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Federal Hospital Inspectors Miss True Dangers, Focus On Documentation Minutiae

In an effort to promote transparency in healthcare, the Association of Health Care Journalists (AHCJ) has published a database of recent hospital deficiencies discovered by Medicare and Medicaid  inspectors. They then highlighted 168 reports containing the phrase “immediate jeopardy.” This, of course, piqued my interest as I presumed that hospitals who were putting putting patients in “immediate jeopardy” must be some pretty bad actors.

After sifting through the hospital names, I saw no record of ones who should probably be on the list based on my personal experiences. I did find some surprises, including well respected academic centers (including Stanford, UCSD, and Intermountain Health). I did a “deep dive” on a hospital for which I have a good deal of respect and some familiarity. What I discovered was both funny and sad.

In the case of the hospital that I knew, the very grave concerns expressed by the inspectors turned out to revolve around patient signatures on HIPAA documentation, and physicians refreshing their electronic restraint orders on patients with traumatic brain injuries. These documentation mishaps had landed the hospital on the ominous list of institutions who are “putting patients lives in immediate jeopardy.”

What a waste of inspector time and hospital resources! Apparently, a hospital who passes CMS muster simply means that they are providing documentation correctness to patients. Forget the real sources of life-threatening dangers – medication errors, poor physician handoffs, unnecessary testing and treatment, and unsanitary conditions. What the safety police are focused upon is whether or not the sick and delirious signed their health information privacy paperwork.

Now don’t get me wrong, I think it’s important to let patients know their rights, etc. But I’ve yet to see more than 10% of patients even read the HIPAA-related documentation that they sign.  Surely an absent signature or two shouldn’t land a hospital on a humiliating federal watch list.

True patient safety cannot be regulated. It is far too complex and nuanced, requiring collaboration between all members of a hospital’s staff. From frequent nursing surveillance, to careful medication review, to laboratory critical value alerts, to conscientious sanitation practices – hospital culture dictates whether or not a patient receives excellent care. Watch lists would be far more accurate if they were simply based on hospital employee questionnaires. As Dr. Marty Makary has discovered, complicated care quality algorithms are no more accurate at predicting hospital excellence than simply asking staff if they’d recommend the place to family members.

So next time you see your hospital flagged by the feds, don’t assume that there is a serious problem going on – better to ask someone who works there if it’s a safe place for care.


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5 Responses to “Federal Hospital Inspectors Miss True Dangers, Focus On Documentation Minutiae”

  1. edwin leap says:

    Val, awesome post and excellent work! It’s about control, busy-work and job security. Period.

  2. Ben says:

    Great post! I’ve found that this basic flaw is true (maybe inevitable) when trying to measure the performance of virtually any large, complex system. The measure of whether an organization is doing a “good job” is so complicated and includes so many key factors that cannot be controlled for (i.e. patient demographics), that inspectors are forced to rely on small number of objective heuristics (“did paperwork X get filed”,”have doctors spoken to patients about smoking and documented it”, etc). These heuristics can be measured, and they’re sometimes correlated with quality, but more often than not they’re weak stand-ins for a more subjective analysis… which of course carries its own pitfalls. I’m not sure what the solution is, exactly, but I suspect that this type of “checklist” review is more misleading than it is illuminating.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

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Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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