October 15th, 2009 by Happy Hospitalist in Better Health Network, Opinion
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Over at the WSJ Health Blog, some academic docs, such as hospitalist Dr. Wachter are suggesting just that.
Punishments such as revoking privileges for a chunk of time tend to be used for administrative infractions that cost the hospital money – things like failing to sign the discharge summaries that insurance companies require to pay the hospital bill. By contrast, hospital administrators may just shrug their shoulders when it comes to doctors who fail or refuse to follow rules like a “time out” before surgery to avoid operating on the wrong body part.
Docs and nurses who fail to follow rules about hand hygiene or patient handoffs should lose their privileges for a week, Pronovost and Wachter suggest. They recommend loss of privileges for two weeks for surgeons who who fail to perform a “time-out” before surgery or don’t mark the surgical site to prevent wrong-site surgery.
This couldn’t have come at a better time. At Happy’s hospital there is a massive witch hunt to crack down on not signing off verbal orders within 48 hours. This has nothing to do with patient safety. It has everything to do with meeting the requirements of CMS so the hospital does not lose their funding. Read more »
*This blog post was originally published at A Happy Hospitalist*
July 6th, 2009 by Shadowfax in Better Health Network, Health Policy
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Oh, man, I picked a fight with Ezra and he got all wonky on me, even with a chart. Oh Noes! Not a chart! And … it’s actually a pretty interesting chart. Here it is:
First of all, just for the record, let it be noted that my previous post was entirely about Medicare’s under-reimbursement of physicians, and Ezra’s clearly going all Willie Sutton and going where the real dollars are: facility reimbursement. Fair enough, though I’ll disclaim that I’m not nearly as well-versed in hospital reimbursement as I am in the professional side of the Medicare fee schedule.
The above graph would seem to disprove Ezra’s original thesis, that hospitals continue to participate in Medicare because it is profitable for them to continue to do so. As you can see, there’s rampant cost shifting, as Medicare pays only 92% of the actual costs of inpatient care whereas the commercial payers are in the high 120s%. Right?
Well, yes and no. The lifeline in this case is some very interesting testimony by the head of MedPac regarding a small subset of hospitals (about 12% of all hospitals) who were actually able to eke out a positive margin (0.5%) on Medicare payments in 2004-2006. The contention is that since these hospitals were able to do so, and with higher quality than the other 88% of hospitals, that the hospital industry in general is inefficient and if they were only able to get their act together Medicare payments would be sufficient to support a viable hospital industry.
The key factor which Ezra glides over is that these hospitals are in the “financially pressured” category. There doesn’t seem to be a definition or cross-tabs on what exactly “financially pressured” means, but these hospitals actually have a worse operating margin on their non-medicare business (-2.4%). Given that, it’s fairly safe to conclude that this means hospitals with crummy payer mixes — high medicaid and uninsured, low numbers of commercially insured patients. This occurs most commonly in rural and inner-city markets — underserved areas in which there is usually one hospital at best. These undesirable markets do not encourage other providers to enter and compete for customers and so the hospitals there tend to undercapitalize, willfully or no, and offer bare-bones services. That some fraction of “financially pressured” over-perform on outcomes is not explained in the testimony. It could be a statistical aberration, or cherry-picked data; giving credit to the integrity of MedPac, it might be due to the exceptional leadership that some of these financially stressed hospitals have developed. The testimony does not reveal what fraction of “financially pressured” hospitals outperform on quality measures — if less than 50% of “financially pressured” hospitals outperform on quality, it would imply that the under-funding of these facilities harms quality of care more than it helps. Note that those that outperform have substantially worse margins (0.5% vs 4.2) on Medicare payments, implying that there is some linkage between higher expenditures and better outcomes.
I am gallant, however, and I will concede the key point here: hospitals which are well-funded do tend to be inefficient. Specifically, areas with enviable payer mixes are generally served by multiple hospitals and those hospitals compete for patients and revenue by over-capitalizing and improving amenities and customer service. This is just another example of the perversion of the market in which patients do not directly bear the costs of their health care decisions.
Coming back to the original point: if Medicare were such a lousy payer, hospitals would opt out, yet this never occurs. Interestingly, the well-heeled suburban hospitals who lose the most money on Medicare patients are the least likely to opt out of Medicare. They have such high margins on their commercial patients that they can view Medicare as their charity contribution to the community. On the other hand, the financially pressured hospitals do better on Medicare than the rest of their payers, so Medicare is their economic lifeline. Or, more formally, the value of Medicare patients to a hospital varies inversely with the number of commercial patients in their payer mix.
