Posts Tagged quality

Medical Care and Control Theory

sweatshopPiecework maximizes human productivity.  Make more things, get more money.  Garment workers and physicians both have been paid under this system — it’s great if the payment per piece is high but miserable if the price is low.  Because piecework itself is no guarantee of quality inspectors were invented to reject low quality products.  Thus, the little piece of paper in your new shirt pocket “Inspector 23”.

What if you went to a doctor’s office and had to be inspected before the doctor was paid?  You had to have that little piece of paper “Inspector 23” to submit an insurance claim. That’s never going to happen but you get the idea.   The doctor is paid by the number of services but the service should meet a quality standard.

This example is just the tip of the iceberg.  Medicine is discovering process control without much input from the well established engineering field of process control.  It’s sad, and perhaps a little arrogant on the part of medical administrators and law makers, to ignore the extensive work on process control.  People do not like to be considered as little boxes in a system diagram — understandable — but a failure to think in this way is wasting trillions of dollars.  The time for change has arrived.

PieceworkThe black box of medical care is what happens with the doctor-patient interaction.  1) A patient enters the office, operating room or x-ray office then health care happens then 2) the patient leaves.  As it stands now the physician is paid by the number of services performed so the possible process control at points 1 and 2 are wide open.  Nothing is measured, nothing is controlled, and quality is not guaranteed.

Control Theory

Now, consider modern process control with 5 control points, a measurement point and feedback to control the input to the black box of health care.  What is in the black box?  Perhaps just one health care provider.  Or perhaps many health care providers. Instead of a black box it might be a grey box with lots of individual elements.

Parallel SystemPerhaps the box contains whole specialties or perhaps many hospitals within an accountable care organization across many states.

At the highest level of abstraction the feedback loop is intended to minimize cost but at the lowest level the feedback loop is intended to maximize quality.  To make sure throughput is maintained the providers need to be paid by the number of services performed but the flow of patients is choked off if quality is not adequate.

This is rocket science.  But, as Einstein says, a system “should only be as complex as needed”.  Health care is very complicated and at the present the garment industry is not the model the world should be using.  Simplistic ideas of supply and demand are not adequate to make a rocket fly nor to control cost in a health care system.

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Direct Primary Care — where’s the quality?

greedydoctorHappy doctors seeing fewer patients and making more money — what’s not to like?  According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.

The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork.  So, they developed a model of care where the patient pays $65/month and receives all the primary care they need.  And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article).  Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.

The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss.  For the libertarian-minded physician it’s nirvana.

Piece-work is indeed a hard life as physicians and many in the garment industry know.  A monthly salary is much easier on the worker.  And, the salary model is not new in terms of primary medical care.  The physicians working for the National Health Service (NHS) in the UK have had this system since WWII.  However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work.  And, they found it necessary to monitor quality since quality slips without oversight.

So, this “Direct Primary Care” is not new in the world.  In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US.  But, physicians need to realize they need to be part of a large organization to ensure quality care.  The future for primary care is to be an employee, not a mom-and-pop store.  Most of doctor’s patients work as employees, is that so bad?

$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!)  So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?

  1. Measure and report quality in a transparent way — like on the office website.  And, keep it updated.
  2. Deliver patient-centered care and prove it.  Survey patient’s expectations and record whether the expectations are met with office visits.
  3. Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
  4. Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
  5. Take a financial stake in what is prescribed or ordered.  Pay some fraction of the cost of all medications prescribed and all tests ordered.  They need to have some “skin in the game”.  (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).

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Ambulatory Surgery Centers — where’s the data?

undertherugAmbulatory Surgery Centers (ASC) are adept at hiding problems.  Just try to find death rates, numbers of transfers to hospitals, organ punctures, and surgical procedures required to correct errors.  Nope — you won’t find those crucial bits of data for public view.  Here is a link to statistics collected for “internal” review:  Quality Reporting Program.

As with most health care entities the public expression of “quality”  is “certification” — which means an outside reviewer thinks the organization has the right programs and procedures so nothing stands in the way of quality care.  Likewise, nothing usually stands in the way of a student getting an A+ on a test — but A+ is not always the grade.  As Confucius says: “there are always greater and lesser”.

So, as a patient, what should you look for; what questions should you ask?

