BR/><BR/>http://www.hanys.org/communications/pr/2005/103105_pr.cfm<BR/><BR/>Quality reporting drives quality improvement, pure and simple. Consumers getting something to look at is (at this point anyway) a bonus.<BR/><BR/>http://content.healthaffairs.org/cgi/content/abstract/24/4/1150?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Hospital+Performance+Reports%3A+Impact+On+Quality%2C+Market+Share%2C+And+Reputation+&andorexactfulltext=and&searchid=1139907897953_80&FIRSTINDEX=0&resourcetype=1&journalcode=healthaff<BR/><BR/>J. H. Hibbard et al. (2005) Hospital Performance Reports: Impact on Quality, Market Share, and Reputation. Health Affairs 24, 150–1160.<BR/><BR/>For those who are genuinely interested care, here is a link to the Cardiac Surgery report, it contains a full, open methodology. See page 13 for variables.<BR/><BR/>http://www.health.state.ny.us/diseases/cardiovascular/heart_disease/docs/cabg_2002-2004.pdfJazhttps://www.blogger.com/profile/06624232605595849074noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-86851457568145783182007-07-17T18:44:00.000-04:002007-07-17T18:44:00.000-04:00Just to echo a bit of what james says above, give ...Just to echo a bit of what james says above, give the public some credit in being able to sift through the data that is reported.<BR/><BR/>And heres a challenge to the docs that have been posting saying this is such a bad idea, come up with a better system that takes into account risk factors and comorbidities,etc. The current metrics aren't perfect, but its better than nothing and its the public who wants this. Public reporting is not going away.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-83973909322768272592007-07-17T14:46:00.000-04:002007-07-17T14:46:00.000-04:00Why are they sensitive? Because their craft is uni...Why are they sensitive? Because their craft is unimaginably complicated, incomprehensible to lay people, and often a matter of judgment and experience that defies measurement.<BR/><BR/>That's why not everyone is a doctor. A pilot has an aircraft. Its design is known. Its failure points are (mostly) known. Yes, s/he may have two hundred lives in hir hands, but almost all the variables have been worked out.<BR/><BR/>Human beings, and human bodies, are works of natural art, not an engineering project.<BR/><BR/>Which (to harp on the subject) is why healthcare is NOT a "consumer market."<BR/><BR/>That said. It's helpful to know more about potential outcomes, since, let's face it, Doctors can't be sure about them either. All we have IS statistics.Robhttps://www.blogger.com/profile/14085759273215853991noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-22074516625368321592007-07-17T12:47:00.000-04:002007-07-17T12:47:00.000-04:00Two thoughts:I want to echo Paul's statement of th...Two thoughts:<BR/><BR/>I want to echo Paul's statement of the urgency for providers to get involved in quality metrics. The demand is there and growing. The realistic choice facing providers is between ensuring that the best possible metrics are used or falling behind the curve and suffering the fate of public school teachers.<BR/><BR/>Secondly, many of the doctors in the above comments show great anxiety over people learning about the cases that just went wrong under their care. I think it is important to give the public some credit here. Just as we, to return to the opening analogy, not only understand but celebrate the fact that David Ortiz FAILS to reach base more than two-thirds of the time, we understand that doctors, nurses, and hospitals are not perfect. Things go wrong. We know. Of course proper risk adjustment and consideration of sample sizes is needed, but I don't think doctors need to have such anxiety about how they will be judged by a few cases.jmaddenmasshttps://www.blogger.com/profile/13117353395168137154noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-53735495417753854602007-07-17T11:56:00.000-04:002007-07-17T11:56:00.000-04:00It sounds to me like a number of commenters here c...It sounds to me like a number of commenters here could use a Fenway Frank.<BR/><BR/>Then again, maybe that would put them in a higher risk tier...Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-91917196682270921402007-07-17T10:47:00.000-04:002007-07-17T10:47:00.000-04:00Holy cow, what a mass of thought and commentary. I...Holy cow, what a mass of thought and commentary. I've been friends with (and patients of) many caregivers and administrators in the past 30 years, so I see both sides of this pretty clearly, I think.<BR/><BR/>And, being in my 7th hospitalization of 2007 (at BIDMC), with quite real implications for my working life and life outcomes, the simple question is always there: "Where's the best provider?"