The new study in the Archives of Internal Medicine http://archinte.ama-assn.org/cgi/content/short/170/4/347?home documents 48,000 hospital aquired pneumonias and sepsis leading to 2 week additional stays, millions of dollars and 19.5% increased mortality. Doesn't sound like hospitals are doing the right thing, one hundred percent of the time. Or are we not defining the problem correctly? Protocols for hospital acquired pneumonias and for blood stream infections exist and yet, how widely are they integrated?
Since my own mother accounts for several avoided, my observations are these.
The most critically ill are receiving care that reflects evidence based protocols and diligent attention to process. For example 30 minute vital sign checks and screening by protocol. But as the patients remain in hospital and are gaining independence the diligence may not be as consistent. Changing caregivers each shift and each day does not appear to contribute to better quality. In some instances a fresh set of eyes help, but the consistent application of orders and the understanding of slight changes seem to be a factor of staff knowing the patient well as much as their ability to read the computer.
In our case, IV fluids were missed leading to dehydration and several UTIs. IVs that were ordered in the computerized system. (Of course we were DNR for sepsis related events, so we were very diligent as family).
On the other hand, rapid and consistent action on pneumonia precautions and aggressive RT prevented a pneumonia that easily could have added to the mortality rates documented in the study.
The cost of the UTIs alone in terms of lost therapy, additional days, pharmacy and labs was significant. The cost of treating the precursor of pneumonia was also significant but not as costly and actually contributed to recovery instead of potential death. Not all care is equal and boards need to wake up to this fact.
And not all costs will be covered in the future...Boards will surely pay attention to that.
Tuesday, February 23, 2010
What does federal oversight of premium increases mean for you?
I keep going back to the quote a few months ago by Jim Skogsbergh at Advocate "the only thing I know for sure is that we will be paid less".
It means less money and more oversight. Is that bad? Not necessarily but it definitely requires hospitals to do what they say they are doing for the right reasons 100% of the time.
More importantly, it requires alternatives. And how do you turn that ship in the most efficient way.
It means less money and more oversight. Is that bad? Not necessarily but it definitely requires hospitals to do what they say they are doing for the right reasons 100% of the time.
More importantly, it requires alternatives. And how do you turn that ship in the most efficient way.
Monday, February 8, 2010
The White House Health Reform meeting
that President Obama is planning is intended to shine a light on the real issues and force a compromise. While I loved his open mike event with the Republican Caucus, this "single" issue, convoluted set of entangled proposals is going to feel more like a reality TV show somewhat like the ones with the Osbornes.
I highly suggest that it be structured like Project Runway with specific assignments (challenges) with definite deadlines, a smooth behind the scenes guy like Tim Gunn and a moderator like Heidi Klum who has ice running through her veins. A three person panel with ultimate decisionmaking power might not be a bad idea. Without that structure, we might never see a thing come out of this event...if it ever happens.
I highly suggest that it be structured like Project Runway with specific assignments (challenges) with definite deadlines, a smooth behind the scenes guy like Tim Gunn and a moderator like Heidi Klum who has ice running through her veins. A three person panel with ultimate decisionmaking power might not be a bad idea. Without that structure, we might never see a thing come out of this event...if it ever happens.
EMR is in your future of course
So what are your top concerns? What should they be?
One is that you get to a point where data from all your systems are retrievable. THis is not just important for the large research centers that are creating unified enterprisewide data centers but for all organizations that intend to be around for the next decade. Why, because the structure with or without reform is going to change rapidly BECAUSE THEIR ISN'T ENOUGH MONEY TO PAY YOU FOR THINGS YOU ARE DOING NOW! So your business model will be changing and you are going to need to analyze things across systems not in small departmental or institutional batches. What you do as an outpatient will need to be viewed in the context of the ER and inpatient. You will need to act like a research facility, asking broader questions about innovation and using all the data at your disposal.
