Quality and Safety

By Michelle Andrews, Kaiser Health News In his recent book, “The Finest Traditions of My Calling,” Dr. Abraham Nussbaum, 41, makes the case that doctors and patients alike are being shortchanged by current medical practices that emphasize population-based standards of care rather than individual patient needs and experiences. Nussbaum, a psychiatrist, is the chief education officer at Denver Health Medical Center and practices on the adult inpatient psychiatric unit there. I recently spoke with him and this is an edited transcript of our conversation. Q. Your book is in some ways a lament for times gone by, when physicians were “artisans” who had more time for their patients and professional independence. But you’re a young doctor and you must have known at the outset that wasn’t the way medicine worked anymore. Why do you stick with it? A. The first thing I’d say was that I didn’t know right away that medicine is no longer universally understood as a calling instead of a job. We are describing health as if it is just another consumer good, and physicians and other health practitioners as the providers of those goods. That is the language of a job. When you remember that being with the ill is a calling, then you remember that it is a tremendous privilege to be a physician. People trust you with their secrets, their fears and their hopes. They allow you to ask about their lives and to assess their bodies. So my lament is not for the loss of physician privilege — goodbye to that — but to the understanding of medicine as a calling. Q. You don’t like checklists and quality improvement measures that dictate how physicians care for patients because you say it turns doctors into technicians and is an obstacle to “moral reasoning.” But those tools, which generally take a systems approach to providing care and rely on evidence-based guidelines, aren’t going away anytime soon. How do you do the kind of doctoring you want to do in this environment? A. Quality improvement seems to be here to stay. Regulators at all levels require it. But I believe that evidence of its success is not as clear as they suggest. Just last week, the British Medical Journal published a study that found no evidence that introducing quality metrics has resulted in a significant reduction in patient mortality. The leaders of the quality movement’s version of quality improvement developed out of industrial engineering, so they are always comparing the care of patients to things like the production of cars or the flying of airplanes. People are far more varied than cars on assembly line or planes on the runway. So quality metrics always feel forced to me, especially for the more interactive medical encounters. In my own specialty, the current quality metrics all encourage me to perform standardized screens on patients or to document carefully. None of them require me to develop a relationship with a patient so that I can, say, foster hope after a suicide attempt, or knit a psychotic person back into the life of their family. Yet that it was my patients want, those human relationships. It is also what physicians want, and the most recent studies suggest that most physicians are dispirited by quality metrics. Q. But not all physicians are equally skilled or conscientious. As a patient, I feel more comfortable knowing there are rules and standards that doctors have to meet. A. I don’t think physicians should be free to do whatever they want. Their thinking and decision-making should be held up to scrutiny. A physician’s standard of quality should be evidence-based, but even more, it should be patient-centered. The standard should be what the patient defines as what matters. So if you are suffering chronic pain, it is not just a reduction of your score on a standardized pain scale, but your ability to resume the activities you identify as constitutive of your life. Q. You talk about wanting to be able to sit with patients and talk with them, to really “see” them. All that takes time that physicians don’t generally have. I understand your book isn’t a how-to manual. But, really, how can physicians do this, even if they want to? A. It’s a real challenge. It’s important to use the time you have in service of the patient’s needs. I don’t review records while I’m in the room with a patient. I try to make every question be about the patient. I have to ask standard questions, but I try to do that as way to get to know the patient. For example, if I have to ask questions about what they can remember, I’d ask about a book they have with them. Part of my concern about checklists is that they train you to follow a script instead of following your patients. Q. Only 55 percent of psychiatrists take insurance compared with nearly 90 percent of physicians in other specialties. That puts their services out of financial reach for many people who could use their help. How does that square with your vision of doctors as healers and teachers? A. It’s deeply concerning to me. I’ve made a conscious choice to work at a safety net hospital, so I can see people regardless of their ability to pay. I hope that through things like the Medicaid expansion and mental health parity, more psychiatrists will work with people who have mental illness. Q. You talk about the virtues of “slow” medicine, similar to the slow food movement, where physicians reject providing care in a standardized, mass-produced fashion. One path that some physicians have chosen is to establish boutique practices that accept a limited number of patients who pay extra fees for more personal attention and better access. What’s your perspective on that? A. It sounds appealing to me. In most descriptions of boutique medicine, they talk about it like a lovely restaurant, one that I couldn’t afford to go to every night. I think it’s an interesting model but not a solution to the large problems facing medicine, in particular the ability to provide care to the most needy among us and the indigent. This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.    

