The Healthcare Management Council, Inc. Delivering Cost and Quality Benchmarks for your Hospital organization.

New patient web site may offer lopsided view of care

By Thomas Day

So now there will be a website for patients to  share detailed views of adverse medical events.  The grandly named “Empowered Patient Coalition,” in collaboration with the Consumers Union Safe Patient Project looks to give voice to these patients and their loved ones.  I hope they’re not offended when I suggest this will not provide reliable or truly analyzable data, as it will be impossible to discern the crazy posts from the legitimate ones. How can I be *so* sure?

I had a knee replaced in September. The surgeon did a great job, the device fit great, the hospital care was spectacular, and I was given a home rehab program to help me heal well and strong. When I saw the surgeon for a follow-up visit, I told him, “Great job, you did your part and gave me a plan to do mine and everything works great!”

And then the surgeon took off. “I can’t tell you how many people blame the surgery procedure for their knee not working right,” he said. “They’re 200 pounds too heavy, didn’t do the exercises for strength or flexibility, and they complain to me about how their knee doesn’t work, and that I can’t expect them to lose weight, and that the exercises were hard. So many patients feel so little personal responsibility for their care and recovery, it’s discouraging.”

I can only imagine how that would look on this Empowered Patient Coalition website – posted anonymously, of course. While it has the patina of an egalitarian, high-transparency effort to bring adverse events out into the open, this looks more like Yelp, but with even greater extortion potential.

Thomas Day is president of HMC.

Watch for the “I-formation”

by John Whittlesey

HMC’s Span of Control Analysis (SOC) measures the efficiency of your departmental organizational structures. With it, we sometimes see the dreaded “I” formation.  It exists when there is a middle manager that reports to another manager or director, and that other manager or director has no other direct reports. It almost always generates an immediate flag for a potential span problem.

There may be logical reasons for this, such as a succession plan, or if one of the managers has specific content knowledge. But generally it means that one of the positions is redundant, and the questions become:

1) Do I need either or both of these positions?

2) Do I have an extra layer of management?

3) Does the under-spanned position(s) have the capacity and the skill set to take on additional responsibilities?

4) How does this structure help or hinder decision making?

Take a look at the example below. The director of supply chain management only has one report; the supply chain manager has 6.8 direct reports. Technically, both positions are under spanned (the director should have about four DREs and the manager should have about 16 DREs). The department is too small to support its existing management structure. So, one of the positions is redundant, and one of the positions could take on additional responsibilities – such as patient transport, valet, security, sterile processing, or the print shop.

So now it’s up to the senior team to evaluate the skill sets and abilities of the two management positions and make a decision. “Do I get rid of the director, or do I get rid of the manager?”

John Whittlesey is a principal at HMC.

Better than nothing

By Thomas Day

AHRQ (The Agency for Healthcare Research and Quality ) recently issued a report about infections patients acquired while receiving healthcare treatment. The agency asserted that efforts to lower these infections had met with little success. True, the report used data through 2007, so it’s dated. And efforts since 2007 have surely been ramped up, given the success of checklists in their prevention and the focus of professionals on the problem.

Three societies – the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, and the Association for Professionals in Infection Control and Epidemiology – went further. In a statement, they criticized the reliance on administrative billing and coding data from the CMS,saying it “paints an inaccurate picture of healthcare-associated infections for the public.”

Not so fast!!! Assembling these data has been a giant step forward in providing a much higher level of transparency to the issue and ranking the performance of healthcare providers in their prevention. To criticize the use of billing and coding data  is a bit like criticizing economic analysis built from income tax returns. Income tax returns are also prepared for a different purpose, are self-submitted under penalty of misrepresentation, and submitters are optimizing their own data within the limits of law. If billing data is being mis-submitted and overstates infections – well then I’d have to wonder why… and expect the now-harsh spotlight on the infections reported would certainly fix things for the better.

Surely, I’d feel more comfortable if these groups offered their own comprehensive assessment, didn’t cherry pick a few encouraging stats, and provided a method that could be replicated across the board. Absent that, it sure sounds like unproductive whining to me. Give me that CMS data any day. It’s better than nothing.

Thomas Day is president of HMC.

HMC: AHRQ quality report too little too late?

