Uncategorized•
on January 11th, 2011•
My husband reached a milestone a few months ago – his first screening colonoscopy. The prep and procedure went surprisingly well; he looked good and seemed “with it” when he came out of the procedure room (although I found out later he remembered next to nothing!). According to the nurse who reported out, he had one polyp; they removed it. It was small, about 5 mm in diameter. She showed me a picture of it. She said they would biopsy it and let us know the results.
About three days AC (After Colonoscopy), a letter arrived. It seemed to be an informational letter about Tubular Adenoma Polyps, what they are, how they may be pre-cancerous. The last line of the letter said my husband was recommended for re-screening in five years.
We were both confused by the letter. Was his polyp a Tubular Adenoma Polyp or some other kind? It says they MAY be precancerous – that’s a scary sentence. Was his polyp pre-cancerous? If it was, does that make a difference? Why was “polyp” plural throughout the letter when the nurse said he only had one polyp? Did he really have more than one? Did they biopsy it/them? What was the result of the biopsy?
The letter did NOT say, “Your polyp was not cancerous.” The letter did NOT say “The results of the biopsy on your polyp were negative.” The words results and biopsy weren’t anywhere in this letter. My husband was perplexed. His exact quote was “My little engineer brain is looking for a test result. I can’t find it in this letter.” So we waited a few more days, assuming that a “results” letter or phone call would arrive.
When none was forthcoming, he called the office to ask for clarification. Now, we’re not sure whether he was speaking to the receptionist, a nurse, a CNA, a PA or a physician. They don’t really make the distinction when you call and my husband didn’t think to ask. He called the office and assumed, like most of the population, that he’d get a thoughtful, medically appropriate answer. The response was stunning, and not in a good way. The person told my husband, “The name of the polyp tells you it’s benign.” Really? We re-read the letter. It didn’t say benign tubular adenoma polyps. So, exactly how should my engineer-brained husband be able to ascertain that tubular adenoma polyp means benign? Especially when the text also says that they may be pre-cancerous? She offered one other helpful bit of advice. “You can look it up on WebMD and see what it means.” Really? Really? We go to the physician; they do tests and procedures; they send us a letter but we, the people with little engineer brains, the paying customer (!), have to go online and interpret the results ourselves?
An aside: I entered “tubular adenoma polyps” into the search box on WebMD. It returned an overview of colon polyps. No mention of tubular adenoma polyps. I had much better results on Wikipedia.
The reporting of the results was incongruous to the prep. There were four phone calls prior to the colonoscopy to make sure he did the prep just so; they canceled two scheduled colonoscopies because he had taken a medication they deemed unsuitable. They put a great deal of time and effort into making sure he understood everything leading up to his colonoscopy; too bad they couldn’t put a little more effort in reporting out the results so that the “little engineer brains” of the world would understand.
I have two suggestions. First – don’t let your front-line staff direct patients to a third-party website for medical information, especially if you are not 100% sure of the website content. Second – carefully review the discharge instructions and reports you give patients. We aren’t physicians or nurses. We have no clue what “tubular adenoma polyp,” or many other common medical words mean. We can, however, understand “You had one polyp and we removed it. Your polyp was a tubular adenoma polyp. The biopsy of your polyp was negative and showed no evidence of cancer. Sometimes tubular adenoma polyps can be pre-cancerous, but yours was not. We recommend you for re-screening in five years.” Trust me; it’s much better to personalize the result, be succinct and direct; and it’s impossible to overstate the obvious for the non-medical brains out there.
Shelley Burns is the Director of Knowledge Management for HMC, Inc.
Uncategorized•
on December 20th, 2010•
This recent article revealed that physician self-referrals of imaging services other than standard x-rays resulted in higher costs with no demonstrable improvement in quality of care or patient convenience. Yikes. The implied promise when physicians lobbied to purchase complex medical equipment like ultrasounds, mammogram machines, MRIs, CT Scanners, and the like was four-fold – improved quality, faster diagnoses, patient convenience and lower costs.
The article’s result is counter-intuitive, isn’t it? Of course, if you go to the doctor with a headache and she says, “Let’s zip into the MRI and take a look”, we Americans are pleased. How convenient! And something is happening, an aggressive action to uncover the malady. The American patient isn’t. We are allergic to the tincture of time, so an MRI is much better than “Let me know if the headaches are still bothering you in two weeks”. Even if after the MRI we are told, “Come back in two weeks”, we are pleased that at least some diagnostic work-up was done.
