Archive for category Culture of Quality
Bernie Sanders popularized the idea of US national healthcare during his 2016 campaign. He described the idea as “Medicare For All”. That was a genius idea since most Americans have a family member with that program for seniors. In fact, with its 44 million participants it represents a very large, although incomplete, national healthcare program. It is very popular among seniors since it reduces insurance premiums dramatically.
There are two major versions of Medicare: Standard and Advantage.
- It sets the allowed price for hospital and medical provider services
- It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.
- Limits participants to one insurance company or organization
- Has lower premiums
- Wraps Medicare and a supplement together
What about Medicare For All
- What about premiums or supplements or services? (the specifics need to be chosen, not guessed at.) It’s like a dream house, but without a drawing or a list of deliverables.
This is really the nuts and bolts of a national plan no matter what you call it. And, if the current providers sense they will make less money, the self-serving complaints will be very loud. Who will complain if patients don’t get a better deal — not very many people. That’s because not very many people understand healthcare. So, what do you as a consumer want?
☐ Same old insurance, high drug prices and poor quality
☐ Premiums paid via payroll deduction
☐ Premiums paid via annual income tax
☐ Allow supplemental insurance for non-covered items (like plastic surgery or special drugs)
☐ Profits for drug companies limited to 5%
☐ All covered medications available for $10/month
☐ All approved hospital days available for $400/day
☐ Out of pocket annual expenses limited to $5000/year
☐ Approved child medical care is free
☐ 0.5% of premiums for research
☐ Regional claim processing (by current insurance carriers, limited to 5% profit)
☐ Limited list of available medications, generics are required where available, brand name drugs are selected by the plan
☐ 30% of provider payments linked to quality and quantity measurements
☐ Medical school tuition paid in exchange for 5 years of service in designated (poorly served) areas
☐ Mental health service included same as other health care (includes PhD psychologists)
☐ Maternity care, including midwife care at home when safe
☐ Primary care provider available for all persons
☐ Physicians and surgeons are salaried (not paid by number of services)
☐ Same day service for urgent problems
☐ Clinics open nights and weekends
☐ Massive increase in numbers of physician assistants and nurse practitioners with tuition paid in exchange for service
☐ Video visits with providers via Internet if desired
☐ Hospitals paid according to diagnosis (DRGs)
☐ Regional specialty hospitals (5% for growth and development)
☐ Local general hospitals (5% for growth and development)
☐ Providers all use the same secure medical record
☐ Annual adjustment of payment levels based on a budget
☐ Ongoing and up-to-date quality measurements on all services
☐ No need for malpractice suits — immediate compensation for injuries instead
☐ Strong quality system capable of sanctioning administrators and providers (important!! may need lawyers here)
- use good judgement — nice
- revere your teachers — nice if you are a teacher
- order a good diet — still a matter of question
- don’t hurt or damage people — really or just statistically?
- don’t poison people — makes sense to me
- comport oneself in a Godly manner — doctors have no problem here
- don’t do surgery if you don’t know how — duh
- doctor visits should be for the advantage of the patient — patient centered care is nothing new
- keep medical information private — HIPPA before its time
Doctors often take some revised or modernized version of the Hippocratic Oath. Sadly, the idea that doctors have some responsibility for the care provided by other doctors is missing. The idea is front-and-center in most work on quality improvement — where the idea is indeed to improve everybody’s care. Doctors should have 2 responsibilities: 1) care for the patient and 2) improve the quality of care for all.
Most doctors don’t accept item #2, instead the list is: 1) care for the patient and 2) care for personal finances. In essence, doctors shun quality improvement because “I’m not paid to do that”.
How many doctors participate in quality improvement activities? Meaning, find a problem, make a plan, do something, study the result, then act to improve the plan and repeat the cycle. This is not rocket science. A physician is not expected to do molecular biology research in the office but there is an expectation they will improve waiting time and reduce prescribing errors — things easily within their grasp. How many physicians have a quality improvement meeting each morning or at least once a week — I dare say less than 1%.
