Samsung's Smart Window

A really neat invention.  Thanks to Bertalan Meskó, MD (@Berci on Twitter), who notes, "Such windows would look great in hospitals as well.

Thanks for nothing

I have been reading and listening to media reports about recent deals between Partners Healthcare System and insurers in Massachusetts and experiencing a case of cognitive dissonance.  From the reports, you would think that PHS is reducing the rates it gets from the payers.

Well, that just shows the power of PR spinmeisters.  Let's start by recalling that PHS has used its market power for well over a decade to extract payments from insurers that are dramatically above those received by other hospitals and physicians.  Those out-of-market rates were built into the contracts that were to extend a year or two into the future, and the annual increases included in those contracts were likewise out-of-market. 

So, what has happened is that PHS has agreed to lower the rate increase for the last year or two of those contracts and for the succeeding years to something in the 2-3 percent range.  It then claims to produce "savings" of $45 million over two years for Tufts Health Plan and $80 million annually for Blue Cross Blue Shield.

These "savings" mask two phenomena.  First, the base upon which those 2-3% rate increases will occur remains substantially above the rates paid to other hospitals and doctors.  Second, the rate increases that PHS has received are no lower, and sometimes higher, than those granted to other systems whose base rates were already lower.

In short, the disparity between the PHS rates and those of other providers will not drop an iota as a result of these deals, and is likely to increase.

The only good thing about these announcements is that they provide, for the first time, a sense of the tax imposed by PHS on the region's health care budget.  We now see that it can forgo what it has characterized as $345 million in future revenues and still maintain its financial health.  Looking back over the past decade, it is not unreasonable to posit that this system has added in the range of two billion dollars to the health care costs paid by the state's businesses and individuals.  The newly announced deals change little in that regard, extending that hidden tax for years to come.

Thanks for nothing.

Carrying a lot of baggage

In contrast to the story below about treating airline priority customers well, let's turn to baggage handling.  I recently traveled on American Airlines through Miami en route to Boston.  The luggage from my first flight was to be shifted from that airplane to the Boston flight.  I had used some mileage credit to get a first-class upgrade so my bags were tagged with a special red marker indicating "priority handling."  According to AA, this would ensure special and expedited treatment: 

Immediately available system-wide, select American Airlines customers will experience Priority Baggage Delivery. Upon check in, your luggage will be tagged with branded Priority bag tags. And when you arrive at your destination, those bags will be the first ones delivered to the baggage claim area, allowing a swift, convenient exit from the airport.

I got to Logan Airport and waited at baggage claim for 45 minutes until all the luggage had been unloaded.  Mine was missing, so I went to the baggage service desk.  A very nice person looked up my record and said, "Oh yes, your bag missed the connection and is on the next flight."  So the company's baggage tracking information system had worked.  They knew where my bag was and had known for several hours.

Query:  Why hadn't they notified me upon arrival -- or even before arrival when I was aboard the plane?  They knew what plane I was on.  Why have me go through a long fruitless wait at the airport?  If you have such a powerful information system, why not use it to the benefit of your patrons?  Especially your so-called "priority" customers.

Indeed, why can't all customers gain access to the baggage information system on their computers or iPhones?  Sounds like that would be better service and possibly save money for those companies, too.

Airline priorities

First impressions about service issues can sometimes be misleading, especially if you don't understand aspects of traffic flow.  Here was my first impression, and then something I learned afterward.

We start with this scene of a Delta airlines gate area.  It happens to be at the Atlanta airport, but the same configuration is used elsewhere.  (See the Memphis set-up below.) Note the sign indicating two lanes of traffic, "general boarding" and "Sky Priority."  Note, too, the special carpet with "Sky Priority" printed on it.  As you can see, the two lanes go to exactly the same door.

Here's what happens.  When a plane is being boarded, passengers who have the "Sky Priority" status are boarded first and directed to use the right-hand lane.  Indeed, a ribbon is stretched across to prohibit entry through the other lane.  When those passengers have finished entering the plane, the ribbon is moved over to block the priority lane, and the general boarders use the other lane.

I asked my gate attendant why this was done.  She giggled and said, "It is kind of silly, but it makes the Priority passengers feel important."

Priority route

General route

I know this is not a big deal in the scheme of things, but let's calculate how much money Delta spent on those signs, the fancy rugs, the barricades, and so on.  I wondered, "Have they really done research to show that passengers care about having a special lane?"  Early boarding, sure.  But in an industry that never makes a profit, why spend money on something silly like this?

But then I talked to a friend who is on the board of an airline company.  He said, "It is all about traffic control at the gate.  If you don't have a physical separation for those classes of customers who are entitled to early boarding, everybody else just piles up at the gate.  It slows things down, plus the passengers who have paid for or otherwise earned priority status get shoved aside.  Those loyal (and mainly full-fare business) passengers are very important to an airline, and they value unfettered early boarding.  So, we incur a little extra expense to give them higher quality service."

Inventory Productivity Webinar from MIT

Inventory Productivity: Missing Link Between Supply Chain Management and Sales

MIT SDM Systems Thinking Webinar Series

Jonathan L.S. Byrnes

Senior Lecturer, MIT

Date: January 23, 2012

Time: Noon - 1 p.m. EST

Open to all

Register

 

Traditionally, supply chain and sales have been managed relatively independently, despite the critical impact that each has on the other. Systems thinking provides the key to linking these two critical business functions.

 

Inventory productivity, the return on invested capital in your inventory, is the single systems measure that links these two cornerstone functions. This webinar will: 1) explain the central importance of this critical metric; 2) describe how to measure inventory productivity in a practical way; 3) outline the levers that both sales and supply chain managers can use to radically improve inventory productivity; and 4) describe how leading companies have created core processes for sales and supply chain managers to work together to achieve stunning results.