But that’s not what the data says happens. The data says that doctors over prescribe when the MRI is just sitting there, lonely and woeful, waiting to be paid off. Their usage patterns change and it’s not to our benefit.
Do the physicians do this on purpose – intentionally set out to over-utilize a highly specialized imaging procedure? Undoubtedly some did. But my bet is that many truly believed that patient convenience, faster diagnoses and tighter quality controls would yield a better, less costly result than either watchful waiting or referring a patient to a hospital or imaging clinic.
Unfortunately, though, physicians neglected to measure their assumptions and we did not require it of them either. They did not perform a rigorous study of their results and utilization patterns post ownership.
The best study would have been a cost/benefit comparing utilization and results before and after owning the MRI. Lacking that, a comparison of clinical utilization with all the patients reporting a specific type of symptom would work. Compare results broadly too – not just against other self-referral docs, but also in hospitals, in urgent care centers, and in practices who don’t own the MRI. That’s the only way that we’ll be able to know what really works and is a good use of our precious healthcare dollars.
And once they have the results of their comparative clinical utilization studies? They must actually make practice changes based on the data.
Luckily lots of clinical utilization comparisons are available in your HMC Benchmarks. Have you and your physicians had a look at it lately?
Uncategorized•
on November 29th, 2010•
One simple tool – a checklist – is known to reduce the risk of costly mistakes, strengthen patient care, and improve overall patient health outcomes. A recent study in the New England Journal of Medicine found that using the World Health Organization’s (WHO) “Surgical Safety Checklist”– which requires surgical teams to complete certain tasks before “sign-in”, “time-out”, and “sign-out”– can reduce both post-op complications and death rates by about 36%. Surgical patients are not the only ones who benefit from checklists. HMC Partner hospitals have demonstrated success with checklists for hourly rounding and whiteboard content among others. It’s safe to assume that checklists of all varieties are in wide usage throughout hospitals, right?
The best answer to that question might be “maybe”. HMC Partner hospitals use a wide variety of checklists including surgical safety checklists (see “The Checklist” Survey for details). Only 20% of US hospitals, however, are known to be using the WHO checklist. Some hospitals have embraced checklists and others are using them while working through resistance and pushback, stemming from another step added to an already confusing array of patient care. Still others are in various stages of developing, implementing, and/or monitoring checklist usage. In a recent article, checklist advocate Dr. Peter Pronovost notes: “I am heartened by the growing use of checklists in hospitals, and flattered to see that leading medical journalists, such as Atul Gawande, are supporting our work and helping us spread the word”.
Checklist Questions and Caveats
In the same Huffington Post article cited above, Dr. Pronovost goes on to mention that checklists alone will fail at improving anything if there is poor communication between doctors and nurses. A paper checklist will work best for a well organized, cohesive patient care team that fosters open communication and encourages input from all members. In this setting, the checklist serves as a reminder to those doing patient care and takes the burden of remembering everything off the individual(s) performing a procedure, rounding on patients, or any other task that can be written up as a checklist. Without a checklist, the individual performing any action must remember all the steps associated with that action. With a checklist, pressure is removed as steps that formerly had to be committed to memory are now committed to paper (or electronic records). In addition, more than one person sees the steps written out on the checklist, reducing the room for errors.
HMC Partners can find additional information and checklist successes in this related HMC white paper.
Michelle Gray-Bernhardt is a Knowledge Manager at HMC. Reach her at mgray@HMCCentral.com or 262-242-9471 for information about joining the HMC KnowledgeWeb for Nurses.
Uncategorized•
on November 23rd, 2010•
By Michelle Gray-Bernhardt
“Solution-oriented”: have you heard this term? A solution-oriented approach focuses on outcomes over challenges. It works backward – it starts with an ideal situation, and then determines steps necessary to attain the ideal situation. A problem-focused approach analyzes the problem itself in detail before taking action. A solution-oriented approach dwells on solutions; no detailed analysis of the challenge is necessary other than the knowledge that things can improve.
In a traditional approach, be it budget, staffing – really, any common challenge in healthcare – managers often delve into every aspect of a problem, analyzing it from all angles. While such analysis may be prudent for some challenges, what would happen if it were simply acknowledged that improvements could be made? In this model, visualizing the ideal outcome leads the improvement process, without getting mired in details. While it sounds simple, it is a real change in mindset for many people to relegate the problem to the background and the solution to the forefront.