  • Is the ASC certified?  If not, find another ASC.
  • How many patients does the surgeon treat at the ASC  — expect at least 10 per week.
  • How often does the surgeon do the procedure you need at the ASC — expect at least 10 per month.
  • Will you be sedated? — if so, make sure an anesthesiologist or nurse anesthetist will be monitoring you while sedated — if not — find a different ASC.
  • How close is a hospital if you have one of those serious complications listed in the consent-for-surgery form?  If an ambulance would take more than 10 minutes to get you to the hospital consider another ASC.
  • If you have severe heart or lung problems (like a history of congestive heart failure or COPD) consider having your procedure at a hospital rather than at an ASC.
  • Ask if a pre-op check list, like the one the World Health Organization recommends, is used for all surgeries — if not, quality is a questionable.  If the surgeons says they don’t need a check list find a different surgeon.  Keep this in perspective — every airplane pilot must follow a pre-flight checklist, is your surgery any less important?
  • The person that comes with you needs to write down what the surgeons says after the procedure.  Patients who have been sedated, even if they seem fully awake, will have impaired memory for many hours.  Have the person with you write down what was found at surgery — what is the diagnosis and what are the specific instructions.
  • Absolutely avoid late afternoon surgery — because you will be shipped to the hospital for minor complications — the ASC will close and they don’t have staff to provide care after closing.

 

 

 

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Nursing Quality — paperwork problems

nurseWhen Quasimodo answers your call light instead of the the nurse you know something is wrong.  It probably has to do with all that paperwork — one third of a nurse’s time is spent doing clerical work either on paper or on the computer.

Laura Landro of the Wall Street Journal reported 7/21/14:  “Nurses Shift, Aiming for More Time With Patients”.  Ms. Landro highlights one hospital where nurses are getting more help from LPNs and CNAs so they can spend more time at the bedside.

More low-level helpers — where does that lead?  Probably not to more Florence Nightingales at the bedside but rather fewer RNs who will mainly serve as supervisors.  Nurses are getting expensive so the trend will save money for hospitals.

Nurses are hit from many directions.  Shift-work is hard on family life and the educational requirements have increased.   Highly motivated nurses often escape the shift work by training to become outpatient nurse practitioners — why try to climb the corporate ladder?  Nurses aspire to be more like doctors at a time when doctors as hospitalists become more like nursing supervisors.  And, hospitals don’t see much value to experience —  they fire a 50 year old nurse so they can hire 2 twenty something nurses to save money.

Nurses are criticized for quality issues as well:

  • Poor shift to shift communication — who knows what the guy at the end of the hall has?
  • Collection of information that has no value 24 hours later — a huge waste of time.  Unfortunately, the nursing model is focused on filling out forms or online queries.   Always made worse by legal concerns.
  • Training that inhibits drawing a conclusion.  For example,  if a nurse finds a patient is on the floor bleeding from a cut on the head … the conclusion is “deficit of patient comfort”  rather than “scalp laceration and possible brain injury”.  That’s the doctor’s job — too bad the doctor is not always there.

It’s almost a perfect storm.  A general shortage of nurses, a background of quality problems, hospitals anxious to find lower cost employees, and nurses obtaining more training to command higher salaries.  Nursing is not going away but the RN job will be different in the future.

 

 

 

 

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Accountable Care Organizations — fee for service decline

Payment of health care providers by volume of service (fee-for service) rather than quality of service is blamed by many as the cause of  high cost and low quality in the US health care system.  

A possible solution was proposed in 2006 as the Accountable Care Organization (ACO).   The concept is modeled after other advanced countries which have lower cost and higher quality health care than the US.  The idea is to pay a large organization (the ACO) to provide all the  care needed for a large group of people.  In other words, a per capita system, with payments not related to volume of services.

 Medicare and the Affordable Care Act are betting on ACOs.  The private sector is moving that way as well.  The following graph shows the number of ACOs in the United States (CMS data)
aco map 2012

The following graph shows the increase in the number of ACOs starting in 2009 and ending the first quarter of 2012.

Rising Number ACOThe insurance industry is so entrenched it is hard to think outside of terms like deductible, out of pocket cost, and premiums.  And, current ACOs indeed use those terms.  But, under the hood, the ACO is run with a budget based on the cost to take care of a person for a year.

So, perhaps sometime in the near future you will just purchase health care by the year — something based on your age and ranging between $100 and $400 per person per month.  Undoubtedly, there will still be some co-payments in order to avoid over use of services by some people.

A well formed ACO has a strong focus on a medical home and should include pharmacy service (not Walmart,Target or Walgreens etc.), hospital service (not every hospital), doctors, nurses, physician assistants, x-ray services, medical equipment, and devices.   Not every hospital in the ACO would duplicate services — some would have specialty expertise, like brain surgery or heart surgery.

The materials to run the ACO would be purchased in bulk.  The providers would be predominantly on salary and the hospitals under a strict budget with  mandatory quality levels for all.

The rise of ACOs is encouraging but the actual number of covered patients is not large and the internal payment for ACO  providers is still rooted in volume of services.  But, with time and pressure (mostly from the business community) ACOs should begin to lower costs to levels enjoyed by other countries.

Congress could speed the process to be ready for the aging baby-boomers.  But, action in Washington seems nearly impossible.  It seems hard to argue against lower cost and higher quality, but they will.

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