Routine or rote?

I am reprinting one of my favorite columns, first posted here on April 26, 2007.

A story for all who have been through the multiple rounds of medical histories upon entering an emergency department.

A good friend found herself in a local ED with symptoms of appendicitis. The first medical history was taken by the triage nurse. Then, another nurse. Then, an intern. Then, a resident. Finally, the attending arrived, and he started the process again, writing while talking and making no eye contact.

By this time, my friend had memorized all the questions, and she figured she could speed up the process by anticipating the next questions and giving the answers in advance of their being asked. "Have you ever had abdominal surgery?" "Yes," she replied, and proceeding to the next as yet unasked questions, offered, "It was a complete hysterectomy, and it was three years ago."

Without pause, and without thinking, he said, "Is there any chance you are pregnant?"

She, feverish and in pain, raises up one elbow, looks directly into his eyes and says, "Either you are trying to introduce some levity into this situation, or that is the dumbest question you ever asked."

He turns deep red and leaves the room without another word.

Moral of the story: In a busy environment like an ED, it is all too easy for providers to go on "automatic pilot" and not really pay attention to what the patient is saying.

Costs of Care essay winners -- Part 1

Do you remember my post back in September helping to publicize the Costs of Care essay contest?  Well, the judges have acted and picked the winners.  Organizer Neel Shah writes:

Two of the winners are from Boston, including an internist who described how a pharmaceutical cost-shifting strategy left him unable to discharge his patient from the hospital, and a medical student who described how she was able to treat a patient in her clinic on a $100 budget by avoiding an unnecessary hospital admission. In all, we received more than 100 submissions from patients and providers all over the country that illustrate both challenges and opportunities to improve the value of care.

We also plan to summarize the lessons learned from the stories we received over the last two years in the form of "quick guides" and educational web-based videos that we will release over the next few months.

I'll print two of the essays in this post and two others by patients below in a separate post.  Here is the first one Neel mentioned, by Andrew Schutzbank.

Peggy was in her early 70s and suffered from a terrible lung disease known as pulmonary hypertension.  So bad in fact, that she had a pump infusing a medicine under her skin 24 hours a day to keep the blood supply to her lungs open.  Once started, this medicine, treprostinil, was known to improve life in those with pulmonary hypertension.  Unfortunately, like all continuous infusion medicines of this type, it has the unfortunate side effect of sudden death if stopped for more than 4 hours.  Starting it was a difficult choice for Peggy and her expert team of physicians, but her disease had progressed to a point where it was the right decision.  As you can imagine, this drug was mighty expensive.  We would only find out how expensive later.

On the day that I met Peggy, she was being admitted to the Intensive Care Unit (ICU) not for her pulmonary hypertension, but because she had a bleed in her stomach, which caused her to swallow blood/stomach contents into her already damaged lungs.  Once stabilized, our first challenge was to ensure that she continued on the treprostinil.  It took a little magic from pharmacy and the drug’s manufacturer, but we were able to get everything together and Peggy was no worse for the wear.

A few days later Peggy was improving, breathing tube out and awake and back to herself. Due to the special nursing needs with treprostinil, Peggy was required to be in the Cardiac Care Unit (CCU), a special type of (ICU), despite her progress.  Even though Peggy managed this medicine at home by herself, hospital policy prevented her from transitioning out of the ICU to the general medical floor, at a fraction of the cost. Conceding that point, the decision was made to try and transition Peggy directly to Rehab.  But her progress was stalled for one simple reason: treprostinil. 

It turns out that if Peggy were to go to a rehab, they have to pay for her medications out of the money they receive to care for her.  As it turns out, treprostinil costs $1400 per day.  $1400.  Now, Peggy does not pay that amount, she has a special arrangement worked out with the company and the state.  But in order to make that arrangement work, the company charges full freight for the drug when the patient is institutionalized.  Since the drug cost alone would wipe out payment for her stay, no rehab would accept her. So Peggy was stuck in the hospital, and stuck in one of the most specialized and expensive beds in the hospital in the CCU.

Think about that for a moment.  A critical care bed was tied up for days for a patient that was well enough to leave the hospital, just not ready to go home.  Arbitrage was suggested—would it not make more sense for our hospital to buy the drug for her at rehab, freeing up the CCU bed (which costs far more than daily dose of treprostinil).  But we are doctors, not financial engineers.  We work in the world of medicines and were unable to orchestrate such an unusual arrangement.  So we did the only thing we know how to do.  We stopped the expensive medicine.

This was not a financial decision.  Peggy had been describing vague body pain, a known side effect of all prostaglandin medicines.  Think of treprostinil as a 24-hour infusion of anti-Ibuprofen. Her breathing was actually quite good despite her recent trials in the hospital, so stopping the medicine made medical sense.   We monitored her closely during the transition and she quickly improved!  She was able to move around more and started on recovery.  She was transitioned to a rehab shortly thereafter and continued to improve.

My colleagues’ decision to stop treprostinil was a medical one.  But ironically, we would not have considered it if were not for the cost factor of the medicine.  Peggy would have gone on for some time on an expensive medicine that was not helping her.  At the same time, it was through one party’s insane attempt to “control costs” that simply caused costs to be shifted and multiplied.  The entire health care system spent much more on Peggy’s care because no one had the vision or authority to deal with $1400 a day.  Pennies compared to the amount wasted, and nothing compared to the risk undertaken by Peggy and her family during this trying time.

And here is the second essay mentioned, by Molly Kantor.

As a third year medical student, I spent one afternoon each week at a health clinic at a community hospital affiliated with my medical school.  This health clinic was focused on primary care for patients with HIV, and many of our patients were poor, homeless, immigrants, or uninsured.  Many were also living with their diagnosis in secrecy and had to hide their medications and medical bills from family members.

