Posts Tagged hospital quality

Do Hospital Amenities Impact Quality Care?

Acccrystalchandelierording to a study at Johns Hopkins (2/1/15) improving hospital amenities improve patient satisfaction with the facility but otherwise do not improve satisfaction with care.  This is important for two reasons:

  1. Patients really can tell the difference — a crystal chandelier hanging in the hospital room does not make nursing care better!
  2. Patient satisfaction measurement is a powerful tool to assess medical care — if the patient’s expectations are met, it is likely good care is delivered.

The tremendous building boom for hospitals is strange given this bit of science  — are CEOs trying to improve quality by remodeling?   Now it seems clear CEOs should focus money and energy on improving hospital quality until the level of quality is very high then if there is money to spare consider improving the physical amenities.

Increasing the distance a nurse must walk to see patients results in decreasing nursing visits.  This seems simple enough, but the current trend in hospital remodeling is to eliminate rooms with multiple patients.  The trend reduces RN visits, increases the need for nursing assistants, increases hospital cost and may increase falls for elderly patients.

The hospital that looks like a nice hotel seems to be the desire of hospital CEOs.  This may be fine for obstetrics but may be wrong for geriatrics.   A multi-bed ward with 4 patients allows one nurse to check on 4 patients quickly.  4 times the number of nursing visits makes it much easier to prevent falls.  When nurses still wore those pointy white hats they had this figured out.

Progress marches on.  American health care quality is as low as many 3rd world countries but at least we have nice surroundings in which to suffer the complications.

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Hospital Re-Admissions — the revolving door

revolving door

Hospitals have ignored the obvious problem of patients returning to the hospital soon after discharge.   Decades of re-admissions have enriched hospitals — same charges over and over.  Now re-admissions for heart attacks, heart failure and pneumonia lead to Medicare penalties.  The problem is widespread and as always worse in some parts of the country.

Pneumonia Readmissions

The above graph comes from a an excellent Medicare study.  It show a high rate of re-admission after pneumonia in some areas (dark blue).  It should come as no surprise that some hospitals have been able to quickly drop the re-admission rate by 20% (because they were not trying very hard before).

Why did hospitals not care?

  • Re-admissions were profitable
  • Avoiding re-admission was considered an outpatient problem
  • It was the patient’s fault for not taking the medications they were prescribed at discharge (no matter what the cost).
  • Hospitals have no control over outpatient doctors.

What changed?

  • Dr. Donald Berwick cared.  He was the administrator of Medicare who initiated the penalties.
  • Hospitals purchased doctor practices — so now they really do control the outpatient doctors and thus assume a greater responsibility.
    •  Over 75% of cardiologists work for hospital systems
    • Over 50% of primary care work for hospital systems
    • Many health systems operate visiting nurse services.
  • Hospitals have no excuse for failing connecting discharged patients with primary care (they own primary care)
  • Hospitals have no excuse for failing to engage patients in heart failure clinics (they own cardiology).
  • Hospitals must take an interest in what medications are prescribed at discharge — the right medications and generic medications if possible.

What can patients do to cut the odds of re-admission?  According to a report by Jason Kane of PBS there are 7 things a patient can do:

  1. Work with the hospital to plan ahead (days before discharge)
  2. Understand your illness and ask questions about your health care
  3. Have a written discharge plan
  4. Understand your medications
  5. Don’t go it alone
  6. Follow through with follow-up care
  7. Find out how good the care is in your community for patients leaving the hospital.

A word of caution:  just because you have been re-admitted, it does not mean you need to be on hospice care — indeed that will stop re-admissions but perhaps not the way you want (dead patients don’t return).

Your ace in the hole:  strong primary care.  The hospital team MUST communicate with primary care — make sure they do.  A quick follow-up appointment and several short interval appointments will help to get back on track with the management of chronic illnesses.  If you were just in the hospital for a heart attack, congestive heart failure or pneumonia (or other chronic conditions) an appointment in 6 months is totally inappropriate.

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Hospital Quality Bomb — behind the veil

bomb

When a headline reports a doctor did something bad at a hospital don’t you wonder what happened behind the scenes?  What was the doctor doing and what was the reaction of people at the hospital?

Case in point:   Michael Booth of the Denver Post reported on 4/11/13 about the disciplinary procedure against a local general surgeon.  According to the report the surgeon was a frequent user of robotic surgery.  But, things were not going well in the operating room.

2008 to 2010 the surgeon had several major complications including perforating the aorta while doing kidney surgery and leaving instruments and sponges inside patients.  After at least 14 such incidents the hospital suspended him for 3 months.

He went back into practice but a formal complaint was registered April 2013 by the Colorado State Medical Board.  Centura Health – Porter Adventist Hospital declined to provide details of the case citing the Colorado law protecting peer review activities from disclosure.

Were there warning signs?  The CMS Hospital Compare website shows Porter Hospital has about average quality among Colorado hospitals.  The Health Grades website entry for the surgeon is fairly unremarkable — no patient comments  and no listing of disciplinary action.  Clearly, these sources are not good for early warning.

Usual or unusual?  The course of these events seems typical for a surgeon with quality problems in the hospital setting.   Although typical,  these events causes agony in the hospital quality department.  The hospital board (mostly non-medical people) is involved and they are always  horrified.

Cost to the hospital — a lot.  The cost to the hospital in terms of staff to investigate the surgeon, due process, legal counsel, physician (peer) review, and extensive documentation is likely at least a half  million dollars.

Money down the drain.  All the hospital actions motor upstream against the current of revenue generated for the hospital by the surgeon.  In other words, it’s really hard to barbecue a cash cow.

Is the hospital hiding something?  One might wonder why the hospital peer-review process is protected (kept secret).  The answer is very simple, if there was no protection then  no quality review would ever be done.  Lawyers are sometimes accused of chasing ambulances to get clients — no hospital quality review could be done with hungry lawyers reading every word.

The trip-wire.   The main concern in this situation, and many others like it, is the extremely slow detection and subsequent resolution of the problem.  The hospital department of surgery is on the front line for spotting surgeons with quality problems.  If that department does not have a strong warning system then years can go by without other surgeons realizing bad things are happening.  Sherlock Holmes would be using his magnifying glass on that department.

The nurse knows.  Operating room nurses often know about a surgeon’s problems.  But, saying something is like reporting on your boss — not so easy.

An eye in the OR.  One simple way to check a surgeon’s technique is to video record surgery (it is especially easy to do this with robotic surgery) — then if questionable cases come to light the record can be viewed.  Surgeons hate the idea of being recorded, again due to the legal implications should such a recording land in court.

Not over yet.  It take several years before all the suits and Medical Board actions are settled.

The point:   When you read something about a hospital taking action against a physician it is just the tip of the iceberg.  The quality problem took time to find, took time to research, took time to try (unsuccessfully) to correct, and finally took time to take  disciplinary action.  Once the last step is taken the hospital tries to stay out of the news with the hope the trouble will not rub off on them.  The hope is often dashed once the state investigates the actions of the hospital.  Hindsight is 20/20, the typical state investigation concludes the final action should have been taken on day one.

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