<BR/><BR/>I don't think anyone is saying "That's none of your business ," but I don't see anyone pointing me to the list.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-36935156860002102032007-07-17T09:43:00.000-04:002007-07-17T09:43:00.000-04:00Glad to have been so persuasive! :)So, we all see...Glad to have been so persuasive! :)<BR/><BR/>So, we all seem to agree that (1) PCPs should have access to risk-adjusted clinical results for specialists to whom they might refer.<BR/><BR/>(2) Hmm, maybe it's just (1).<BR/><BR/>----<BR/><BR/>But one final coment to anon 9:17. This is not about me or my ability to make sense of the issue or even be persuasive. It is about a greater societal trend that doctors can either get in front of and help frame in a positive way or get steamrolled by legislated solutions.<BR/><BR/>And, anon 8:21, if you want to impute malice on this blog, feel free, but in so doing you are falling into a bad trap of denial of the point raised just above. The doctors in my hospital and in this community know that I am not malicious in any sense towards them and am incredibly supportive of what they do. Some agree with me on this issue, and some don't, but we don't accuse one another of malice when we have different opinions.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-90620217764304232432007-07-17T09:17:00.000-04:002007-07-17T09:17:00.000-04:00To set the record straight, I am responsible for c...To set the record straight, I am responsible for comments 8:35, 9:56 on 7/16, and (unposted as yet) about 9 am July 17. So Paul, you're not just arguing repeatedly with the same demented commenter, there are a bunch of us anons. I am also retired, so none of this affects me directly. I am still in favor of individual rankings provided to the hospital medical executive committees for privileging and to PCP's, but Paul, your comments on this post have changed my position from one of being willing to explore public reporting, if accuracy can be attained, to one of, no way. If you don't see it yet then neither will the public. Let the PCP's decide which, by the way, is how it happens now anyway!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-43363181471053859352007-07-17T08:21:00.000-04:002007-07-17T08:21:00.000-04:00Paul;What's lost in all your "messianic zeal" (I l...Paul;<BR/><BR/>What's lost in all your "messianic zeal" (I love that one), is that the SF Gate article itself raises questions about the validity of the data - the results re UCSF contrast with both the "high regard" ranking of long duration and the U.S. News ranking, however valid the latter may be. At least one of the surgeons got the strongest possible affirmation from another prominent surgeon in the area ("I'd let him operate on me.") The article says 2 of the patients died of unrelated causes within the 30 days, yet were counted in the operative mortality.<BR/><BR/>Doesn't this give you cause to wonder yourself if the state metrics are accurate? So it's OK to ruin someone's reputation in public on the basis of inaccurate statements? In other venues that would be called libel. Oh wait - I'm not a lawyer, I'm a doctor. Maybe malice is required. I am beginning to wonder about malice on this blog.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-64441274620217477232007-07-17T07:46:00.000-04:002007-07-17T07:46:00.000-04:00I believe that public reporting should be designed...I believe that public reporting should be designed in a way that mirrors the standards of the scientific literature. In other words, it should be readily apparent when the difference between two numbers is statistically significant or not. <BR/><BR/>I am a physician and I agree that some form of public reporting is inevitable, and I also feel that it is important for patients to have access to objective information. I thus think that clinicians, as opposed to simply objecting to the trend towards public reporting, should be advocating for sensible presentations. Those presentations that emphasize whether there is a meaningful difference in performance, rather than simply presenting numbers side by side, make the most sense to me. Given the issues of risk adjustment, presenting raw numbers ONLY can be worse than no information as incorrect conclusions could be drawn. Dr Lee points this in his article that when dealing with small volume numbers a few bad outcomces could quickly adversely affect the calculation of a rate. But because of the small numbers it would not be a statistically significant difference. We would not allow this in the scientific literature to be held up as a true difference. <BR/><BR/>On the other hand, if we wait for perfect risk adjustment, that day will never arrive. Similar to the scientific literature, a conclusion might be drawn based on a statistical difference, but the discussion will note that risk adjustment is not perfect and that bias could theoretically have influenced the findings. <BR/><BR/> But if public reporting venues emphasize whether performance is "as expected" or outlier based on statistical methods, as oppposed to absolute numbers, the potential for misinterpretation is reduced.