One of my patients, who I will call Clara, was a 65 year old Haitian immigrant who diabetes, heart failure, and depression, along with HIV.  Due to her medical conditions, she was unable to work.  She had two grown children, but they did not live nearby and did not know about her medical problems, especially her HIV.  Her husband, unfortunately, was very ill and lived in a nursing home.  Clara somehow managed on her own, but her lack of insurance, poor medical literacy, and limited English proficiency made it difficult for her to stay healthy, and she was constantly coming to clinic for help.

At one visit, Clara seemed unusually tired and revealed that she had been feeling short of breath at home.  In my mind, this raised many questions—Could this be a heart attack?  Worsening heart failure?  A blood clot in her lungs?  Pneumonia?   I took a history and did a physical exam, and my top concern was that this was an episode of worsening heart failure, what we call a heart failure exacerbation, and this typically occurs because the body accumulates too much fluid that the heart has trouble pumping it all so it backs up into the lungs.  Usually, this is a patient who you would send to the Emergency Room (ER) and have them admitted to the hospital so that they could get diuretics (water pills) and slowly lose the extra water—all while being carefully monitored in the hospital.  However, Clara refused to go to the ER.  “Too expensive,” she stated firmly.  “I can’t go into the hospital again.”

We realized the burden this would have on her and her family, so we worked around the problem by getting an EKG done right in the office and getting a chest x-ray.  When her EKG and chest x-ray supported our diagnosis, we decided to give her the diuretics as an outpatient and to have her come back for a second office visit in a few days.   When she returned, she felt that breathing was much easier, and her physical exam supported the improvement.  Instead of this heart failure exacerbation costing thousands of dollars for an ER visit and hospitalization, this cost only a few pills (furosemide 80mg PO costs about $0.29 per pill, and she was prescribed this once daily in addition to her normal medications) plus an extra primary care doctor visit, which runs about $100.

Costs of Care essay winners -- Part 2

Here are two more of the winning essays from the Costs of Care essay contest described in the post above.  These are by patients.

Renee Lux, Connecticut
Patient Cost Anecdote: an unnecessary CT scan raises a patient’s insurance premiums

One morning this May, I woke up with a stiff neck. I applied hot and cold therapy all day and took an Advil before bed. By the end of that week, I was unable to comfortably move my head and I was feeling numbness down my left arm to my fingertips. I saw my doctor within 24 hours of calling his office. After a brief exam, he was sure of my diagnosis, but he scheduled me for a CT-scan at the hospital the next day, “Just to be certain.” A day after the CT-scan he diagnosed me with Radiculitus Cervicalgia- inflammation leading to nerve root impingement. I was prescribed a 10-day regimen of prednisone. By the end of my prescription, the pain was gone and my total out of pocket expense was $55 in co-pays. The unintended result of this diagnosis will cost me $2,220 a year in increased health insurance premiums for the foreseeable future.

Stress and anxiety was likely the root cause of my radiculitus. Stress and anxiety brought on by my search for affordable private health insurance. My husband had been out of work for over a year and our COBRA, with the government’s Premium Assistance Rate (ARRA), was about to run out.

I contacted a health insurance broker and explained that I needed an affordable, high-deductible plan for a family of four with no pre-existing conditions. We are all healthy, all average weight and height, non-smokers, none of us are on medication and we have no issues with cholesterol or allergies and no plans for more children.

The broker found us an affordable plan and sent over an application for underwriting which I carefully filled out. Within hours of emailing it back to her I received a frantic phone call. “You said you had no pre-existing conditions!” she bellowed down the line.

She explained that having had a CT-scan and prescription medication within 30-days of my application made me practically uninsurable. She was adamant that the CT-scan alone would trigger an automatic denial.  The broker suggested a high-risk plan, which is very expensive. If I couldn’t afford it, I could apply for Connecticut’s High Risk Insurance Pool, but I would have to be un-insured for 6 months in order to qualify.

“High risk?” I thought meekly. I don’t have diabetes, cancer or HIV. I don’t even have high blood pressure. How can I be high risk when my diagnosis was resolved with $5 worth of prescription drugs? 

Now I was frantic! I called my doctor. He was incredulous, insisting that my radiculitus was resolved. He offered to write a letter on my behalf. I contacted a friend of a friend, a medical underwriter in another state. All she would say was that my diagnosis within a month of my application throws up red flags for insurance companies.

I took a deep breath and started over with a new broker- we talked over the phone. When I told him about my recent CT-scan I could hear him sucking in his cheeks. There was a long silence.

Finally, he suggested we apply to three insurance companies at once, in the hope that one would accept me. The underwriting process requires me to state if I have ever been declined health insurance. A denial by one company would trigger automatic denials by other insurance companies.

I filled out three applications and agreed to phone interviews with underwriters for two insurance companies.

Eventually, one company offered to cover my family, but denied coverage to me. One company offered us coverage with an exclusion: “This policy does not cover any loss incurred by Renee Lux resulting from any injury to, disease, or disorder of the cervical spinal column, including the vertebrae, intervertebral discs, surrounding ligaments and muscles, treatment or operation therefor and complications therefrom.”

The third and final insurance company approved my coverage with a premium increase to cover my medical condition, “Cervicalgia/Inflammation of the neck.”

Had I known what the repercussions of that doctor visit were, I would have asked my doctor if the CT-scan was absolutely necessary for my diagnosis. Perhaps even the prescription could have been replaced with a higher dose of over the counter anti-inflammatory. The long-term affect of my “pain in the neck” is an additional $189 a month for the foreseeable future.  

Here's the second one.