Right now we are looking at patient compliance across a group of patients at Northwestern - measuring whether compliance equates to improved outcomes. It means that we need to be about to look at all the data for that patient - so that simplistic assumptions don't define the outcomes.
So as you approach this new world - which many of us have been approaching for awhile you may want to make sure that your very expensive software purchases do not come with any glitiches. The following article has a couple ideas to keep in mind. http://www.healthcareitnews.com/news/five-healthcare-it-decisions-avoid
One is that you get to a point where data from all your systems are retrievable. THis is not just important for the large research centers that are creating unified enterprisewide data centers but for all organizations that intend to be around for the next decade. Why, because the structure with or without reform is going to change rapidly BECAUSE THEIR ISN'T ENOUGH MONEY TO PAY YOU FOR THINGS YOU ARE DOING NOW! So your business model will be changing and you are going to need to analyze things across systems not in small departmental or institutional batches. What you do as an outpatient will need to be viewed in the context of the ER and inpatient. You will need to act like a research facility, asking broader questions about innovation and using all the data at your disposal.
Right now we are looking at patient compliance across a group of patients at Northwestern - measuring whether compliance equates to improved outcomes. It means that we need to be about to look at all the data for that patient - so that simplistic assumptions don't define the outcomes.
So as you approach this new world - which many of us have been approaching for awhile you may want to make sure that your very expensive software purchases do not come with any glitiches. The following article has a couple ideas to keep in mind. http://www.healthcareitnews.com/news/five-healthcare-it-decisions-avoid
Tuesday, February 2, 2010
Why Boards should care about worklife balance.
I mean really care, not give lip-service to the concept to sound politically correct - even though you can't believe you have to kowtow to the weak among us who "can't" cut 60-70 hour-weeks. You know the people, they don't give a damn, they race home to every kid event and whine about missing dinner. The people we have always loved are the "when I did that job, I worked 14 hour days". And instead of saying, "why what took you so long", we puff up our chests and say "well I have a home office where I answer emails at 4:30 am".
Okay, so my point was to convince you that that is nonsense and that you should care about worklife balance but I can tell that most of us are relating to the first paragraph and are about to brag at how we missed our 15th anniversary because of a big project. (I missed many - and rarely arrived with a present when I did show. I also missed volunteering at school and baking a few cookies.)
So why do I think it matters. Because you lose perspective and what you gain is ego. When ego outbalances love of the work, the challenge, the creativity, the teamwork, then you are underutilizing your resources.
Productivity study after productivity study shows that good work, results and break-through thinking happen after a time of "digestion". Meaning that you can only move so fast through a pile of issues before your process and thinking are stagnant and non-productive. You can't walk away because there is too much but you don't have the brainpower to process how to get work done more efficiently.
If you are saying, not me....I work out -- I don't drink smoke or dance....I can handle it. I say that is ego talking and when ego talks, nobody listens. They may cower but nobody listens. And listening is one of the broken skills in healthcare, including management.
Whole people make better managers. People who value life beyond their work, put their work in perspective and keep their own ego in balance. They make leaders not cattle herders. Studies suggest that after 8 hours productivity diminishes greatly. Without adequate sleep, the brain doesn't retain what it learned the day before. Without family and spirituality or a wholeness to life, jobs lose meaning.
And when it comes to solving the intense workforce problems in healthcare, worklife balance should top the list. Through my ezxperience, I have had no sense that unions in healthcare helped the care or the employee but I had to stop and think of the comment of the unions on tthe AHA's new workforce report. Their comments reflected a deep suspicion on the part of nurses that they are treated as piece workers instead of professionals with little regard to life or need outside of work. Its time we thought of these workers as breadwinners who need a salary and schedule that they can count on if we ever want to attract more women to the profession.
Okay, so my point was to convince you that that is nonsense and that you should care about worklife balance but I can tell that most of us are relating to the first paragraph and are about to brag at how we missed our 15th anniversary because of a big project. (I missed many - and rarely arrived with a present when I did show. I also missed volunteering at school and baking a few cookies.)