Systems of care are very important. But, the lack of physician involvement in quality improvement is a serious deficiency in many health care systems. In some respects this is a structural issue for health care — it’s not a process, and it’s not an outcome. It’s like a foundation for a house — no foundation means the house will not last.
Highly educated and experienced cardiologists just can’t get it right: the correct dose of aspirin after a heart attack is 81 mg (called low-dose), NOT 325 mg (called high-dose). The current prescribing error rate is 60.9% as published by the American Heart Association in 2014.
Personal communication with several cardiologists elicits the comment: the higher dose is needed because of the risk of another heart attack — and “in my experience” it just works better. It’s hard to believe this clinical error in this age of quality assurance. The problem is BLEEDING not heart attacks! The stomach BLEEDS due to aspirin and the higher the dose the higher the risk of BLEEDING.
Just imagine the risk and strain for a recent heart attack victim who vomits blood, needs a transfusion and must undergo a stomach scope — some patients die. From a cardiology standpoint: “they died from something unrelated to the heart attack” — great thinking.
Cardiologists completely and totally get it wrong when they simultaneously prescribe high dose aspirin and the anticoagulant warfarin — the ghastly mistake happens 40% of the time.
The chemical reaction of “acetylation” is caused by aspirin within small blood cells called platelets. Acetylation of platelets is responsible for the favorable heart effects of aspirin. It has been known for at least 30 years that 81 mg of aspirin completely acetylates every platelet a person has — more aspirin does no more. According to the 2012 TRITON-TIMI trial:
“We observed no difference between patients taking a high dose versus a low of aspirin as it relates to cardiovascular death, heart attack, stroke or stent thrombosis,” according to Payal Kohli, MD involved in the study and quoted in Science Daily.
Hospital quality improvement programs need the “guts” to just say NO. 325 mg is not correct. Cardiologists are the sweetheart doctors making millions of dollars for hospitals — it should not matter, JUST SAY NO.
It’s almost impossible for even the most proactive patient to question the great doctor that just saved their life. So, hospital quality assurance has an even greater responsibility than usual. The prescribing error needs to be corrected — hospital pharmacists and quality improvement departments need to be strongly involved — this error has gone on far too long.
Saying “sorry” is the human thing to do. Doctors and nurses should say it when they feel it.
Saying “sorry” seems to have two meanings: 1) something bad happened and I understand your emotions 2) something bad happened and I had some connection with the event for which I feel partly responsible. Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.
Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things — neither said “sorry.” Sorry truly does not fix anything; but, the absence of “sorry” is infuriating.
The problem is ego. Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME. Absence of “sorry” is a sure sign of defense (a defense of self). Perhaps the health care provider was spanked as a child or yelled at by teachers. Who knows … ego has gone wild.
Quality health care depends on people believing errors are due to system failures. When providers fail to embrace that philosophy they fail to correct problems. No failure, no correction.
A fall in the hospital can be deadly. Recently, a family member fell in a room while no nurse was present and they died. The nurse did not say “sorry.” There was no acknowledgement of responsibility. No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths. The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.
Lawyers are not the cause of excessive health care ego. However, lawyers with the threat of suit are a convenient excuse. When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.
Doctors could learn a lot from pilots. Flight simulators have revolutionized commercial aviation so pilots can train without endangering passengers. Patient-care simulators do the same for doctors yet doctors fight the idea. See the article in the Wall Street Journal 7/21/14 by Melinda Beck “Doctors Upset Over Skill Reviews.”
There are cognitive skills and procedural skills; both are amenable to testing and training. The current buzz words are “maintenance of certification” or MOC. The specialty societies have raised the bar –and the price –for the MOC tests. Each state empowers a board, or group of people, to oversee medical quality and issue licenses to practice medicine at a much lower educational standard than the MOC. So, many physicians feel the specialty boards have gone too far.