Court Nederveld, Florida
Patient Savings Anecdote: a frugal patient saves money on routine prescriptions and testing by having a frank conversation with his doctor about costs.

Hypertension was the trigger that forced medical cost awareness to the forefront. My doctor decided that with a rise in blood pressure it would be prudent to proscribe a blood pressure drug and order a nuclear stress test. With only a catastrophic insurance policy with a $5000 deductible it was imperative from our personal financial state that the cost of both the drugs and the procedure be known up front.  The prescription was the first thing we faced. The script for Lotrel was written and a trip to the pharmacy revealed an out of pocket cost of $200 for a thirty day supply. This was way beyond my means especially factoring in that this drug would most likely be required indefinitely. Relating this information to the doctor resulted in a prescription for the generic Norvasc and the pharmacy cost was to be $138 for 30 days. Still beyond household finances. I then began to research Lotrel and Norvasc and discovered that they are two old blood pressure medicines, amlodipine besylate and benazepril hydrochloride. I requested that my doctor write the script for these two separate drugs and I now take them daily at a cost of $7 for a thirty-day supply of both drugs.

Having successfully challenged the cost of prescriptions my eyes were wide open as I began the quest for a nuclear stress test. My doctor, fully aware that I would be a self-pay referred me to a colleague in our area. A phone call began with introductions and the statement that because I would be a self-pay patient it was imperative that I know the cost of the procedure before hand.  The doctor was unable to immediately provide a cost and after checking with staff requested $2500. I reminded him that I was uninsured. He replied that it could be done for $1900.

I told the doctor that I wanted to be sure I understood. I asked, “if I walked in with a check for that amount I would walk out with the test results?”  The physician responded that I would need to come in for a consultation first. Cost $250. I asked again, “if I walked in with $2150 would I walk out with the test results?” Again the reply was that there would have to be a follow up visit to review the results. Cost $250. Hesitation must have been detected in my voice or the doctor detected a possible mark, because the doctor then said that perhaps I didn’t need a nuclear stress test and a regular stress test would suffice. Cost $800. Consultation and follow up not included. I then asked what would occur if the regular stress test revealed nothing. His response was that we would do the nuclear stress test to be sure. The inverse was also true; if the regular stress test revealed any anomaly then a nuclear stress test would be ordered to provide further information. Total cost out of pocket would be $3450.

Feeling much like a cow on a milking machine I began to test the theory that medical procedures were money making enterprises and as such should be available as a commodity. Using the Internet to begin my search, the only specific criteria required was that the location of the facility performing the test be within a short drive from home. It took very little time to find and confirm a company that would provide a nuclear stress test sans consultation, follow up and would willingly and promptly forward the results to my primary care physician.  To verify that all was understood I informed then that I would have a check for the exact amount they quoted and no further remuneration would be forthcoming. All was as stated and the procedure was done. Total cost was $938.11. 

While these two episodes have been the only challenges faced so far, having related these stories to friends and family, they also have begun to challenge costs and procedures with very similar savings.

It will be several years before Medicare is available to me and until that time I intend to challenge every prescription or procedure as to necessity and cost.

What would Richard do?

When it comes to hotel service, I have a new standard by which I measure facilities:  "What would Richard do?"  Richard Caines, you may recall, is director of training at the Gaylord Palms Resort and Convention Center in Kissimmee, Florida.  The hotel appropriately prides itself on a very high standard of service, based in turn on a respectful and congenial approach to its staff.

So, today, I am at the Gold Strike Casino Resort, in Tunica, Mississippi, where I will be giving a speech to a group of health care finance people.  Hearkening back to my years in Arkansas, I decided to start my day with a good old-fashioned Southern breakfast in the comfort of my room.  Now, there was no way I was going to eat all 2000 calories, but I was looking forward to sampling the grits, biscuits, and fried ham steak.

Well, as I dug into the ham, I discovered that it was resting comfortably on a rather long and dark human hair.  That quickly ended breakfast, and I called room service to report the matter.  The woman who answered was very apologetic and offered to send up another meal.  I said that I no longer had an appetite for that and was only concerned that they find the cause of the problem so it wouldn't happen to anyone else.  She told me that someone would come up to investigate.

A short while later, a man from Security showed up.  He took a picture of the evidence; took a picture of me to document that the hair could not have come from my head, and then asked me write out a description of the event and sign it.  He also donned surgical gloves and put the offending hair in an evidence bag.  He left behind a card, with contact information for the security department, saying that I could contact them in about five days to learn the results of their investigation.  He was polite and helpful throughout.

The way the hotel choose to handle this case made me feel like I felt like a witness at the scene of a crime more than a customer reporting a service quality problem.  Yes, both people with whom I was in contact were friendly, concerned and appropriate.  Each one asked if there was anything further they could do to help me.

I think Richard and his colleagues at the Gaylord would have handled this differently.  I think they also would have apologized profusely.  I think they would have offered to refund the cost of my breakfast.  I think they would have gone further to make sure I would want to come back to their resort, perhaps even so much as refunding a portion of my room charge or offering me a discount on a future stay.  They would not have asked me to fill out an affidavit, which in essence made me feel like the hotel didn't trust my oral report. And they NEVER would have taken a picture of me to substantiate the nature of my complaint -- as though a customer would choose to lift up a ham slice and put a hair underneath.  Finally, they would not have left it up to me to contact the hotel in several days.  They would have taken it upon themselves to send me a report, along with remedial steps they had taken.  I imagine, too, that a senior manager would have come to visit me within an hour or so to apologize again and explain their process improvement plans.

Minor points?  Maybe.  But in a highly competitive resort marketplace, details matter.

(In health care, too, by the way.)

