Healthcare has long resisted learning – truly learning – from other industries. One of the first blogs I wrote was on this subject.  Yes, healthcare is different. But is it so different that other industries’ ideas, best practices, and demonstrated successes can’t be adapted and applied to healthcare? So different that ubiquitous process improvement strategies don’t apply?

I don’t think so. I read Health Leaders, coverage of Captain Chesley “Sully” Sullenberger’s address to the American Hospital Association Leadership Summit. He described the evolution of aviation safety improvement – there’s no denying the data – and how the industry’s founders found practices that worked. And the key tenets can be applied in multiple enterprises, including healthcare. It’s not rocket science. Well, maybe it is … aviation science, anyway.  The key takeaways  from Captain Sullenberger’s presentation on quality transformation in aviation were:

• Standardize equipment and responsibilities
• Strictly adhere to checklists
• Cultivate a team culture of safety and quality – zero tolerance
• Eliminate individual blame for systemic failures
• Reframe the captain role from god or cowboy to leader
• Measure, monitor, and communicate quality – incidences, outcomes, and the cost of off-quality

Are these principles really inapplicable to hospitals because their work is so different?It’s not rocket science. That’s not to say it’s easy, that it won’t require a great deal of courage and hard work. It’s difficult, but it’s doable. And it’s the right thing to do. Hospital-acquired infections, medication errors, patient falls, and the like are not uncontrollable collateral damage. They can be prevented if we summon the will to make the seismic mindset shift that Captain Sullenberger recommends, to stop thinking of mistakes “as inevitable and start thinking about them as unimaginable.”

Shelley Burns is head of knowledge management at HMC.

I read this article with dismay last month.  Why, in a profession that prides itself on evidence-based care, does the C-section rate continue to increase?

The increasing C-section rate is *almost* a microcosm of what is happening in many areas of healthcare. This overutilization of a medical procedure is driven by misaligned incentives for nearly everyone involved – except, perhaps, the baby. Like other causes of overutilization, the drivers of C-section rates are complex and intertwined. And while the scientific evidence is clear, it’s the cultural and market issues that make reducing the C-section rate more like a wild game of whack-a-mole.

Medical advances have lowered the attendant risks of C-sections, a great boon for those mothers and newborns who need them. Mothers who don’t require a C-section understand that the risks are lower, and consequently aren’t as wary about having a C-section as they used to be.  They also understand that sometimes, to prevent risks to mother and or baby, a C-section is necessary.  AND you can schedule baby arrival to the minute. Mothers don’t want to add the increased risks mentioned in the article to themselves or their babies. Yet, they are faced with work deadlines and short maternity leaves, and so don’t have much time to cobble together a support network after the birth. So, many mothers feel some slight increased risks are worth it.  After all, they know plenty of other women who had a C-section and everything turned out just fine.

C-sections are attractive to physicians, too. One source claims that C-sections can eliminate six of the nine most common reasons for obstetrician lawsuits. Faced with declining reimbursements and increased litigation, where is the incentive for the physicians to advocate strongly for a vaginal delivery? C-sections make their paychecks and schedules more amenable; the likelihood of litigation is reduced; and, their patients want C-sections. If the consumer is supposed to drive the care, and the physician has explained the risks, what’s a physician to do when an expectant mom wants a C-section?

Hospitals, as well, are caught in the consumer-driven care trap. Their customers, physicians, and mothers want C-sections and hospitals deliver (pun intended) what the market wants. Hospitals get additional benefit because accommodating C-sections gives them more control over delivery volumes and schedules, and they can forecast their costs and staff requirements more accurately.  C-sections also generate more services from the hospital, and our reimbursement system is service-based, not outcome based.  Hospitals get higher reimbursements for C-sections.

So the primary participants in the C-section decision are today incentivized to increase C-section utilization. Each person/entity in this scenario faces undesirable consequences if they do the right thing, according to evidence-based medicine. Until there are changes in the payment system, legal system, and our overall business culture, evidence-based care will continue to take a back seat to societal and market forces. And this example of overutilization typifies many of the other conundrums present in our current healthcare system.

At the beginning of this post I said that the C-section trend was *almost* a microcosm of healthcare utilization issues overall. For many other medical activities, the gorillas in the room are the drug, implant, and medical device companies. These companies’ presence in the C-section microcosm is very small; in this instance, they aren’t driving increased utilization. But for those procedures where they have a stake, add another market force incentivized to increase utilization. Another conundrum for another day.