Examples of specialties include: family medicine, internal medicine, general surgery, ophthalmology, and gynecology just to name a few. The MOC process requires many hours of education each year and periodic tests. If the process is not completed the physician is designated “not meeting MOC requirements” which is a black mark for any specialist.
The offended doctors object to being forced to learn about subjects like:
- how to recognize abuse of children and elderly adults
- teamwork during operating room emergencies (a simulator lab)
- how to review a chart to identify areas for improvement
- principles of quality improvement
- new information about cost effective drugs
Of course, all those topics are a waste of time for busy doctors that stay on the cutting edge of medicine by getting information from drug reps and journal ads. The high cost of continuing education, $2000 for a refresher course, is ridiculous since that is the usual salary doctor receives for 3 days of work. Who ever heard of using a simulation laboratory; it’s not proven. Practicing on live patients to see what works and what doesn’t is the way — some live and some die. Besides, what does a pilot really learn when they crash a simulator rather than a real plane!
It sounds like a paradox: science studying itself. But, that is exactly what is happening in medicine. Basic research has led to applications of the research and the applications are studied for effects, benefits and cost. For example: invent robotic surgery and apply it to patients, then set it up as a program in an operating room and try to improve the technique and patient selection, and finally evaluate the program to see if it meets stated goals of quality and cost and decide if it should continue and under what conditions.
This huge simplification helps with terms doctors and hospitals often talk about:
- Discover and apply — called research.
- Try to improve — called quality improvement (QI).
- Continue the effort? — called program evaluation (PE).
Patients can be subjects of research. But, participation in research requires explicit permission since the outcome is not known and it could be bad.
If we knew what it was we were doing, it would not be called research, would it? (Albert Einstein)
Patients are hopefully impacted by quality improvement since the purpose is to make things better and thus no patient permission is required. As part of QI a hospital may try to make sure antibiotics are given before surgery because there is research evidence the practice reduces infection. Quality improvement focuses on a cycle of planning, doing, study and revision. QI has become a huge area of study with numerous books and journals on the subject. Virtually every hospital has a quality manager who is charged with improving the care at a hospital.
Patients are only indirectly affected by program evaluation. Clinics and hospitals constantly evaluate programs for positive or negative effects. Whether programs continue depend on such studies. People may read about evaluation of medical programs like care at VA hospitals and may be impacted by decisions of policy makers based on such evaluations. PE is likewise an important and growing discipline.
The concepts of research, quality improvement and program evaluation do tend to overlap. One could imagine using QI techniques to improve the quality of research. And, one could imagine research to find the fastest way to do program evaluation. However, research is mainly for the purpose the researcher decides. Whereas QI and PE are mainly for patient care, business or institutional purposes.
Quality healthcare depends on QI and PE. Patients often don’t see these efforts in action. But, ineffective QI and PE are hazardous to your health. Although doctors and hospitals don’t like the idea: law suits are a warning flag of inadequate QI and PE.
The above prescription example comes from Medical School Headquarters intended as an example of what doctors should NOT do — that is to issue handwritten prescriptions. There are just so many possibilities for error mostly coming from illegibility. Also, errors from inadequate information provided to the pharmacist and the patient.
Electronic prescribing is unquestionably the best solution. Patients should choose prescribers who use computer software to send prescriptions to the pharmacy. In fact, prescribers who don’t use computers to do this are dinosaurs soon to be extinct — perhaps it would be a good time to leave that office practice and find something more modern.
You might think electronic prescribing solves all the problems, NOT SO. Just ask any patient taking a few medications on a regular basis! Here is what they say:
- My office appointments never match when prescriptions expire –so I either have to change appointment times or hope the office will renew the prescription early — always involves a phone call and wastes my time.
- I had no idea the doctor prescribed a brand name drug instead of a generic and I got hit with an unnecessary huge bill.
- The doctor has no idea how much medications cost.
- I need 90 day prescriptions for some things and 30 day prescriptions for other things but they can’t get it straight.