---

Addendum:  A short time after I wrote this, I went to the front desk to check out.  The process was taking longer than expected, as the desk clerk stepped away to consult with her supervisor.  After some time, she returned, and I asked if everything was all right.  "Yes," she said, "we were figuring out how to 'comp' you for your breakfast order this morning."  A nice gesture, I thought, but why had no one mentioned it earlier during my talks with the room service or security people?  By delaying the gesture, they lost a chance to make a good impression in real time.

De-Magnetizing

One study does not a trend make, but this one has conclusions that are so direct that it is bound to attract lots of attention . . . and anger from certain quarters.  This post, likewise, may prompt additional anger from some of my readers.

C.J. Goode and others have published an article in the Journal of Nursing Administration entitled, "Comparison of patient outcomes in Magnet® and non-Magnet hospitals."  You can view the abstract here.  Let me give you the highlights: 

Non-Magnet hospitals had better patient outcomes than Magnet hospitals. Magnet hospitals had slightly better outcomes for pressure ulcers, but infections, postoperative sepsis, and postoperative metabolic derangement outcomes were worse in Magnet hospitals.

What an indictment of a certification process that the American Nurses Credentialing Center describes as follows: 

The Magnet Recognition Program® recognizes healthcare organizations for quality patient care, nursing excellence and innovations in professional nursing practice. Consumers rely on Magnet designation as the ultimate credential for high quality nursing. Developed by the American Nurses Credentialing Center (ANCC), Magnet is the leading source of successful nursing practices and strategies worldwide.

What is the ANCC? It claims to be "the world's largest and most prestigious nurse credentialing organization." Its website explains: 

The American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association (ANA), provides individuals and organizations throughout the nursing profession with the resources they need to achieve practice excellence.

For purposes of this post, let's accept that and stay away from credentialing and professional advancement programs for individual nurses and focus on what it takes to receive Magnet® designation. Well, like other types of certification programs in other industries, your organization needs to meet an array of standards based on certain philosophical underpinnings, and you need to "pass" a review by independent surveyors.

You also need to pay a lot of money.  There is an application fee, an appraisal fee, a documentation review fee, a site visit fee, and an extension fee if you want to postpone your site visit.  In all, the process costs tens of thousands of dollars, paid to the ANCC, not to mention the costs incurred by the hospital on internal organizational matters.

So, here's the question:  With all that it takes to receive Magnet® status, and with all the assertions by the ANCC about the superior nature of Magnetized institutions, what peer-reviewed data exist that support the assertion that such hospitals do in fact deliver higher quality patient care than the non-Magnetic hospitals?  We now have one such study that indicates the contrary.

Currently, there are 391 Magnet hospitals.  As I look through the list of those from my own state of Massachusetts, I don't see any that offer sufficient public, real-time data about clinical quality to prove the case of higher quality.  And given the dearth of transparency with regard to clinical outcomes nationwide, it is hard to believe that one could do so in any other state.

I did a Google search on the topic of "quality of care at Magnet hospitals" and found very little.  There was a 2010 thesis by Kelly Scott, a nursing student at the University of Kansas, entitled "Magnet Status: Implications for Quality of Patient Care," which said: 

In summary, this study did not find evidence to support the expectation that Magnet accreditation directly correlates to lower rates of hospital‐acquired infections. There was evidence to support existing research indicating that nursing workforce characteristics are better in Magnet hospitals. While Magnet accreditation remains the gold standard for nursing work environments, this status does not automatically lead to better patient outcomes. 

And in the absence of real data, it seems that a hospital's enthusiasm for the importance of this status can be transitory, at best: 

Magnet hospital status was "the ultimate benchmark to measure the quality of care" for the University of Kentucky until it failed to get renewal of the designation.

A hospital official questioned its importance last week. "It is a recognition from a professional society," said Dr. Richard Lofgren, chief clinical officer for UKHealthcare. "You can get recognition from a whole lot of professional societies."

Uh oh, it sounds like a lot of revenue for the ANCC might be at risk unless peer-reviewed articles emerge that document real quality improvement results from this certification process.

Read more here: http://www.kentucky.com/2011/03/07/1660635/nursing-care-designation-doesnt.html#storylink=cpy

Wachter explains private practice in the UK

Bob Wachter continues to offer thoughtful  perspectives on the British health system.  The latest is about the role of private insurance and private doctors operating in parallel to the National Health Service.  Here are some excerpts:

[F]rom the time of its founding in 1948, the British National Health Service has allowed – and, depending on which party is in power, promoted – a private insurance market. Private insurance in a single payer, government run healthcare system is a funny animal: one part incest, one part conflict of interest, and three parts strange bedfellows. And it’s infinitely fascinating. 

The action in the private world stems from occasionally poor access to specialty care in the NHS, both because of limited numbers of specialists and gatekeeping by GPs. The result of these limitations is the famously long NHS queues. . . . [M]any patients still have to wait longer than they’d like in the NHS. Such patients find the private sector’s shorter waits attractive.

Who are the doctors who provide this private service?

There are few purely “private doctors” in Britain – most private care is delivered by moonlighting NHS physician-specialists. . . . [T]he NHS’s 30,000 specialists have had no cap on the amount of money they can earn from private practice, as long as they clock 40 hours a week for the Health Service.

Hmm, doesn't this create a conflict of attention?  Yup.

The conflicts play out within the specialists’ practices themselves. One London neurologist told me that he might see a patient in consultation for a neurological disorder and offer a follow-up appointment in several months, assuming there is no urgent clinical need. “But if the patient has private insurance, she can see me tomorrow if she’d like.”

The average specialist in the UK augments his or her income by about 50 percent through private practice, but there are wide variations. Specialists operating in the countryside, where few patients have private insurance, may have no opportunity to practice privately. On the other hand, some London specialists double or triple their salaries through private work.