Ask “What would make things better?” around a specific challenge. Visualize the ideal outcome (not always an easy task), and work backward from there to identify steps to bring about the desired outcome. When you are approached to tackle quality improvements, cost savings initiatives, or the implementation of new clinical practices, what will your reaction be? Will you be tempted first to justify the status quo, thinking that new ideas or practices won’t mesh with your hospital culture or your current budget, that your staff won’t react kindly? Might the next reaction be to over-analyze the problem in an attempt to make it go away with minimal change? With this approach, it’s easy to get mired down in the details of a challenge — and the subsequent gathering of data to defend oneself from ultimately addressing that challenge. This mindset discourages innovative solutions.
Try working backward. Strip your challenge to its fundamentals: “What would improved patient satisfaction look like, feel like – what would be different?” A focus solely on improving patient satisfaction scores on an assessment tool in a low-scoring area (room cleanliness, as a random example) might miss the soul of the issue – relationships with people. An ideal outcome might be identified as happier patients, people who feel less vulnerable and more in control of their hospital visit, improving their perception of their care. This is very different than simply focusing on room cleanliness, reminding nurses and housekeeping staff to pick up debris from patient rooms and empty trashcans in a timely manner. While clean rooms are certainly one piece of the puzzle, there is a larger goal to work toward.
With budget adjustments: “What would an ideal budget look like? How much do you have to work with, and how close to the ideal can you be with what you have? Your ideal budget probably contains significantly more dollars for things like additional staff, continuing education/training/certifications, etc. What might it take to make that happen — are there any grants or other outside funding opportunities? Could you partner with local universities/schools to start an internship program? Could hospital volunteers work in a non-traditional capacity to help your unit or department? These ideas may not occur to the person solely seeking to eliminate line items from the budget. Solution-focused problem solving requires a forward-thinking mindset with the ability to visualize an ideal outcome and recognize that this ideal will be reached in steps both large and small.
Want to see what steps others have taken to improve? Check out HMC’s KnowledgeWeb (www.hmccentral.com). We have compiled over 8,000 ideas from your peers to help you move forward!
Uncategorized•
on November 8th, 2010•
By Shelley Burns
One promise of the Internet was that it offered a Utopian vision of collaboration – a community of truth-seekers motivated by their desire to improve. But somehow, it came about that the Internet Utopia was only possible through anonymous commentary. That meant that people’s names must be hidden, shielded to promote the free exploration of ideas, and protected against the burden of an identity.
Has web anonymity been a boon or a bust for collaborative idea exchange?
The anticipated power of the Internet was that it would create a platform for the masses who previously lacked a broad medium to communicate and debate. The dream was that it would drive communication exchange in heretofore unimaginable ways and complex issues would be more readily and comprehensively resolved. It meant that enhanced understanding and compromise would rule – even the thoughtful give-and-take at the local diner could be shared beyond the participants. There would be a wide-ranging, universal diner conversation to improve the world.
This Utopian idea exchange requires that each truth-seeker modify their position based on the voices of other truth-seekers. They integrate their concerns and worries into their solution and repeat it back. Similarly the other truth-seekers do the same with their own issues and concerns. It is not a zero-sum, winner-take-all game, but a process that acknowledges the situational complexities and the diverse experiences of others. Through the threaded back and forth conversation – “What if …?” “What about …?” – issues surface and are dealt with, and each participant shifts their perspective until a solution emerges. The collaborative result is a step forward, an improvement of the status quo, an aggregation of the best ideas.
However, Internet anonymity required truth-seekers to find another method to organize and distinguish their comments. They developed online personae, which they promptly name using words representative of their new images. Internet identities abound with characterizations contained within the name itself – political leanings, lifestyle choices, job aspirations and more.
But the problem is that once your persona is defined by your name, you lose your ability to shift your point of view. Imagine two commentators, “Red or Dead” and “2Blue4U.” Will they be able to really collaborate around a situation or idea? Will true exchange occur or will their debate be a furious, noisy volley of increasingly polarized and ad-hominem remarks? Similarly, how likely is anyone to consider a response, no matter how well thought out, from “CrazyCarrieRN” or “WillWork4Beer”?
No, anonymity on the Internet hasn’t progressed to the truth-seeking, collaborative Utopia we envisioned when Al Gore “invented” it. The Internet identities we circumscribe for ourselves inhibit our capacity to change our point of view. When our point of view doesn’t change, we can’t grow intellectually. And without forward movement on individual thinking there will be no collaborative improvement of the whole.
That’s why you’re encouraged to be yourself on the HMC KnowledgeWeb. Your name. Your title. Your hospital. Because we want your views, not your Internet persona.