Shelley Burns is head of knowledge management at HMC.

U.S. News & World Report‘s 2010-11 has named Sentara Norfolk General Hospital and Sentara Heart Hospital as offering some of  the United States’ best heart programs. In a recent announcement, Sentara claimed this was the 11^th time it had been so recognized. The newspaper’s  rankings in the  heart and heart surgery category are based on death rates, patient safety, and other care factors, such as technology and patient services. Sentara also noted that it was listed as 43rd in the best hospitals category. Additionally, Sentara posts a mortality score that exceeded five of the top-ten-listed programs. Sentara stated it’s one of only two hospitals in Virginia ranked by U.S. News & World Report.

I read and listened with dismay over various outcries about the recess appointment of Dr. Donald Berwick as administrator, or head of the Centers for Medicare and Medicaid Services (CMS). He’s a smart, thoughtful man with a good deal of common sense. Just what we need as we attempt to tame the raging tiger that is healthcare. We’re lucky that he’s willing to serve.

As much as the next American, I’m all for learning about political appointees’ opinions and plans. I am not, however, a fan of political posturing and commissions that are only masquerading as being useful. The latest hue and cry about the recess appointment of Don Berwick puzzles me: “We need to know where he stands!  We need to know what he’s going to do!”

Really?  The American public, and especially Congress (supposedly well-read in healthcare issues) doesn’t know where Berwick stands or what he proposes to do? This man has written volumes and given countless speeches outlining what he thinks the United States should do. He has built a foundation that transforms those thoughts into action, helping hospitals deliver higher-quality and lower-cost care. He’s thoughtful, smart and…most worrisome to the status quo, honest. He is willing to put the unpopular positions forward for discussion. He’s right – the waste in healthcare is astounding, full of non-value added activities that sap the strength from our country.

And yes, he does want to reform healthcare because it’s broken and needs to be reformed. Our quality compared to other developed nations is slipping. Our system is fragmented, much too expensive, burdened with extraneous care of dubious usefulness, and often inaccessible. We can do better. Why wouldn’t we borrow lessons from other countries where care is better and costs are lower? I think Berwick can help remove the blinders of arrogance that keep us from objectively analyzing results, both good and bad, from other countries. This also involves compiling the ideas that work, adapting them for our purposes, and ultimately improving healthcare for all Americans.

Healthcare reform is too complex and too critical, and the problems Dr. Berwick (and all of us) are facing are too important to be relegated to a “He wants death panels!” Twitter post. We all deserve better.

Shelley Burns is director of knowledge management at HMC.

NEEDHAM, MASS. – July 14, 2010 – The Healthcare Management Council, Inc. (HMC) has recognized client hospitals for its first annual Top Quality Award winners.

“Over the past several years the microscope has been increasingly focused on improving quality in healthcare,” notes HMC Principal John Whittlesey. “The Centers for Medicare & Medicaid Services (CMS) has adopted the Agency for Healthcare Research and Quality (AHRQ) standards for uniform reporting on patient safety and inpatient quality across all hospitals in the United States, and more indicators are coming down the pike.”

To assist clients to achieve their performance initiative goals, in 2008 HMC implemented the Quality Benchmark tool. HMC has steadily improved the product since then, and subsequently, most clients have deployed it as part of their integrated performance improvement programs. ” Many clients have successfully realized significant improvements across a wide variety of  indicators, and HMC is recognizing these high achievers with its 2010 Top Quality Awards. We congratulate the winners,” says Whittlesey.

The need to improve quality is increasing, given the prevalence of easily accessed data sources about hospital performance. Whittlesey notes that quality comparisons are readily available online to the public via web sites. Moreover, consumers are quickly becoming savvier about evaluating cost and quality measurements in making their healthcare decisions. “Hospitals are also on the financial hook for off-quality events that occur in their facility,” he says. “So there’s a strong incentive to reduce these events and improve patient outcomes.”