Isn't this unsustainable?

Yet while they differ at the margins, both parties seem content to allow private practice to exist, and sometimes thrive. I wondered why: doesn’t the private sector siphon off resources – both money and providers’ time – from the NHS? I finally had my aha moment when one NHS manager likened the situation to that of US private schools operating alongside our underfunded tax-based public school system. “All the people using the private system have already paid their taxes, so they are siphoning volume out of the NHS that the system otherwise would have to manage,” he said. “The NHS would come to a grinding halt if private practice went away.”

None of this is surprising.  Back in 2007, I wrote about how the US and European health systems will eventually converge.

The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.

[In a nationalized health system, the] appropriation by the parliament is a politically derived decision. . . .  In the face of inevitable limitations on the ability of the national hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.
 

I predict . . . that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.

Water interests in hospitals: Spraying infections?

By now, you may have heard about the outbreak of Legionnaires’ disease in Wisconsin that was linked to a decorative water wall in a hospital lobby.  As noted in this Washington Post story: 

In 2010, eight people contracted the severe and potentially life-threatening form of pneumonia caused by the bacteria. None had been admitted to the Milwaukee-area hospital at the time of exposure. But they all had walked by the water wall in the main hospital lobby, researchers said. 

I wonder how many more people may have been unknowingly infected.  The article continues: 

The study, published online in Infection Control and Hospital Epidemiology, is the second documented outbreak of Legionnaires’ disease in a health-care setting associated with a wall-type water fountain, a design that is increasingly popular in hospitals, hotels, spas and other public settings, the study said. In 2007, two cancer patients at the National Institutes of Health in Bethesda were diagnosed with the disease after being exposed to a contaminated wall-type water fountain. 

I see this as yet another example of an expensive and poorly thought through health care fad: 

Decorative water fountains and water walls can be soothing and calming, so many hospitals and clinics included those amenities as a way to be more patient-friendly, said Jan Patterson, a professor of medicine and infectious diseases at the University of Texas Health Science Center at San Antonio.

Here's a lovely example from Carson City:

.

People probably crave views of water in Nevada

I would go further and suggest that this particular fad was often driven by a desire to persuade rich people to make donations to support hospitals' capital expansion programs.  I can see it now:  A visit by the hospital CEO to a wealthy potential donor, showing the architect's rendition of a beautiful lobby, complete with "water interest." 

Wait!  You can see it now, too!

A happy donor, no doubt.

 By the way, The Joint Commission has rules about this issue that were prepared in 2003 by Centers for Disease Control and Prevention, Healthcare Infection Control Practices Advisory Committee (HICPAC): 

Although not considered a standard point-of-use fixture, decorative fountains are being installed in increasing numbers in health-care facilities and other public buildings. Aerosols from a decorative fountain have been associated with transmission of Legionella pneumophila serogroup 1 infection to a small cluster of older adults. This hotel lobby fountain had been irregularly maintained, and water in the fountain may have been heated by submersed lighting, all of which favored the proliferation of Legionella in the system. Because of the potential for generations of infectious aerosols, a prudent prevention measure is to avoid locating these fixtures in or near high-risk patient-care areas and to adhere to written policies for routine fountain maintenance. [page 47] 

Hmm, is a cancer center a high-risk patient area?

But "routine fountain maintenance" may not always work, notes the story in the Washington Post: 

The fountain at the Aurora St. Luke’s South Shore hospital was installed in 2008. All visitors using the hospital main entrance passed by it on their way to the information desk. Water flowed down a tile wall about 8 feet wide by 5 feet high, and through a bed of decorative rocks that rested on a spongelike foam material.

Although hospital staff performed weekly and monthly maintenance, “it’s very difficult to clean those things out,” Haupt said. A sampling of a 3-inch by 4-inch piece of the foam material found it had more than 1 million bacteria, he said.

Canadian court to address end of life support

The Supreme Court of Canada will soon be taking up the issue of whether doctors need consent before taking a patient off life support. As reported here in The Globe and Mail:

The country’s top court has granted leave to appeal to the doctors of . . . a man who has been in a coma at Toronto’s Sunnybrook Health Sciences Centre since October, 2010. His doctors diagnosed him as being in a “permanently vegetative state” and recommended he be taken off life support, but his wife and substitute decision-maker . . . strongly opposed. Now the doctors have turned to the Supreme Court in hopes of disconnecting Mr. Rasouli from the medical machines that are keeping him alive.

The outcome of the case could set a national precedent on protocol for end-of-life care when physicians and families don’t see eye-to-eye. The issue is fraught: Medical technology can now keep patients technically alive, so their loved ones sometimes keep them connected to machines for months or years, even when doctors advise against it.

As it stands, all provinces but New Brunswick require consent from the patient or substitute decision-maker for medical treatment, and Ontario is the only one with a tribunal that makes decisions on a patient’s behalf.  

Of course, the ideal is for the patient and family and doctor to have talked through such matters in advance, but where that has not occurred, a clear legal standard will come in handy.

In my former hospital, we had a procedure in place for those instances in which a doctor felt that a patient or family was demanding a harmful or ineffective treatment.  But as I re-read that policy today, it seems to be focused on the initiation of such treatment.  I am not sure whether it should or could apply to the withdrawal of treatment, i.e., the kind of case being considered here by the Canadian court.

I think, too, in the United States, that these would be matters of state, and not national, jurisdiction.  Perhaps readers who are more familiar with the various states' laws on these issues will provide us all with the benefit of your comments.

NPSF listserv

Many thanks to Dr. David Lawrance, at University of Illinois at Urbana-Champaign, for a lead to a good listserv run by the National Patient Safety Foundation.  He notes:

I find a lot of value following the National Patient Safety Foundation's listserv, which has a very ardent group of patient safety professionals. However, there is not enough participation by senior hospital administrators, current, former, or future. The consequence is a frustrating disconnect. I thought you might be interested.