- My doctor’s computer system can’t send things to my mail order pharmacy
- I have to send prescriptions to my mail order pharmacy myself — usually they are the handwritten type and sometimes the pharmacy can’t read them.
- If my doctor issues a duplicate prescription so it will last until my next visit sometimes I get more medication (and cost) than I need.
- Often generic medications are less expensive if I purchase them without involving insurance — the pharmacist sure does not tell me that!
Here are some prescription suggestions for PATIENTS:
- ALWAYS take a list of prescriptions with you to health care appointments (or just take the bottles, but there is a risk of loosing expensive medications in the process).
- Your record should include the name of the medication (brand name if appropriate) and generic name
- Dose — that means the size (mg) of the pills and number taken, or amount of liquid (ml) or strength (%) of a cream or ointment
- How often taken and whether scheduled or as needed
- Why the medication is taken
- Number of doses of medication prescribed AND exactly how many days that covers (like 30 day supply)
- When that medication will expire and need refill
- The pharmacy phone number and FAX number (the latter is very important for mail order pharmacies)
- ASK if a new medication is generic and if not if a suitable generic is available. Or, if a suitable generic in the same drug family is available.
- ASK if the medication is short term or long term. If it is long term usually ask for 90 day supply with 3 refills (if insurance will approve). And, use mail order services advised by the insurance company since they are usually less expensive.
- BEFORE leaving the prescribers presence ask if the number of refills on a new prescription will last until next appointment? And, ask for an extension of refills for older prescriptions that will expire before the next scheduled visit (otherwise you get the fun of calling the nurse for refills)
- If a specialist prescribes a medication ASK if the specialist plans on long term follow-up and providing refills — if not what communication with primary care will convey the needed prescription information. But, if the specialist plans on managing the medication expect a full review of all medications to avoid duplicate prescribing and adverse drug interactions.
Here are some prescription suggestions for PRESCRIBERS:
- Consider the cost of medications — you can’t do that if you don’t find out how much they cost, especially the brand name drugs
- Prescribe the lowest cost alternative. Before prescribing a brand name drug ask if you are sure there is a real cost benefit over an older generic. If you don’t know, find out.
- Don’t prescribe antibiotics for viral infections
- Think about refills, don’t just write some arbitrary number. Make sure the patient has enough refills and will not have to call your nurse to get them. Contrary to popular belief patients do not like to go the the pharmacy — give 90 day prescriptions where possible.
- Have a patient Internet portal to deal with medication refill issues.
- Although it’s nice to compute the number of pills a patient will need it is sometimes better for insurance reasons to say the number of days of medication is needed ( 7 days, 90 days etc.)
- To avoid duplicate prescriptions when the patients prescription will not last until the next scheduled visit the following statement is helpful “extend existing active prescription so refills last until ____ “(e.g. a year from today). Sometimes: “stop refills on current active prescription. This is a replacement so note the changes.”
- Most mail-order pharmacies will take either electronic prescriptions or faxed prescriptions — it is not rocket science to get those numbers into the electronic prescribing system — make it happen.
Finally, sloppy prescribing causes patient injuries, provider law suits, extra time, and extra costs for both the patient and the prescriber. Electronic prescriptions are a step in the right direction but they are now mostly geared for pharmacists and not the real-world problems of patients. The integration of pharmacies within care delivery systems (e.g. an ACO) is an urgent need.
This clinic has a pharmacist on staff to discuss medication issues with patients. And, that pharmacist calls all new patients to review ongoing medications, record them in the medical record and make recommendations that the new doctor will review at the upcoming visit. Recommendations like problems with drug interactions, newly available generics, less expensive alternatives and contraindications.
That same pharmacist arranges refills and responds to drug questions on the clinic Internet Portal.
What a great service. Discussion of medications by physicians is usually too brief. And, any input from the pharmacist is usually after the fact so physicians are not too happy to call the patient and admit a problem with prescriptions they just wrote.
Sometimes great ideas just need a SHOUT-OUT. This idea is super — an actual partnership between a prescriber and a pharmacist.