Shelley Burns is head of knowledge management at HMC.
Uncategorized•
on November 1st, 2010•
By Michelle Gray-Bernhardt
Do nurses take their breaks? We asked them in the survey titled: “Nurses – Give Me A Break.” Results to date are mixed. A handful of nurses and nursing leaders feel break policies are working well. Others note that break policies are not working at all. The majority feel that while allocated break times are fair, nurses may not take breaks. That’s because of patient load and other variables, including the daily staff mix and the desire to shorten a shift by skipping an unpaid 30-minute lunch break.
The benefits of breaks are well documented in current literature. A nursing administrator echoes this in the survey results: “They [RNs] come back more prepared emotionally to handle their patients’ needs when they totally get away from the unit and take a real break.” One nurse who noted that there is a policy in place for breaks at her facility said: “You [RNs] make the time to get a break – it isn’t guaranteed. We signed up to be tough.”
Is this just the way it has to be? Or are there some solutions for making break time more accessible and more appealing to nurses? Survey responses ranged from the theoretical (create a culture where nurses want to take breaks) to the logistical (offer a call ahead or pick-up service at the cafeteria). Broad categories included:
- Culture change – Create a culture where nurses WANT to take breaks off the unit.
- Add structure to break times – Schedule break times, take away pagers, require nurses to sign off the unit, etc.
- Add staff – Use SWAT nurses, PRN staff, or some type of additional staffing.
- Improve access – To cafeteria and food (especially for night shift); improve access to staff lounges, staff bathrooms, etc.
- Offer paid lunch breaks – Or other financial incentives for nurses to take lunch breaks.
Given budget constraints and government regulations, adding staff or paying for lunch breaks may not be an option. Adding structure to break times may feel draconian to some RNs. Creating a culture where nurses want to take their breaks is a tall order. Has your facility done anything to encourage nurses to use break time? Provided any incentives for nurses to use their breaks?
We welcome your comments.
Michelle Gray-Bernhardt is an HMC knowledge manager
Uncategorized•
on October 20th, 2010•
Is nurse recruitment and retention still a hospital issue? Well, yes.
Overall, in the past three years, it may have become more of an employers’ market rather than an employee’s. However, in nursing, hiring and retention challenges still exist. Preliminary results for HMC’s new survey “Recruiting and Retention – Is It Still an Issue?” have been interesting.
Many hospitals face nursing personnel challenges, but the causes have changed. Examples of these challenges include: budget freezes; loss of good nurses who relocate because their spouses have lost their jobs; and nurses who could retire, but don’t because of personal finances. Sometimes new nursing school grads clearly don’t belong in the field, but don’t want to leave the industry for fear of being unable to obtain another job. There is a younger generation of nurses that feels no qualms about leaving the job abruptly; and there is increasing nurse dissatisfaction because of forced floating.
The survey results will be available in early November. Stay tuned for more info here on the HMC blog. And if you have opinions about this issue or experiences to share, we’d love to hear about them – you can participate in the survey by clicking here. Participants will receive an e-mail summary of the results.
For more information, please contact Pamela Paxton at ppaxton@hmccentral.com
Uncategorized•
on October 11th, 2010•
By Shelley Burns
I listened today to Janie Wilson’s outstanding presentation about reducing elective inductions and the concomitant positive impact on outcomes and cost. (Wilson is operations director for W&N Clinical Programs at Intermountain Healthcare.) She made a point on changing behavior and culture that made me think. She said: “We try to make it easy to do the right thing.”
The implication of that comment – namely, “It’s too hard to do the right thing” – is a pretty good categorization of the current healthcare system in the United States, isn’t it?
It’s too hard …
· for the oncologist to view images or lab work performed by a different hospital, so they perform all the diagnostics again, increasing utilization and cost.
· for some families to get insurance so they use the Emergency Room as their primary care, using expensive resources to treat a sore throat.
· to get all the orthopedic surgeons to agree on a standard supplies and clinical criteria for specialty products, therefore the hospital inventory is bloated with high-priced, non-standard implants.
· for patients to be followed across the continuum of care, so no one does, resulting in unnecessary re-admissions. No one really knows if discharge instructions and suggested follow-up care actually occur, even for chronic diseases such as asthma, congestive heart failure, COPD, and diabetes.
· for the nurses to communicate easily with far-flung and multiple family members, so they answer random phone calls at impromptu times, increasing the likelihood for errors.