Ezra’s conclusion here is that we need to cut costs, hospitals are in many cases inefficient, and so we should just reduce payments to them until they feel the pain and dial it way back. As my old medical director used to say, “We’re building a Buick, not a Cadillac.” But there are many problems with such a strategy. For one, the hospitals most dependent on Medicare would be harmed most by reductions in payments. While workarounds could be crafted for financially stressed hospitals, it’s unclear what effect reductions in payments would have in quality, but it would be hard to imagine that quality in general would improve. And it’s not clear to me that this really addresses the key drivers of cost: wasteful and redundant care, as opposed to more-expensive-than-it-needs-to-be inefficient care. Given the volume incentive of the fee-for-service game, reductions in compensation usually just drive increases in utilization, not the other way around.
Ultimately on this point, I have to concede ignorance. I know that the Medicare Professional Fee Schedule for phyicians is woefully inadequate and needs to be increased. I do not know if the same applies to the hospital fee schedule — I’m just not well-enough versed in the economics of that game. I should point out that while medicare payments to physicians have been essentially frozen since 2001, the facility fees, unconstrained by the SGR, have risen year over year to keep pace with inflation. I never did see any disagreement with my original points, by the way, that for professional services, the underfunding of Medicare is leading to decreased access as physicians close their practices to new Medicare patients, and that hospital-based physicians are unable to opt out due to the nature of their relationships with the hospitals who employ them.
*This blog post was originally published at Movin' Meat*
June 11th, 2009 by MotherJonesRN in Better Health Network
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Life is good. I’m settling into my job at UGH (Undisclosed Government Hospital) and I have a couple of days off from work. I’m using my time constructively. My house looks like hell, but I am doing other important things like writing, reading blogs, and visiting Twitter.
Yes, I’m addicted to Twitter. I started tweeting when I hooked up with Pixel RN and Dr. Val at BlogHer last year. They showed the joys of micro-blogging and my life was changed forever. Twitter is great place to meet people using 140 characters at a time. You can hangout in cyberspace with people like Ashton Kutcher, Lance Armstrong, and Stephen Colbert. You can also hangout with a lot of great healthcare providers. I make new “friends” by putting the word “nurse” into the Twitter search engine. Then I sit back and see what pops up.
Yesterday, something very interesting caught my eye. Dr. Hess, a plastic surgeon, tweeted that nurses were being offered free plastic surgery. I love free stuff, so I followed the link in his tweet, and checked out his blog. He wrote a great post. I also checked out the link in his post to the New York Times. The upshot of the story is that some places in Europe are offering plastic surgery as a recruiting tool for nurses. The story talked about the enormous social pressure that some nurses are under to look good. It’s true. Even some hospitals in the United States are using young and beautiful nurses as a marketing tool to entice more patients into their facilities. Age discrimination is rearing its ugly head. I wrote this post about a nurse who lost her job because she was getting old and because she wasn’t pretty anymore.
I tweeted Dr. Hess. I told him that there wasn’t enough plastic on the planet that could make this sow’s ear into a silk purse. I also told him that I look forward to tweeting with him in the future. He wrote back and told me that he thinks that I’m charming. Just wait till he really gets to know me!
I’m going to Twitter my way through life.
*This blog post was originally published at Nurse Ratched's Place*
April 7th, 2009 by Dr. Val Jones in Expert Interviews
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Network technology giant Cisco Systems, Inc. invited nurses to offer focus group feedback on a recent study that showed that 92% of nurses believe that communications lapses adversely affect patient safety. I joined five nurses in a cozy break out room at the HIMSS convention center and asked about their real-life experience with communications lapses in the hospital. Here are the highlights:
1. Technology Isn’t Perfect – although some hospitals have instituted bar code scanners and wireless computers to help to reduce errors, these devices often drop their connections. One nurse said that the devices actually slow down the process of distributing medications, and bypassing the system simply results in a loss of automated medication cross-checking. The devices don’t perform well in the case of an electrical surge, and nurses often waste time finding computers on wheels (affectionately known as “COWs”) that have a full battery.
2. Where’s The Patient? – the group of nurses all agreed that poor coordination of care inside the hospital can harm patients. Some nurses expressed frustration at having proceduralists and radiology teams remove the patients from their rooms without scheduling it with the nurses. They explained that nurses give out medications at specific times, and when the patients are taken to another part of the hospital without their knowledge, then they can’t plan to give them their medications appropriately. Missed doses or missed meals (for patients with diabetes for example) can result in dangerous hypoglycemic episodes, syncope, and various other harms.