He's right.  I joined and took a look around at the conversations.  They are thoughtful and professional.  You can find more information and join in the conversations here.

Making the constitutional argument

MA Attorney General Martha Coakley has submitted an amicus brief in the pending Supreme Court case about the national health reform legislation.  The brief focused on the "individual mandate" portion of the law.  I think it is really well done and I copy the argument summary here:

Having enacted six years ago a prototype of the comprehensive healthcare reform package that Congress would later adopt in 2010, Massachusetts is in a unique position to assess the rationality of the assumptions that underlay both enactments. Specifically, the Court has held that the Commerce Clause empowers Congress to regulate activities that substantially affect interstate commerce. Congress properly exercised that power in adopting a provision in the ACA that requires all non-exempt persons to purchase at least a minimum level of health insurance coverage. Through its legislative findings, Congress rationally concluded that those who fail to purchase health insurance despite their ability to pay for it (“free riders”) not only drain finite State and federal free-care resources, but also negatively impact the availability of privately-issued health insurance policies and the prices at which such policies are sold. Congress further concluded that curtailing the practice of “free riding” would make private health insurance coverage easier for individuals both to procure and to afford.

Having examined data for four years following the adoption of its own individual mandate, Massachusetts can attest to the rationality of Congress’s conclusions. Massachusetts now finds that its efforts to stop healthy people from opting out of purchasing health insurance have increased health-plan enrollment and helped decrease the rate of premium growth. These developments, in turn, prompted a significant reduction in governmental and private free-care expenditures. Because Massachusetts’s empirical experience demonstrates a strong link between eliminating “free riders” and improving access (and reducing costs), Congress acted rationally in drawing the same link as one basis for its regulation of activity affecting interstate commerce.

The Massachusetts experience further demonstrates that Congress was also empowered to enact an individual mandate under the Necessary and Proper Clause. That clause authorizes Congress to
take the steps necessary to implement legislation that falls within a specifically enumerated power. Thus, even if an individual mandate did not fall within the ambit of the Commerce Clause, the broader machinery of the ACA -- provisions broadening access, controlling costs, and eliminating denials based on pre-existing
conditions -- was constructed precisely to regulate the interstate features of the health insurance marketplace. That attacking the “free rider” problem is rationally related to achieving the ACA’s interstate commerce objectives likewise finds strong support in the Massachusetts data.

Finally, while Massachusetts has reaped many benefits as a pioneer in healthcare reform, its experience also demonstrates the limitations on a single State, acting alone. Many aspects of health insurance are the exclusive domain of federal regulators, while innovations by individual States have consequences beyond that State’s borders. This demonstrates both the interstate character of the health insurance market and the need for a coherent federal approach to its regulation.

Earle of the islands

Earle Nelthropp and daughter Sonya

Here are some stories from one of my ancestral homes, St. Thomas.  You may recall a previous one about how the island came to be covered with flamboyant trees.

Today's stories are about an interesting personage from the Virgin Islands, Earle Nelthropp.  You met his daughter, Sonya, in an earlier post, in which she presented several sayings from the islands, updated here.

Earle served as Administrator of St. John from 1966-69, appointed by his old friend, Governor Ralph Paiewonsky.  In 1970, he took over as manager of the Magens Bay beach authority.  But it is his earlier history that offers a sense of the color of the times.

Earle was born in St. Thomas in 1906. In an interview with Sonya in his later years (1988), he reminisced about the arrival of Halley's Comet in 1910:

Halley's Comet in 1910

I was in St. Thomas.  I was only four years old at the time.  My father and I went out in the evening to see this comet over the town of Charlotte Amalie and from where we were standing, we were facing the town across the Harbor of St. Thomas.  It seemed to me at the time that we were standing from one end of the town to the other end.  The sight was very spectacular.

Shortly after, Earle was sent to Denmark for his early schooling. 

In Denmark, I was enrolled in a boarding school.  The schools were very rough on children who did not speak Danish; therefore it did not take me long to learn.

King Christian the Tenth used to ride by the school yard every Thursday on his horse.  At that time, 10:00 in the morning, we were out in the play field when he rode by.  He would give us a bag of sweets over the fence.  That's the kind of King he was.  He was 6 foot 6 or 6 foot 7, a big man, a wonderful man.

Apparently, Earle became a bit more mischievous upon returning to St. Croix, attending Mrs. Lauder's School at the corner of Church and Queen Street.  A contemporary, Antone Taytoe, relates this story:

One day, Earl N., who was always up to tricks like this, brought to school a large centipede which he had caught and removed its poison fangs.  Now, with the fangs removed it was perfectly harmless; but if you did not know that the fangs had been removed it was still very frightening. So, while we were all seated and busy with lessons, Earl removed the centipede from a little box in which he carried it and place it on the floor and called the attention of one of the more timid girls to it.  The girl took one look and let out a scream of course and pandemonium broke loose.   Earl had to push one boy out of the way just as he was about to stomp on his centipede.  Finally Earl got it back in its box and took it outside in the yard ostensibly to kill it, as he said.

Mrs. Lauder cautioned loudly, "Look out, they always travel in pairs, another one might come along at any moment." This gave Earl just the opening he wanted.  After coming back into the classroom saying not to worry that he had disposed of the creature, he let a few minutes go by and when things had settled down and lessons resumed, he let his centipede out of its box again to the accompanying shrieks of the children.  "See what I told you," said Mrs. Lauder, now a proven naturalist, "They always travel in pairs."