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-52435499000278689182007-07-17T07:15:00.000-04:002007-07-17T07:15:00.000-04:00The problem that I see here is that some docs don'...The problem that I see here is that some docs don't see themselves as "regular" people. They are above the rest of us. We are all guilty of allowing this or becoming a part of it. Now they are beginning to be held accountable, just like the rest of us, and it is not welcomed. The facade is crumbling. I would also lose the Dr title and merely add the MD at the end of your name like the rest of us. It's just the job that you chose to do and the public trusts you to do your best but we now want proof.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-3876340222147897202007-07-17T05:17:00.000-04:002007-07-17T05:17:00.000-04:00Anon 11:51. I'm not being glib. I was giving a b...Anon 11:51. I'm not being glib. I was giving a bit of personal background. Please read the context again. I was asked by another commenter to put my name next to hospital measures of safety and quality, and I was explaining why my background made me comfortable with that.<BR/><BR/>As to your point "When I finish residency, if this sort of scheme is around then quite frankly I'm not taking patients who have a good chance of dying in 30 days," you are now another data point in support of the conclusions written by Dr. Lee and his colleagues.<BR/><BR/>Sr, thank you. I haven't dismissed hospital-wide reporting. See above. I have strongly advocated it. I think it should be supplemented with physician-specific reporting. I agree with you regarding hospital medicine, by the way, and also about several of the currently required reporting metrics. I think there are very good measurements of surgical results, though, as I have mentioned.<BR/><BR/>Anon 1:12, thank you. People don't have to be "last", but they could be grouped by statistically valid quartiles -- if the data show a strong enough statistical variation to create quartiles.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-58362594700947125632007-07-17T01:12:00.000-04:002007-07-17T01:12:00.000-04:00Perhaps a patient's perspective from someone who r...Perhaps a patient's perspective from someone who recently had surgery at BIDMC...<BR/><BR/>This blog made me wonder just how I happened to have one of the best doctors in my specialty operating on me.<BR/><BR/>When my primary care physician referred me to a specialist, I said "ok" without question. When this specialist referred me to another specialist, I still said "ok" with no questions asked about who they were referring me to. I of course wanted the best doctor, but I assumed that I would always be referred to the best doctors. I think it's generally the case that patients trust their doctors, right?<BR/><BR/>Which leads me to my point...I am incredibly lucky that the first specialist I saw "knew" who was best for me. But what if I didn't live in this medically talented/connected Harvard/Boston area? Would my doctor know who's actually the best? I think that when patients blindingly trust in their doctors, it's only right (and expected) to give them evidence-based information (and I agree with Paul that it's possible to come up with a fair methodology if not in the numbers). I can't believe that I was relying so much on who my doctor happens to be acquainted with...<BR/><BR/>That said, I feel bad for the doctors who would end up last on the rankings, no matter how poorly they performed. Is there any way for this transparency thing to not be seen punitively? What if the names of just the best performing doctors appeared publicly, like the top 25%? That way, consumers and referring doctors would know who's up there, while those who didn't make the cut would privately know where they stand but aren't exactly blacklisted and publicly humiliated...Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-55619144746076318122007-07-17T01:10:00.000-04:002007-07-17T01:10:00.000-04:00Paul--I think you fail to give doctors enough cred...Paul--<BR/>I think you fail to give doctors enough credit. I think most physicians realize that public reporting is inevitable, and would simply prefer it to be done right. Despite the messianic zeal with which you (and the IHI) advocate for public reporting of individual physician performance measures, there are real problems with the measures currently being reported. The article you linked to provides a perfect example: Dr. Hoopes performs about 26 CABG's a year, so one death in an extraordinarily high-risk patient over a two-year period causes his rating to go from average to poor. Risk adjustment notwithstanding, small sample sizes will always be subject to undue influence by a few cases. That is why, for now at least, reporting outcomes at the hospital level makes more sense than at the individual level. The NSQIP model is explicitly for inter-hospital comparisons, not for comparing individual surgeons. <BR/><BR/>And surgery (particularly cardiac surgery) is the area where risk-adjustment methods are the best! For many other fields--including my own, hospital medicine--there simply are no validated performance measures that can be reliably applied to an individual physician. I work at an academic hospital similar to BIDMC, so my group is judged on pneumonia quality of care measures. We do reasonably well on things like using the correct antibiotics and administering them in a timely fashion, but our rates of pneumonia vaccination are low. Now, pneumovax does not save lives; it does not reduce the chance of hospitalization due to pneumonia; it only marginally reduces the chance of the patient getting pneumonia again. But our numbers are low, so in order to fix this, over the last two years we've probably spent more time and effort on pneumovax rates than any other quality effort. There are definitely other quality problems at my hospital that are going unaddressed because of the focus on pneumovax. Until better measures are developed, we might be better off deciding for ourselves what needs to be fixed.<BR/><BR/>Finally, you said "But whether there are other apt examples [of individual performance reporting] is not quite the point. Medicine is an intensely personal craft. The individual doctor can make the difference." This is true, but only to a point. Patient safety and quality is largely a function of teamwork and the system as a whole, less so the individual physician. Understand, I fully believe that as a physician I am responsible for my patients' outcomes. But the physician is not the only one responsible. Look at the New York CABG data--hospitals with persistently elevated CABG mortality rates often had systematic problems with the care they provided, not incompetent surgeons. You seem to dismiss hospital-wide reporting because it "doesn't help me choose a surgeon." You, of all people, should understand that the quality of the surgeon and the quality of the hospital are closely linked.<BR/><BR/>Let me say (again) that I am not at all opposed to public reporting of performance. However, you should realize that this is a very complex issue with good arguments on both sides, especially regarding individual vs hospital-wide measures. Of course all of us--patients and physicians--want measures that explicitly tell us which physicians do a better job. But those measures don't exist yet. Physicians who object to public reporting often have legitimate grievances. Stereotyping them as mere obstructionists doesn't help your cause.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-54171149095712672952007-07-16T23:51:00.000-04:002007-07-16T23:51:00.000-04:00Paul: I'm afraid you're being rather glib if you c...Paul: I'm afraid you're being rather glib if you can't see the difference between being publically responsible for drinking water quality and having a list of people you killed published next to your name. That's essentially what it's saying - only 4 people should have died, 8 did, QED. I can think of few more powerful motivators than this.. but they're not going to be the kind of motivators people want. When I finish residency, if this sort of scheme is around then quite frankly I'm not taking patients who have a good chance of dying in 30 days. It's certainly better than accepting them and then having arbitrary benchmarks influence my care decisions. Let them subject some other sucker to getting their name written up in major newspapers as World's Worst Physician. I bet it won't take too many of those SFGate articles before nobody will operate on them them at all, and operative mortality rates will plummet! Wonderful!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-76072059712961287182007-07-16T22:39:00.000-04:002007-07-16T22:39:00.000-04:00Fine with me, anon. Check the BIDMC website with ...Fine with me, anon. Check the BIDMC website with the numbers. That's my name, my face, my words in the introductory video.