By Shelley Burns

I am a hospital. Unless I have my head under a rock, I know that healthcare quality is a hot-button issue for the government, the public, think tanks and the media. I am taking flak from all sides: Medication errors are killing 100,000 annually. Methicillin-resistant Staphylococcus aureus (MRSA) and other infections are rampant. We have been woefully unprepared for the swine flu epidemic. People complain that my bills are too high – but I know my margins are thin, payments are often delayed, or they are less than my costs.

To help cure healthcare’s quality ills (a good thing), the government publishes a report where I can learn how to fix quality problems. It cites increases of post-operative sepsis and post-operative Catheter Associated Urinary Tract Infections (CAUTI) through 2007 as an indication of how well (or how poorly) efforts to reduce hospital-acquired infections have been?  Please.

In the 28 months since the last data bit was captured for this report, a lot has changed. Almost 18 months ago, the Centers for Medicare & Medicaid (CMS) stopped reimbursing for a long list of hospital-acquired conditions and infections, including CAUTI. In 2007, billing and coding data were not required to carry a Present-On-Admission (POA) flag – making it difficult to readily ascertain whether an infection was due to hospitalization or, oddly enough… present on admission. It’s required, now.

More importantly, in the past 28 months, we hospitals have made big changes internally. We’ve had a paradigm shift – we know that good quality healthcare costs less and that variation – in cost, in practice, in utilization – is cause for investigation. We’ve improved our tracking programs, implemented electronic medical records (EMRs), posted our quality data to multiple sites, and beefed up our technology and education to help us eradicate our quality issues. We’ve done a lot in 28 months.

So how about giving me some data I can use? Help me identify my quality issues, how big they are and what I might do to fix them. Give me a recent and repeatable picture of the quality at my hospital so I can set goals and measure my progress. Give me real time dashboards so I can see when my quality issues get out of control. Just don’t tell me my quality isn’t improving based on what I was doing 28 months ago.

Well, I have a suggestion for the here and now. Want to see how your hospital cost and quality stacks up and whether you’re improving? Want best practices that are actually in practice (and not just on paper) at other hospitals? Want a dashboard to monitor quality events in real time? Call HMC.

Shelley Burns is director of knowledge management for HMC.

Much ado about nothing in proposed Medicare cuts

By John Whittlesey

On Monday, the Centers for Medicare & Medicaid Services (CMS) proposed to cut Medicare payments to acute-care hospitals for inpatient services by 0.1 percent year-over-year, or $142 million in fiscal 2011. This has created a bit of a groundswell, according to an article published Monday in Modern Healthcare.

However, 1 percent isn’t enough of a cut to spur administrators into action.  And, so often, these cuts get delayed or reversed from the budget proposal.  It’s often a shell game. The bigger issue is what will happen with the scheduled 21 percent decrease in Medicare MD payments in the next three months.

Will Congress allow the decrease to go through as projected in the health insurance bill, or will it renege? That would blow the projected cost savings over the next 10 years out of the water and give critics legitimate fodder to say that the bill didn’t work.

For more, see this.

John Whittlesey is a principal at HMC.

HMC assembles white paper on decubitis ulcers

HMC has compiled a cutting-edge white paper of best practices to address the expensive and widely prevalent problem of decubitus ulcers.

Research from HMC has indicated that decubitus ulcers cost around $575,000 for an average hospital annually. A patient acquiring a pressure ulcer requires an average of $9,200 in extra care. This cost is not reimbursed by Medicare or Medicaid and in the future probably won’t be reimbursed by private insurers, either. What’s worse is that this is a preventable off-quality condition, according to Shelley Burns, HMC’s director of knowledge management.

There are solutions, however, says Burns. “Being able to readily discern patterns in your ulcer incidence increases the likelihood that you can fix your decubitus ulcer issues quickly and effectively,” says Burns. For more on this, see today’s announcement.

Looking to build physician scorecards?

Interested in physician performance and utilization? HMC is as well, and to facilitate this, we’re organizing a peer group that will focus on building meaningful physician scorecards. Our databases already house extensive clinical data and comparisons, and clients have asked about standard metrics or reports to find opportunities to improve utilization and quality via physician profiles or scorecards. Therefore, we are in the process of building a data pathway to allow hospitals to understand the quality, utilization, and cost impacts of their physician groups and practices. The scorecard will uncover how physician practice, utilization, LOS, and quality directly impact your bottom line, your patient satisfaction, and your market share.