Six winners judged according to strict criteria

HMC scored each of its client facilities along five dimensions:

• Overall AHRQ patient safety quality score in the best one-half of peer group
• Cost versus quality performance in the upper left quadrant of the peer matrix (i.e., low cost/high quality)
• Overall patient safety quality score showed improvement versus the previous year
• Off-quality savings potential was less than two percent of total inpatient clinical costs
• Off-quality savings potential decreased versus the previous year

Finalists had to score “Yes” in each of the five categories to qualify. HMC also considered additional tie-breaking factors including: performance on AHRQ inpatient quality indicators, percent improvement in quality score; largest decrease in off-quality excess; and lowest ratio of off-quality excess to total clinical costs.

The Best Overall Performer was Logan, Utah-based Logan Regional Hospital, a nonprofit, full-service regional medical center located 80 miles northeast of Salt Lake City. It is a member hospital of the Intermountain Healthcare system. ”Logan showed one of the highest overall quality scores in the HMC partnership and has been in the top quartile of cost versus quality for the past two years,” says Whittlesey.

The facility saw a 14 percent improvement in overall quality score from 2008 to 2009, and a 30 percent improvement since 2007. It also realized a 40 percent reduction in cited savings potential for off-quality cases, and had only .28 percent of its clinical costs in off-quality excess.

The Top Performer was American Fork Hospital, based in American Fork, Utah (and also an Intermountain Healthcare member), a 117-bed community hospital and a runner-up for HMC’s 2009 Top Performer Award. “AFH has traditionally been one of the lowest cost facilities in HMC’s database, and this year saw a remarkable improvement in its quality position, as well,” says Whittlesey. “AFH had the largest reduction in cited excess for off-quality from 2008 to 2009 and the second largest improvement in overall quality score.”

In the Honorable Mention category were Sentara Leigh Hospital, based in Norfolk, Va. (part of Sentara Health System); Howell, Mich.-based Saint Joseph Mercy Livingston Hospital, and Ann Arbor, Mich.-based Saint Joseph Mercy Hospital (both are members of the Saint Joseph Mercy Health System). The most improved facility was Rome, Ga.-based Floyd Medical Center.

For inquiries regarding the Top Quality award, please contact John Whittlesey:

Email:                  jwhittlesey@hmccentral.com

Office number:  (781) 449-5287

Question:  When is texting at work a good thing? Answer: When it’s used as a minimally invasive tool to keep nurses apprised of patient requests without leaving the patient bedside.

Intrigued? That’s the lesson learned at  Sentara Leigh Hospital (SLH) in Norfolk, Va. The hospital implemented a house-wide text messaging system using Ascom wireless phones to keep its nurses at the bedside with few interruptions.

In the past, nurses at SLH were frustrated because they had ringing wireless phones that rang until the call was answered – this was problematic when the nurses were busy. In response, the SLH Six Sigma team and Nurse Practice Council proposed a new system. Now, when a patient calls, an administrative assistant answers the phone and sends the nurse a text message. The text page triggers a different beep that can be silenced with the push of a button. This allows the nurse to first complete whatever conversation or procedure they were conducting before reviewing the text.

However, if the call is not answered within two to three minutes, it continues to appear unanswered on the administrative assistant’s computer screen.  The assistant then resends the text, or finds an alternate person to answer the request. The staff wears tracer tags that cancel the call bell when they enter the room so the administrative assistant knows the staff went to the room to answer the call, and no further follow up texts are required.

In cases where the patient needs help getting to the bathroom, or other simple tasks, the message goes to assistive personnel, the rounder (a special position at SLH), and the nurse. The rounder or assistive personnel would be expected to answer these requests, but the nurse is kept apprised of the situation. In situations where the nurse is needed, having a text message allows her to prioritize requests without interrupting her current task. It’s a win-win situation. The patient gets a fast response from hospital personnel, and the nurse appreciates the convenience of a text message versus a page.

Want to try this at your facility? Then consider using these tips:

*Ensure you have the telecommunications and information technology staff and resources for the roll out and for subsequent usage monitoring.

*Involve bedside staff in development and roll out phases.

* Establish process guidelines to follow, then hold bedside staff  accountable for ownership and for rolling it out on their units.

A nurse manager at SLH also offered the following advice: “We had a few instances in the beginning where staff did not think we could monitor the text messages. Once word got out that we really could track use based on those few incidents, staff compliance with expectations has not been a problem.” They have also established goals around voice response and  in person response, and generate weekly reports to monitor compliance.

Michelle Gray-Bernhardt is a knowledge manager at HMC.