· for the primary care physicians to communicate with patients via e-mail because they don’t get paid for their time and are nervous about getting sued. Instead, physicians require an appointment, unnecessarily wasting their time and the patient’s.
· for patients to understand the tsunami of paper they receive from hospitals, physicians, clinics, and insurance companies. Therefore, they can’t uncover the true cost of healthcare and abdicate their decisions about healthcare value.
· for the obstetrician to counsel watchful waiting as opposed to performing a C-section because the financial, malpractice, and social incentives are completely out-of-synch with less-invasive (and often safer) vaginal deliveries.
· for the hospital to drop a clean bill or claim (no payment denials or partial denials). Instead, they hire nearly as many coders, utilization reviewers, case managers, and insurance verification/authorization/denial management coordinators as they hire physicians, increasing costs for everyone.
There’s really no excuse for these things to be “too hard” A great healthcare system requires that we align the incentives to make it easy for everyone to do the right thing.
Shelley Burns is head of knowledge of management at HMC.
Uncategorized•
on October 7th, 2010•
by Ariana Berberich
Hospitals have instituted widespread quality efforts to prevent the non-reimbursed AHRQ off-quality incidents. While these quality improvement initiatives are well-intentioned, ironically, they are misguided. Based on research using our national database of hospitals (ranging in size from 5,000 to 80,000 adjusted admissions), and their admitting physicians (ranging in number from 35 to 1350), additional expenses related to off-quality incidents are not actually widespread among the hospitals’ admitting physicians but are focused among a handful. The implications of this are that broad brush patient safety initiatives will be less effective than those focused on the few physicians with quality problems.
At each hospital, HMC ranked the physicians by their off-quality expenses and determined the percentage of physicians responsible for 80 percent of the extra expense associated with patients who experienced off-quality incidents. Regardless of size, service, and number of physicians, the pattern remained the same with a mean/median of 6 percent of the admitting physicians responsible for 80 percent of the off-quality expense.
Ignore this at your peril.
The physicians at Hospital A show a typical pattern of off-quality expense with a small number responsible for a majority of the off-quality excess. Those physicians in red contribute 80 percent of the total facility off-quality expense.
Ariana Berberich is an HMC analyst.
Uncategorized•
on October 6th, 2010•
By Marc Songini
Working every day around performance improvement initiatives, it’s easy to think of these things only as abstractions. There are so many numbers and targets and goals. There are deadlines and methodologies and meetings in the slow challenging process of attaining excellence. So many acronyms: DRGs, LOS, AHRQ, and so on.
The dynamic changes the day when we actually are admitted to a facility, in great pain or fear. That’s when we hope that the emergency room is state of the art, with top notch networking and computer systems, and there is quick access to our medical records. We think about performance improvement and hope the hospital we are in is taking it seriously, because now it’s our particular health at stake – maybe our life, too. We hope the best doctors are the ones we will see – that they are the ones with performance-based success, and not just the ones who order the most tests.
I have heard it said that if aviation were as dangerous as healthcare, no one would fly. We think about such things when we are being admitted – sometimes too weak or sick to even consciously make a choice. Rather we go with the flow. We hope that the communications in the hospital – from intake to the emergency room to the ward we spend the night – is efficient. We don’t want to be given drugs that might kill us.
We hope that the doctors are all able to collaborate with nurses and other support and technical staff and that they are pointing us in the direction to get better. There are a million details we notice. We hope the nurses handling the IVs don’t have long nails, that there is some sort of rigid checklist someplace, that someone forwarded our specific instructions ahead if we’ve been admitted late at night. We don’t want to sit in pain waiting for medication.
There are so many things that can go wrong. Lab work; the wrong antibiotic; the wrong meal – was it only liquids we were supposed to eat? Or not? We also hope that the cleaning people are diligent. We know of things like MRSA and other infections that are straight from a horror movie
In short, the performance improvement discussion seems quite real when we are vulnerable. And if everything works, the general public just treats that as normal. But for those that understand all the many small cogs that are in the machine that is a hospital, we know it only all succeeds through teamwork, collaboration, and leadership. Working in the field from the administration’s side, we know that success is a choice in a hospital. When inside the hospital as a patient, we don’t see all the invisible forces behind success, but we’re aware that they were there, like the wind that blows a sail. We appreciate someone paid attention to the details.
On the other hand, the general patient, whose loyalty is so desirable, only knows what happened when a cog didn’t fit in right, and they won’t forget it.
Marc Songini is communications manager for HMC.