So why do I think it matters. Because you lose perspective and what you gain is ego. When ego outbalances love of the work, the challenge, the creativity, the teamwork, then you are underutilizing your resources.
Productivity study after productivity study shows that good work, results and break-through thinking happen after a time of "digestion". Meaning that you can only move so fast through a pile of issues before your process and thinking are stagnant and non-productive. You can't walk away because there is too much but you don't have the brainpower to process how to get work done more efficiently.
If you are saying, not me....I work out -- I don't drink smoke or dance....I can handle it. I say that is ego talking and when ego talks, nobody listens. They may cower but nobody listens. And listening is one of the broken skills in healthcare, including management.
Whole people make better managers. People who value life beyond their work, put their work in perspective and keep their own ego in balance. They make leaders not cattle herders. Studies suggest that after 8 hours productivity diminishes greatly. Without adequate sleep, the brain doesn't retain what it learned the day before. Without family and spirituality or a wholeness to life, jobs lose meaning.
And when it comes to solving the intense workforce problems in healthcare, worklife balance should top the list. Through my ezxperience, I have had no sense that unions in healthcare helped the care or the employee but I had to stop and think of the comment of the unions on tthe AHA's new workforce report. Their comments reflected a deep suspicion on the part of nurses that they are treated as piece workers instead of professionals with little regard to life or need outside of work. Its time we thought of these workers as breadwinners who need a salary and schedule that they can count on if we ever want to attract more women to the profession.
Monday, February 1, 2010
What are hospitals going to do without non-profits
The Wall Street Journal outlined the plight of non-profits....more demand, higher complexity, fewer grants, less government funding, slowing donations, layoffs, fewer services... http://online.wsj.com/article/SB10001424052748704586504574654404227641232.html?mod=igoogle_wsj_gadgv1
For some hospitals they are competing within the same tight government budget or going after the same donors but even so, without the non-profit social services sector many hospitals and not just the poorest will face challenges that they may not be equipped to deal with. This is on top of hospital's worry about increased uninsurance rates.
Patients are more frequently losing their homes, their transportation, are working two jobs or as many as it takes and can't be there for loved ones. Budgets restricted, means out-of-town families that are unavailable. Mental health services that might be lacking....proper nutrition, after school programs for employees. The list of services that intersect with the hospital industry is huge.
Now would you ever recommend when you are up to your neck in your own aligators, that your board consider looking at this issue and how they are might partner with social service agencies to make sure that resources continue to be availabe in the most cost effective manner possible - eliminating duplication (of transportation services or whatever). Reinvigorating donors through shared programs. Joint advocacy to the state. And if your institution has resources during this recession, sharing some with the non-profits that support your community as part of your community benefit report in real meaningful ways.
Hospital costs will go up with patients unable to be discharged and patients returning to the hospital for fully preventable reasons. It makes sense to relook at community benefit as a priority and not as someone else's business.
For some hospitals they are competing within the same tight government budget or going after the same donors but even so, without the non-profit social services sector many hospitals and not just the poorest will face challenges that they may not be equipped to deal with. This is on top of hospital's worry about increased uninsurance rates.
Patients are more frequently losing their homes, their transportation, are working two jobs or as many as it takes and can't be there for loved ones. Budgets restricted, means out-of-town families that are unavailable. Mental health services that might be lacking....proper nutrition, after school programs for employees. The list of services that intersect with the hospital industry is huge.
Now would you ever recommend when you are up to your neck in your own aligators, that your board consider looking at this issue and how they are might partner with social service agencies to make sure that resources continue to be availabe in the most cost effective manner possible - eliminating duplication (of transportation services or whatever). Reinvigorating donors through shared programs. Joint advocacy to the state. And if your institution has resources during this recession, sharing some with the non-profits that support your community as part of your community benefit report in real meaningful ways.
Hospital costs will go up with patients unable to be discharged and patients returning to the hospital for fully preventable reasons. It makes sense to relook at community benefit as a priority and not as someone else's business.
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