3. Where’s The Pharmacist? – easy access to hospital pharmacists is critical for all clinical staff. One nurse relayed the shocking story of a med tech who was unable to get in touch with a hospital pharmacist to confirm I.V. zinc dosing in the NICU, and gave such an overdose that one of the premature babies died.
4. Where’s The Doctor? -during an audience poll at the Cisco booth, most nurses rated physicians as the hardest staff to get a hold of in the hospital setting. There is regular confusion about who’s on call, and there is often no direct line to call the physicians.
5. Where Are The Nurses Aides? – when it comes time to transfer patients (who are often very heavy) or move them in bed, nurses often have no way of finding peers to help them lift the patients safely. This results in wasted time searching for staff to assist, or even worse, can result in low back injury to the staff or patient falls.
6. Language Barriers – when patients are transitioned home from the hospital, they are often given complex instructions for self-care. These instructions are particularly hard to follow for patients whose native tongue is not English. Nurses see many re-admissions based on language-based miscommunications.
7. Decision Support Systems – one of the nurses suggested that a recent study showed that the number one source of clinical information for nurses was their peers. That means that nurses turn to other nurses for educational needs more often than they turn to a textbook or peer-reviewed source of information. Nurses would like to have better access to point-of-care decision support tools for their own educational benefit and the safety of patients.
8. Change of Shift – nurses identified shift changes as a primary source of communication errors. Technology that enables medication reconciliation is critical to safe continuation of inpatient treatment. One nurses said: “shift changes is when all the codes happen.”
And so I asked the nurses what their ideal technology would do for them to help address some of the communications problems that they’re currently having. This is what they’d like their technology to do:
1. All-In-One – nurses don’t want more devices to carry around. They want one simple device that can do everything.
2. Call a code – with one press of the button, the nurses would like the device to contact all staff who should participate in resusscitating a crashing patient.
3. Lab Values – nurses would like the device to alert them of all critical lab values on the patients under their care.
4. Clinical Prompts – nurses would like reminders of clinical tasks remaining for individual patients (e.g. check blood pressure on patient in bed 3)
5. Call and Locate Colleagues – the device should function as a full service cell phone with pre-programmed staff names/numbers and team paging lists
6. Locate Equipment -nurses would like to be able to track and locate wheelchairs, electronic blood pressure cuffs, and other equipment throughout the hospital.
7. Translate Verbal Orders To Written Orders – verbal orders are more prone to errors than written ones. An ideal device would have a voice recognition system in it that would translate physician orders to text.
Is there such a device on the market today? There are many different devices that have the capability to do some of above, but to my knowledge there is no device that can do it all yet. Companies like Cisco are working hard to provide integrated solutions for nurses – and the Nurse Connect phone is an important first step. What technologies would you recommend to nurses?
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More information about the phone (from press release):
Cisco Nurse Connect is a newly introduced solution that integrates nurse call applications, including Rauland-Borg’s Responder product lines, with Cisco Unified Wireless IP 7925G Phones to deliver nurse call alerts to mobile caregivers.
The Cisco 7925G Phone was specifically designed with the features necessary to support the unique safety and biohazard requirements of hospitals, including a battery that supports up to 13 hours of talk-time, ruggedized and hermetically sealed, and Bluetooth support for hands-free use.
The Nurse Connect Solution offers many benefits. For example, by reaching nurses on their mobile devices, the need to continually walk back to nursing stations or patient rooms is greatly reduced. Nurses can also have two-way communications with patients and send immediate requests to different levels of personnel after talking with the patient.
March 10th, 2009 by KevinMD in Better Health Network
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Patients don’t choose the days they get sick.
There are several studies, specifically dealing with heart attacks, showing that the mortality rate increases when a patient visits the hospital during the weekend.
It appears that the same goes for upper GI bleeding. MedPage Today discusses a recent study showing that “patients with nonvariceal upper gastrointestinal hemorrhage had a 22% increased mortality risk on weekends, and those with peptic ulcer-related hemorrhage had an 8% higher risk.”
Staffing issues, leading to delayed endoscopies, appear to be chief culprit. Minutes count in cases of GI bleeding, so the delay is a likely explanation for the higher mortality rates.
Especially in community hospitals, doctors often cover for one another, and in general, there are less physicians available. Short of having more doctors on call, a prospect that faces long odds as hospitals are loathe to pay specialists for additional call, I’m not sure what can be done to rectify this statistic.
One suggestion is to have so-called “bleed teams,” where staff can be quickly mobilized to respond solely to acute GI bleeds. But again, this likely would require more staff, and it’s dubious that hospitals are willing to bear the additional cost.
**This post was originally published at KevinMD.com**