Earl again caught the centipede and was now viewed as a sort of hero.  He took his defanged centipede outside and set it free in the garden.

Semester in Israel for undergraduates

Here is a great opportunity described by Dr. Osnat Levtzion-Korach, Deputy Director, Assaf Harofeh Medical Center.  It is for undergraduates with an interest in medicine, pre-med and other health/science students, to take a semester at a highly regarded Israeli institution: 

We would like to introduce to you our accredited academic elective program:  The Voyage to Medicine in Israel.

 

The Voyage to Medicine is a five-month program (either fall or spring semester) open to English-speaking undergraduate students who express an interest in the field of medicine.  The program is a joint venture between Tel Aviv University and Assaf Harofeh Medical Center.

The course offers participants the unique opportunity to gain experience in one of Tel Aviv area's finest hospitals and medical institutions, under the tutelage of expert physicians in the field. The medical facilities which comprise Assaf Harofeh Medical Center, an 800-bed academic, medical center, treat a broad spectrum of ethnic origins, cultural backgrounds and socio-economic levels of the Israeli population. The program provides the overseas students a wealth and variety of clinical material such as: clinical research, first aid, emergency care, laboratories, adolescent medicine, genetics, psychology and much more.

For additional  information please see the link to our site.

End-of-life conversations, as seen by the intensivist

My recent post on end-of-life care issues, "What if they had had to pay?," generated a lot of comments in the blogosphere and beyond.  One intensive care doctor sent me a particularly poignant note.  It gives a good sense of what it is like on this person's side of the bed.  The note re-emphasizes the need for better end-of-life planning, for the sake of patients, families, and providers.

Here's my day so far.  This is my first day of a 7-day stretch in a tertiary ICU. The average census in this ICU is 10, but today we have had to surge to 15.

Let me stop right there.  This is doctor (and nurse) shorthand for, "I expect to be very busy, very tired, and very stressed out.  I am going to have to make some highly critical clinical judgments, sometimes with very little time to react.  I don't know anything about these patients beyond what is in the charts and what our care team sees and hears for themselves."

Two patients today coded in our hospital. One family wants "everything" done, and seemed shocked to learn that I don't think it is right to provide "everything." The other family wished someone from the healthcare team had bothered to ask them what their 89 year old dad would really like to accomplish from his hospital stay before he tried to die. We decided to let him finish dying.

And I had 3 other similar discussions with patients or their families about goals that can actually be achieved. All of them were already in the ICU, having had no real clear previous discussions. One of those patients was admitted last night, but the other 2 had been in our ICU for days....

Removing barriers on WIHI

Removing Barriers to Better Health and Better Care with
Medical-Legal Partnerships
January 12, 2012, 2:00 PM – 3:00 PM Eastern Time
 

Guests:

Barry Zuckerman, MD, Chair, Department of Pediatrics, Boston University School of Medicine; Founder, National Center for Medical-Legal Partnership

Robert Kahn, MD, MPH, Associate Professor of Pediatrics and Director, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center

Carol Beasley, MPPM, Director of Strategic Projects, Institute for Healthcare Improvement

Let’s face it. If someone mentions the words “medical” and “legal” in the same sentence, the next thing we imagine we’ll hear about is a lawsuit. Picture this instead: empowered, proactive social workers, collaborating with health care providers, lawyers, and legal experts, to ensure that the health of indigent patients isn’t undermined by unsafe housing, lack of food, or lack of access to benefits and entitlements. Some people refer to this type of outreach as “preventive law” because it’s directly related to preventive health measures we now recognize are crucial to help people head off disease or better manage chronic conditions.

Doctors and nurses on the front lines have understood for years the role that social conditions play in improving or worsening health. Also, what happens when problems brewing at home, such as domestic abuse, don’t rise to the surface during a routine medical visit. Fifteen years ago, Dr. Barry Zuckerman founded a program at Boston Medical Center to address a swarm of issues affecting the health of low-income children. Six years ago, this initiative became the National Center for Medical – Legal Partnership, focusing on anyone, at any age, in need of the combined power of medical and legal intervention. The effort and the framing caught on and there are now over 200 programs like Zuckerman’s across the US, one of them in Cincinnati.

WIHI host Madge Kaplan welcomes Dr. Zuckerman and Dr. Robert Kahn of Cincinnati Children’s Hospital Medical Center to the show on January 12 to explain and explore the ingredients of an effective medical-legal partnership and how the efforts to date are making a difference in patients’ health and their lives. At Cincinnati Children’s, key prompts to get at social determinants of health are built right into the electronic health record. This helps screen for health-undermining circumstances — for instance, a landlord’s lack of attention to a faulty refrigerator — that might benefit from legal attention. This is just the type of thing Carol Beasley is keeping an eye on as she continues to help spearhead the work of IHI’s Triple Aim initiative. When the goals are improving the experience of care, improving the health of populations, and reducing per capita costs, it’s increasingly essential to form coalitions and partnerships that integrate legal and social service expertise with health care expertise.

It sounds right, you’re saying to yourself, but how does it really work? Where do you find the resources? And, where do you begin? Bring all these questions and more to the January 12, 2012 WIHI — the first program of the New Year. This topic is the perfect place to start. See you then. 

To enroll, please click here.

Good diagnosis, Zeke. Why no cure?

I really like it when I agree with Zeke Emanuel and never more so than with his recent column in the New York Times about proton beam machines.  You will recall that I addressed this topic several months ago.

He notes:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers. But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. 

And here's the upshot: 

With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy. 

If the United States is ever going to control our health care costs, we have to demand better evidence of effectiveness, and stop handing out taxpayer dollars with no questions asked. 

So why doesn't the administration, which runs and controls Medicare, change this?  Didn't you work in the White House, Zeke?  Can you tell us why?