Archive for May, 2014

VA appointment problems — same everywhere

vaphoenixAccording to “The Fix” blog by the Washington Post the VA has problems making timely appointments for patients to see a care provider.  The issue “hit the fan” when it was reported veterans died while waiting for appointments.   So, can an effort to provide quality care exist in an environment where funds are limited?

The first rule of quality management is  the outcome that a process or system delivers is exactly what it was designed to deliver (this is only obvious in retrospect).  The second rule is to change the process rather than blame the people involved if the outcome is not what is wanted.  The third rule is to change the process when needed.  The fourth rule is to be fair and allocate resources according to need.

The VA has a huge job.  But, it is often congratulated for delivering very good care at a price less than standard insurance based care for similar diseases.  Before firing the managers of the VA ask what the waiting time is for appointments at your local psychiatry office or local internist?  And, how many people die while waiting for those appointments  — lots.

Like it or not the VA is socialized medicine.  The congress sets the budget and sets the benefits veterans may receive.  The VA is not an open system, it has cost constraints.  For the US Congress to suggest otherwise is disingenuous (a lie).  The truth is Congress must manage the VA, must set the budget, must monitor cost, must decide what benefits to offer, must limit the medications to be used, must bargain for good medication prices and must provide access on a timely basis — to be fair.

Short waiting time for a needed appointment is a quality goal.  Monitoring the goal and correcting the process to meet the goal is essential.  The process needs tweaking frequently.  If the active military doctor says the discharged veteran needs to be seen within 2 weeks then make it so!  If other services with less impact on care need to be cut back then make it so!  Initial evaluation is very important because without evaluation the need for care can not be known and the fairness to deliver care to the ones most in need is lost.

Anticipating the need for care is also essential.  VA care is part of the cost of war.  300,000 soldiers suffered traumatic brain injury in the Afghanistan and Iraq wars.  It does not take a brain surgeon to realize the VA will need funds and staff to meet the care obligation.  If we need to train more doctors, nurses, PA’s and nurse practitioners then make it so!  Training takes many years which needs to be anticipated by Congress.  If the boat has a leak don’t wait until it is about to sink before doing something.

Back to the basics.  The very notion the VA problems should or could be fixed by firing someone is counterproductive and uninformed.  Should the process of evaluating recently discharged veterans be changed? — absolutely.   Throwing more money at a problem without changing the system is doomed to failure.  Punishing people is not the answer.  What the VA needs is quality management with guts!  The VA can and does deliver good care with appropriately limited resources.


Addendum (5/30/14)  General Shinseki tendered his resignation today and his second in command (on the job for 3 months) will take over.  One would hope the chaos that it causes will be temporary until a more experienced manager takes over (time will tell).  So what should be done?  The VA needs a manager familiar with quality care who also knows how to manage health care within a budget (that may require someone from outside the country!)  A few realistic things that could be done:

1.  Commission a lean engineering study to make binding recommendations for improved efficiency.

2.  Put the VA care statistics on-line.  Make the VA care  transparent.

3.  Get rid of financial incentives for people who have no control of the process that needs to be changed.

4.  Award innovation.  Awarding “employee of the month” to the person who just got to work on time is not innovation!


Another thought (6/11/14):  the VA should participate in Medicare Hospital Compare.  Obviously they do not require Medicare but they could submit the same data as other hospitals in the name of transparent care.  The current criticism centers on outpatient wait-times.  It might be interesting to know what wait times might be for other outpatient care clinics like Kaiser Permanente or other vertically integrated systems.





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Hospital Readmission — effect of condition at discharge

What aremr-vital-signse the causes of hospital readmission?  A previous post details the most significant factor:  fragmentation of health care.  This post focuses on disease and the condition of the patient at discharge.

Until the past 5 years the prevailing view of re-hospitalization was it is unavoidable due to the nature of the chronic disease.  The view changed when studies showed strong outpatient social and medical management vastly reduce re-admissions.

And yet, disease does catch up with those afflicted causing eventual death.  Sometimes patients are discharged from a hospital and much to the surprise of clinicians the patient is back in the hospital before outpatient care can engage to deal with a potentially unstable situation.  Even before the outpatient check 4 weeks after discharge the person decompensates and is hospitalized again.

Frustration born out of rapid re-hospitalization lead Michael Rothman to develop a statistical method to alert clinicians before hospital discharge to the presence of high risk.   Whether the outpatient care network is sufficiently robust to act on the information is possibly the bigger issue.  But, consideration of the “Rothman Index” is worth a few comments.

Mr. Rothman published the statistical findings “Development and validation of a continuous measure of patient condition using the Electronic Medical Record”  (Journal of Biomedical Informatics 46 (2013) 837–848).

Rothman found he could predict bad outcome (and hospital re-admission) based on routine measurements done in every hospital, just combined in a statistical way.  He divided the measurements into 3 equally weighted groups of (1) lab tests, (2) nursing observations and (3) vital signs.  Overall there were 26 items such as potassium level, nursing charting by exception (like normal or abnormal respiration), and blood pressure.  The index started at 100 and if all items were normal the index stayed at 100.  But, if items were abnormal an amount was subtracted.  The lower the score the worse the situation.  In fact, he showed his index correlated with the 1-year mortality of the patient.  The lower the index at discharge the more likely was re-hospitalization and even death. Mr Rothman started a company to calculate the index for interested hospitals.

The idea is great:  identify high risk patients and focus more outpatient resources quickly.

Doctors always try to normalize abnormal findings.  If the heart rate is too high find out why and correct it.  If the potassium is too low find out why and correct it.  If the blood pressure is too low find out why and correct it.  When the end of the hospitalization comes hopefully everything is in the normal range.  The Rothman Index basically says that if a concerted effort by doctors fails to normalize findings it means the patient will do poorly (an abnormality caused by a stroke just can’t be normalized).  The very definition of chronic illness is that it can not be resolved by modern medicine.

Rothman’s research shows some interesting findings.  The 1-year predicted mortality is increased by 10% if any the following findings are present at discharge:

Clinical item absent or below present or above
 Respiratory rate  14  20
 Heart rate  40  90
 Temperature  96.9  100.2
 Oximetry  96%  –
 Systolic BP  100  190
 Diastolic BP  50  105
 Sodium  138  145
 Potassium  2.9  4.7
 Creatinine  0.4  1.5
 Chloride  98  102
 Hemoglobin  10  17
 Blood Urea Nitrogen  –  25
 White Blood Count  4,000  14.000
 Heart Rhythm    anything other than
sinus rhythm
 Braden Scale (link)  19  
 Nursing Assessment
excluding pain
   any body system


The Rothman Index is important and either that index or other similar index should be calculated at discharge.  If the index indicates an increase in mortality then questions need to be asked and answered:

  1. Have the abnormal findings been investigated and treatment started — if an available treatment has not been started it should be.
  2. Has enough time passed for the abnormal finding to normalize — if not the patient should either stay in the hospital or be seen as an outpatient in just a few days.
  3. The estimate of a poor prognosis should be discussed with the patient and family to make sure they understand why follow up is important.
  4. If the estimate of poor prognosis is very high (over 50% 1-year mortality) and not expected to improve then planning for death should be started.

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