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.


Anonymous said...

Paul - What is your take on the recent CMS Medicare Readmission Penalty data for Mass hospitals going into 2015? Nearly all hospitals in Mass are facing 1-2% payment reductions because they are readmitting Medicare patients at a higher rate than expected by CMS (obviously the hospitals feel differently). This is another big financial hit and is on top of last year's readmission penalties that were imposed on many of the same hospitals. Are hospitals discharging too early for financial or quality purposes? Either the CMS benchmarks are incorrect or the vast majority of Mass hospitals have much higher Medicare readmission rates than one would expect.

Gary Kantor said...

Paul, Thabiso looks like he is not too happy and about to stab me with his fruit kebab, but in truth it was a very amiable conversation.

The misleading data is a consequence not only of the pressure to perform under scrutiny (VAP "compliance" scores are used as KPIs- Key Performance Indicators - in this hospital group) but also the real challenge of measuring processes that can be more or less continuous (e.g. head of bed elevated), or sometimes intermittent (e.g. suctioning), with limited resources and without interfering with workflow or imposing excessive burden on frontline clinical staff.

Bob said...

How about light-of-day transparency as one incentive for hospitals to improve? Or are the measures too inexact? What about light-of-day process measures of Board governance, which I agree is very, very important?

In the case of the Ebola Texas hospital, the culprit is clearly insufficient salaries -- the CEO who departed in April was only getting $1.2 million, and the Chief of Nursing only $425K. For that pittance, who can expect competence, or ask them to answer to the public?

And when it comes to leadership, how on earth can one excuse Frieden for not sending a CDC team immediately to Texas Presbyterian? Hands off advisories for the first case? Just such a stupid decision that he explained away as "20-20 hindsight."

Where have the leaders gone, Simon and Garfinkel might well ask.