This is the chance to start a productive dialog with your professional colleagues and HMC. Ultimately, it will allow you to provide input into the report characteristics – what data and format would be most useful, and what links and pathways would offer the greatest insight. Understanding and communicating these practice and utilization issues will enable your hospital to thrive. This virtual group will collaborate via the KnowledgeWeb with surveys, discussion forums, and Webinars. If you are an HMC client interested in joining our development group, please click here and start to explore the world of physician scorecards.

Shelley Burns, head of knowledge management, HMC.

Chronic disease eats most healthcare resources

By Thomas Day

Recently, I read a McKinsey article titled “Making health care healthy,” by Gary Cohen. While it seemed a call for a type of change that was beyond a comprehensible and actionable scale, he did discuss some very interesting and mind bending issues that gave me real pause.

The central idea is that chronic disease is swamping us. Cohen states that “70 percent of all health care expenditures in the U.S. are devoted to treating chronic disease; only 4 percent of the healthcare budget is focused on primary prevention.”

Some supporting statistics from the article: learning disabilities impact one in six children; infertility impacts one in six couples; one in three women and almost one in two men will get cancer in their lifetimes; among children under 14, cancer is the leading cause of death by illness. Also, obesity affects almost 90 million Americans – at a cost of $147 billion per year!

Cohen notes that our exposure to hundreds of toxic chemicals in our environment is partially to blame. There are also other factors, such as food produced by a “failed industrial food system,” as well as poor individual choices. Our health care system seems to be like a machine designed to pull people out of a river, but that never moves upstream to keep them from falling in, he says.  There is some evidence we can do something better. As evidence, he cites some really small wins: eliminating mercury thermometers; creating medical waste incinerators; and improving the food quality in hospital cafeterias.

Wow, if that’s the best we’ve done to date, this looks like a pretty huge problem.

Thomas Day is president of HMC.

Jury still out on robot-assisted prostate surgery

The long term benefits of using robotic machines in prostate  surgery have yet to be proven, according to a new study conducted at the Sentara Health System/Eastern Virginia Medical School in Norfolk. According to Reuters,  for the study, researchers evaluated 785 men who underwent four types of treatment for prostate gland cancer. The procedures included both robot-assisted surgery and conventional open surgery, as well as the implanting of cancer cell- killing radioactive “seeds,” and cryotherapy.

While advocates claim using the robotic technology reduces the risks of long-term incontinence and impotence that comes with traditional open surgery, the facts apparently aren’t there. In fact, “there were no significant differences in quality of life between men who had undergone open surgery and those who’d had robot-assisted surgery,” states the article’s author.

Given that just to purchase the machines requires a $1.5 million upfront investment, as well as surgeon training and annual maintenance fees, administrators may want to take pause before signing checks.

Low cost and high quality aren’t enemies

By Karen Jorge

I had a doctor’s appointment the other day. While making small talk as he looked through my records, the doctor asked me what I do for a living. After I told him that I work in hospital performance improvement, he said that he was very concerned about healthcare reform, because it made everyone think that they had to provide an “impossible” combination of high-quality and low-cost care, with too much of an emphasis on cutting costs.

While this particular physician may have been correct that only focusing on cutting costs won’t improve care, he missed the point. High-quality care doesn’t have to cost more. It is in fact very possible to inexpensively provide high-quality care precisely because providing such care lowers its delivery costs. Poor quality is much more expensive, as it requires extra resources to fix problems, and results in longer lengths of stay and higher malpractice costs.

HMC has found that hospitals that provide the highest quality care are usually some of the lowest-cost performers. Driving organizational change through quality-improvement initiatives can ultimately lower hospital costs by avoiding expensive off-quality events, lowering length of stay, and making care more efficient. As an added bonus, approaching hospital performance improvement in this vein can be more valuable and palatable to physicians – who are primarily (and understandably!) concerned with providing the best possible care. It also can facilitate getting them on board with strategic improvement projects.

The relationship between cost and quality doesn’t have to be an antagonistic one that makes a hospital try to determine just how much money it can cut from the budget before quality suffers. Instead, by “leading with quality,” the cost drops will follow.

Karen Jorge is an HMC analyst.