In a $36 million contract with Philips, the hospital system is working to improve the collection and management of patient data to standardize clinical practices and enable interoperability with other systems.

Putting patients at the center of preventing mortality from blood clots, and being more aware of them in recognizing their onset, is key to stemming the disease burden. We can do more to engage with information, tools and other patients and programs to help monitor this condition.

Iowa- and Illinois-based Genesis Health Systems has joined forces with visibility and analytics provider, STANLEY Healthcare, and nurse call platform provider, Critical Alert, to streamline clinical workflows using STANLEY'S RTLS platform and Critical Alert's Nurse Call tool, the companies announced last week.   Using the native integration from Critical Alert and the staff workflow function of STANLEY's RTLS platform, the staff at Genesis can locate clinicians and respond to bedside patient alerts and requests. Maureen Nylin, nursing clinical informatics specialist at Genesis Health System told Healthcare IT News that Genesis expects the implementation will improve HCAHPS scores and staff and patient satisfaction.   "The implementation was a collaborative approach," Nylin said. "Alarm management is a hot button issue from everyone across the board; it's getting tongue-in-cheek. It's not about managing alarms, but making sure what you're doing is meaningful."   "For our clinicians, when they're getting messages, they know exactly what the patient needs," she added. "Trying to overcome alarm fatigue is about getting the right message to the right person, at the right time."   Implementation began in June of 2015 at Genesis' DeWitt Community Hospital. According to Nylin, one of the greatest improvements is that patient calls are canceled as the nurse walks into a room, which frees up time for the clinician.   Furthermore, the data is being collected for a knowledge base to "see the low-hanging fruit," Nylin said. "We'd like to use the analytics to see where we can improve efficiencies."   The Critical Alert tool captures data from clinical workflow, allowing staff to analyze the data points into the nurse call system, according to Josh Troop, marketing director for Critical Alert.   "We're working with companies like STANLEY, to create something much more valuable than two equal parts," Troop said. "In this case, we were able to leverage the STANLEY investment that Genesis already made to ramp up our tools already. Our systems work together seamlessly in the background."   For STANLEY, it's about making sure "clinicians have more time to spend with the patient to improve the care arena," Nadav Barkaee, product manager for integrations, STANLEY Healthcare said. "One of the major benefits of being able to offer an enterprise-grade RTLS solution is to make sure the investment can be used across multiple solutions for staff efficiencies and workflow."   Genesis plans to implement the systems at four more of its hospitals in the near future.

Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious. The Centers for Medicare & Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. The delay came after a majority of members of Congress signed a letter supporting the hospital industry’s concerns. Hospital leaders who previewed the preliminary rating system say the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare’s Hospital Compare website. The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility’s rating. Steven Lipstein, president of BJC HealthCare, a St. Louis-based nonprofit that runs 14 hospitals, said the ones in his organization that earned five stars were smaller, located in affluent areas and handled less complicated cases. “They don’t have comprehensive cancer centers, they don’t have major cardiovascular disease, they don’t have neuro-specialties,” he said. BJC’s more advanced hospitals did worse, he said. “That’s not surprising when you look inside the ratings and see how they’re built,” he added. Consumer advocates defend the rating system, saying that while not perfect, it correctly reflects higher rates of problems in some big institutions despite their lofty reputations. They worry that delay and congressional resistance are undermining Medicare’s attempt to help consumers select a hospital based on something more substantive. “The star ratings hopefully will get quality into that decision-making process,” said Andrew Scholnick, a lobbyist for AARP, the advocacy group for seniors. Medicare officials initially said they hoped to release the ratings to the public in July. But in a presentation to hospitals and other interested parties last Thursday, they did not set a firm date. Medicare already has made minor tweaks in the formula to calculate the stars, but it remains a tough grader, the presentation shows. If Medicare releases the star ratings in July, nearly half of the 3,658 hospitals being evaluated would be getting three stars, according to Medicare’s preliminary calculations. Just 100 hospitals would receive five stars, while 135 would receive a single star. Officials indicated they were standing firm in their intention to eventually release the scores. “The Overall Star Rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare,” the presentation said. Officials plan to update the scores every three months through the end of this year and then twice thereafter. The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments. Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, nearly half of major teaching hospitals are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications. Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates. Some health care researchers are also skeptical. “If you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they’re the bomb, there’s a disconnect,” said Ashish K. Jha, a professor at Harvard’s public health school. “If it completely contradicts everything you’ve known, you need to ask yourself, ‘Did I not understand the way hospital care works, or is there a problem with the metric?’” Medicare’s move toward using star ratings is part of a greater focus on easy-to-grasp composite judgments of hospital quality. The Leapfrog Group, a nonprofit patient safety group, uses report-card letter grades to characterize hospital safety based on many of the same individual measures as Medicare. Healthgrades, a Denver-based company, judges hospital quality with one, three or five stars. Consumer Reports calculates a safety score on a 100-point scale. Medicare hopes a star rating from the government will carry even more credibility. “People need this information now,” Scholnick said. “Trying to wait until everyone’s 100 percent happy with everything just delays it further than it needs to be.” This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.  

Decisio Health, a startup that aims to help acute-care provider organizations continually improve their clinical processes, launched the Decisio Health Clinical Intelligence Platform Tuesday and also announced $4.5M in Series A funding.

Proponents of virtual care say it is the wave of the future. But while the healthcare industry might not find much disagreement with the practice in theory, it is in the potential limitations that skeptics might find flaws.

The CERT Division of Carnegie Mellon's Software Engineering Institute has released its list of 10 technologies emerging in the next five years with the greatest vulnerabilities in terms of cybersecurity, finance, personal health and safety.

Valita Fredland most recently served as chief privacy officer and counsel at IU Health. In her new post, Fredland will serve as vice president, general counsel and privacy officer.

UC Health – the flagship University of Cincinnati Medical Center, as well as 167 of its affiliated practices – has reached the Stage 7 on the HIMSS Analytics EMR Adoption Model. HIMSS Analytics developed the EMRAM in 2005. Its eight stages (0-7) track a hospital’s implementation and use of health IT applications. In 2011, it launched the ambulatory model, meant to evaluate the progress and impact of EMRs for ambulatory facilities – physician practices, outpatient centers and specialty clinics – owned by hospitals in the HIMSS Analytics Database. Only 4.2 percent of more than 5,400 U.S. hospitals in HIMSS Analytics' database have attained Stage 7; just 7.9 percent of more than 34,000 ambulatory clinics have scored a Stage 7 Ambulatory Award. [Also: Benchmarks: Stage 7 success stories] UC Health, the University of Cincinnati’s affiliated health system is the region’s only academic health system.  It includes University of Cincinnati Medical Center, three additional hospitals, and the University of Cincinnati Physicians, Cincinnati’s largest multi-specialty practice group with more than 700 board-certified clinicians and surgeons. John H. Daniels, global vice president of HIMSS Analytics' healthcare advisory services group, said UC Health "has gone above and beyond the EMRAM Stage 7 criteria. They have already extended the closed-loop medication administration process to their infusion clinic and for interventional radiology cases. Combined with a strong population health program, the UC Health team is making a real difference in their community." "This accomplishment is due to our commitment to improved patient outcomes through the expanded use of information technology," said Jay Brown, UC Health's senior vice president and chief information officer, in a statement. "As the region’s only academic health system, we are surrounded by innovators and visionary leaders who have recognized the importance of leveraging these tools," he added. "The HIMSS Analytics Stage 7 Award highlights our dedication to delivering the highest quality of care and enhancing the experience of our patients."