Posts Tagged quality improvement

Medicare Penalizes Hospitals — safety problems

MC Hospital Penalties

Hospitals in the lowest quartile of safety scores from Oct 1, 2014 to Nov 30, 2015 were recently penalized 1% of Medicare billings as detailed on the Medicare.gov web site.  The above graphic highlights the results in terms of the number of hospitals penalized per million medicare enrollees in each state.  Red indicates the most hospitals penalized and green indicates the least with the lighter shades in between.

New York had many hospitals penalized but Alaska only had a few.   However, Alaska does not look very good considering they don’t have very many Medicare enrolees (or other people for that matter).  So a patient’s chance of experiencing safety problems is higher in Alaska.  This reflects poorly on the State-wide hospital quality programs and the importance hospitals in that state place on quality.   If you live in a state with poor performing hospitals then be especially careful to pick hospitals with the best scores.  KHN.org  lists the poor performing hospitals.

The four Medicare safety measures were somewhat limited and heavily focused on surgery:

  1. The AHRQ Patient Safety Indicator (PSI 90 Composite)
  2. Central Line-Associated Bloodstream Infection (CLABSI)
  3. Catheter-Associated Urinary Tract Infection (CAUTI)
  4. Surgical Site Infection (SSI) – colon and hysterectomy

What should be done?

  1. Patients should avoid hospitals with lower scores
  2. Poor performing hospitals should make better use of state quality resources.  Spend more money on boosting quality than on remodeling or building new facilities.
  3. High performing hospitals should redouble safety efforts.  Improved performance by competitors could push complacent hospitals toward lower ratings.
  4. Hospitals should not just focus efforts on the few areas that are rated — overall safe care and quality care are the goals.  The basis for financial penalties could, and very likely will, change.

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U.S. Malpractice System is a Failure

Cut the ribbon

The U.S. tort system as a solution to compensation for medical errors is an abysmal failure.   It’s unfair to doctors and  it’s unfair to patients.

Here are a few statistics to make the point:

  • Every year 400,000 patients are killed by medical errors and even more are injured.  But, less than 2% receive compensation through suits.  98% never file suits.
  • 80% of suits against doctors fail.
  • 50% of compensation awards are paid to lawyers.
  • The average time from filing suit to winning compensation is 3.5 years.

The practice of “defensive medicine” is well known.  The fear of suits has caused many doctors to order more tests than are necessary.  Even the AMA estimates the unnecessary tests cost between $84 and $151 billion each year.  Worse yet is the effect on medical records:  doctors make records “look good in court” by leaving out embarrassing details — making the job of quality improvement much more difficult.

There can be no other conclusion:  the U.S. justice system is incapable of providing compensation to the vast numbers of injured patients and it stands in the way of quality improvement.

Other countries have much better systems.  One that really stands out is Finland.  They have separated compensation from accountability and quality improvement.  Compensation is decided by a compensation board — compensation is often paid in as little as 2 weeks.  Physicians can readily admit an error and say “I’m sorry” and go a step further and actually help patients get compensation.  

The Fins have a strong quality improvement program which can change the medical system that allows errors to happen and force practice changes as needed — the primary goal is to reduce errors, not to punish doctors (except for criminal behavior). 

The money spent in the  U.S. for malpractice insurance both by doctors and hospitals, and the fees for lawyers would be much better spent in a compensation system like Finland.  Current efforts at U.S. “tort reform” are aimed at reducing suits and thus reducing compensation.  The suits remain unfair to doctors and inadequate to serve injured patients.  “Tort reform” should be changed to “tort elimination” then replaced with a compensation board type system.

This is an excellent time to change the tort system because the U.S. is on the verge of universal health insurance.  The question of who will pay the cost of health care error  is “insurance” rather than bankruptcy court.  By setting up a compensation system more attention can be directed to fair compensation and much stronger quality improvement.

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Hippocrates — the missing duty

hippocratesHippocrates missed something big — a doctor’s responsibility to improve the care of other doctors.  OK he did get some things right — here are his points from the 5th century BC:

  • 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.

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Wrong Aspirin Dose After MI — frequent errors

ASA81Highly 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.

bloodinsinkJust 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.

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Medical Care — research, quality improvement and program evaluation

grade

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.

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Good Advice from Clinical Research

advice

The ABIM foundation asked all the major medical and surgical specialty societies  in the US to each submit “Five Things Physicians and Patients Should Question“.   The specialty societies picked five tests or procedures they thought were being overused or wasteful.  Each one of the “things” is an important well researched piece of advice the societies believe health care  providers and patients should know.  Who is doing the questioning is not clear — but it seems if providers are not following the advice then other doctors, quality assurance departments and patients themselves should ask questions.

The assortment of ABIM documents is mainly intended for physicians so they do contain technical terms.  Fortunately, the ABIM partnered with Consumer Reports to write FREE consumer friendly versions of the ABIM recommendations.  The site has a nice navigation bar so you can quickly find helpful information.  Here is a link to the site:  Consumer Health Choices.

The author of this blog created an abridged version  for a quick scan of everything to date.  Take your choice, either the original, the Consumer Reports version or the abridged (no beating around the bush) version.   A few societies have not yet submitted information so check back with the ABIM Foundation site later if interested.

There seem to be some common threads in the advice:

  1. Don’t do tests if there is no plan to act on the tests (or to find a disease that has no treatment)
  2. Don’t do screening tests if testing errors cause unnecessary or harmful surgery or other tests.
  3. The time interval for screening tests is very important (especially for cost reasons)
  4.  Imaging (nuclear scans, CT, MRI, PET, ultrasound etc.) has been massively overused — always question whether imaging is needed.
  5. In general, don’t fix things that don’t eventually cause symptoms

The advice is both favorable for patients and favorable to reduce the cost of health care.  The US needs more of these evidence-based guidelines.

 

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