<BR/><BR/>And, as you know, my name is already on all those blog postings in which I posted how we were doing on various metrics -- including the IHI mortality index. See http://runningahospital.blogspot.com/2006/12/first-kill-as-few-patients-as-possible.html.<BR/><BR/>The minute there is a state website or any other of the type we have been discussing, or even on the current websites, I am pleased to have my name on it if the sponsors would like that. (Of course, I'd like it better if my colleagues did the same. You should check with them.)<BR/><BR/>I guess I come from a different kind of background, maybe because I served in the state government. When I ran the local water and sewer authority, it was assumed that I would be held accountable for drinking water quality, wasterwater permit compliance, management of large construction projects, water rate increases, and siting of unpleasant facilities in people's neighborhood. That's drinking water quality for 2.5 million people -- as big a public health responsibility as I can imagine.<BR/><BR/>I'm not saying that to brag. I am saying that I bring that same view to this field -- because hospitals are public institutions with a special charter, and the public has a right to know who is ultimately responsible.<BR/><BR/>Think of the irony, though, if a CEO is held accountable for the performance of a hospital, but the doctors within it (who are not hospital employees and who are essentially self-governing) are not similarly held accountable for their performance.<BR/><BR/>Thanks to Barry for another good thought. As BostonMD was saying, patients are actually already graded by degree of difficulty for surgical cases, so your suggestion could be easily carried out. The American College of Surgeons already does that in their non-public data system. It produces a risk-adjusted summation of how a hospital does on cases (e.g., vascular surgery) compared to what would be expected for the risk profile of the patients who have been treated. It is a thoughtful and powerful analysis.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-85702302858442596052007-07-16T22:00:00.000-04:002007-07-16T22:00:00.000-04:00Just one additional thought. If I projected mysel...Just one additional thought. If I projected myself into the surgeon's shoes, I can appreciate some of the issues they raised regarding complexity surrounding the data. However, I think they should be able to develop reasonable metrics regarding, say, cardiac surgery. Patients could be divided into risk tiers as I mentioned previously. For the adverse outcomes (both complications and deaths), perhaps the surgeon could be allowed to file a supplementary report that would flesh out the circumstances of the case and be part of the record. For example, patient was an 80 year old male diabetic with severe coronary artery disease and below average (for his age) lung and kidney function. He was in the highest risk tier and his pre-op prognosis was poor even relative to others in that group. He didn't make it despite the team's best efforts.<BR/><BR/>Perhaps, from a healthcare system cost standpoint, the surgery should not have even been attempted, but that is a whole different subject and discussion.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-71559017544011556552007-07-16T21:56:00.000-04:002007-07-16T21:56:00.000-04:00Paul;No, I am not a new reader and I knew that wou...Paul;<BR/><BR/>No, I am not a new reader and I knew that would be your response. I've read all those posts.<BR/> But no - I am not speaking of having BIDMC in some ranking vs. MGH or BW, like the U.S. News and World Report or whatever. I am speaking of having Paul Levy's name out there in bold, with his hospital's name in small print, as having the best, or bottom third, or whatever, number of patients die in his hospital. So your neighbors and people on the street and your kids and everyone sees YOUR NAME.<BR/> You and I have previously agreed that process metrics are a poor substitute. And I couldn't care a bit about your salary being related to any performance metrics.<BR/>This is about personal accountability. How many patients did Paul Levy save, or kill, last year by virtue of his competence - published on some state website or nationally. This is what you are asking doctors to do.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-70517007641786071352007-07-16T21:28:00.000-04:002007-07-16T21:28:00.000-04:00Thanks to BostonMD for his/her suggestion.And Barr...Thanks to BostonMD for his/her suggestion.<BR/><BR/>And Barry, you can bet the nurses have opinions as well!Anonymousnoreply@blogger.com