Category Archives: Quality of care

HTA in Italia: pessimismo dell’intelligenza, ottimismo della volontà

Il 24 ottobre scorso sono stato invitato da Giovanni Morana, dinamico direttore della radiologia dell’ospedale di Treviso, ad un convegno sul tema della TAC Dual Energy. Il programma prevedeva una parte dedicata a questa interessante tecnologia ancora in fase di sviluppo e ricerca e una dedicata all’HTA.


L’incontro si è tenuto all’Ateneo Veneto, una fondazione istituita da Napoleone dopo il disfacimento della Serenissima Repubblica di Venezia, in uno splendido palazzo a fianco del Gran Teatro La Fenice.

Per un accidente della storia, il 9 ottobre 1996, nella stessa sede avevo organizzato un workshop, alla presenza dei politici e direttori generali della aziende sanitarie del tempo, dal titolo: “Razionamento o razionalizzazione dell’assistenza sanitaria – il ruolo dell’HTA”, starring Renaldo N. Battista al quale il collega direttore generale di Venezia (il compianto Carlo Crepas) aveva tributato gli onori che la Serenissima Repubblica tributava ai Capi di Stato e agli Ambasciatori in visita a Venezia: il corteo in barca lungo il Canal Grande.


L’invito di Giovanni Morana ha suscitato in me due sentimenti: il piacere di discutere oggi con i clinici (italiani, stranieri e un brillante giovane collega italiano che lavora a Charleston, Carlo De Cecco) e i produttori di tecnologia i metodi e le opportunità offerte dall’HTA; l’amarezza di toccare con mano la lentezza con la quale in questi vent’anni l’HTA si è diffusa in Italia!

Quanta strada ancora da percorrere! Se smettessimo di buttarci a pesce sulle cose urgenti e ci occupassimo un po’ di più delle cose importanti (De Gaulle) …..!!!

Il XXI secolo non ci ha portato ancora superare lo storicismo gramsciano: “Tutti i più ridicoli fantasticatori che nei loro nascondigli di geni incompresi fanno scoperte strabilianti e definitive, si precipitano su ogni movimento nuovo persuasi di poter spacciare le loro fanfaluche. D’altronde ogni collasso porta con sé disordine intellettuale e morale. Pessimismo dell’intelligenza, ottimismo della volontà”. (Q28, III)



The Five Biggest Problems In Health Care Today @WRicciardi @Medici_Manager @LeadMedIt

Leah Binder Contributor

I named this blog “Losing Patients” as a play on words. But in all seriousness, our health care system is literally losing “patients,” killing more than 500 per day from errors, accidents and infections in hospitals alone, not to mention the mortality and suffering from millions of procedures that never needed to be done in the first place. At the same time, the employers and other purchasers paying for this care are losing “patience” with the slow pace of change in cleaning up the mess.

Think I’m a bit too pessimistic? Take the example of early elective deliveries.  These are births scheduled without a medical reason between 37 and 39 completed weeks of pregnancy. The prevalence of these unsafe deliveries perfectly embodies the five biggest problems in our health system. Below I explain how — but keep reading, because I do have some words of optimism in the end.

Problem 1: Too Much Unnecessary Care

Overuse and unnecessary care accounts for anywhere from one-third to one-half of all health care costs, which equal hundreds of billions of dollars, in addition to the half-a-trillion per year experts attribute to lost productivity and disability.

Early elective deliveries are unnecessary, according to advice by the American College of Obstetricians and Gynecologists, that has been repeated for more than 30 years (that’s not a typo – 30 years), a point reinforced today at a press conference. This is a message carried by several other highly respected organizations like Childbirth Connectionthe March of Dimes and the Association of Women’s Health, Obstetric & Neonatal Nurses (AWHONN). All national health plans concur. Nonetheless, we saw a dramatic escalation in the rates of these deliveries from the 1990s to the first decade of the new century.

Problem 2: Avoidable Harm to Patients

This is one of health care’s most common problems. The statistics are staggering. Here’s an example: one in four Medicare beneficiaries that are admitted to a hospital suffers some form of harm during their stay. Would you get in your car if you thought you had a one in four chance of harm during the drive?

Early elective deliveries harm women and newborns. Babies born at 37-39 completed weeks gestation are at much higher risk of death. They are also at a far higher risk for harms like respiratory problems and admission to the  (NICU).

Problem 3: Billions of Dollars are Being Wasted  

A report by the Institute of Medicine Health suggests a third or more of health costs are wasted. The cost of these unnecessary, harmful early elective deliveries was estimated in a study in the American Journal of Obstetrics and Gynecology to be nearly $1 billion per year.

Problem 4: Perverse Incentives in How We Pay for Care

Traditionally, health plans, Medicare and Medicaid pay providers for whatever services they deliver, regardless of whether the service truly benefits the patient. As an excellent new book called “The Incentive Cure” points out (as does a plethora of other literature that could fill several libraries), how we end up with an epidemic of perverse incentives.

The harsh truth about early elective deliveries is that our payment system encourages them. They generate admissions to NICUs, and NICUs are profit centers. Studies suggest that reducing the rate of these deliveries to a reasonable number could eliminate as many as one-half million NICU days, which could lower health costs for the U.S. But this would force hospitals to take a big financial hit. To their credit, in my experience, once hospitals recognize they have a problem with early elective deliveries, they don’t think twice about taking that hit. States like South Carolina and Texas are trying to reverse the incentives, as are many employers. Unfortunately, they are the exception that proves the terrible rule of insane payment incentives.

Problem 5: Lack of Transparency

We have far more information available to us to compare and select a new car than we do to choose where to go for lifesaving health care.

Transparency galvanizes change like nothing else. Early elective deliveries exemplify that: Despite warnings over the years from medical societies and highly respected national organizations, the rates of these deliveries have been rising for decades. That stopped when a purchaser-driven organization, The Leapfrog Group (my organization), started reporting early elective delivery rates by hospitals in 2010. Suddenly, the rates started declining. Just today, Leapfrog released the 2012 data showing that the national rate for early elective deliveries is 11.2 percent, down from 17 percent in 2010. This is a voluntary survey, with nearly 800 hospitals providing the data willingly. Consumers deserve to know these rates for every hospital delivering babies in the country.

Now for a Dose of Optimism

We have a glimpse of success in ending early elective deliveries. Sparked by public reporting, we have seen a growing cadre of providers, policymakers and consumer advocates uniting to address this problem, and the Department of Health & Human Services declared early elective deliveries as a top priority issue. Regional coalitions are also vowing to end the practice in their community.

The next step is for purchasers and consumers to keep up the pressure because that will only help in encouraging real change. And we need to apply that model across the board – the  business community should also work together to address the five big problems in health care that have a direct impact on their own employees’ health and their business’ bottom line. The key message here for all groups is this: don’t financially reward the wrong care and demand transparency.

Solving the high rates of hospital readmissions @kevinmd @Medici_manager @pash22

By  ,

Statistics show that about 1 in 5, or 20 percent of all Medicare patients are readmitted to hospital within 30 days of discharge. That’s a staggering number, not to mention all those patients that are readmitted frequently during the course of a year, but not necessarily within 30 days.

The problem of frequent hospital readmissions is actually one that exists all over the world and not just in the United States. Health care systems everywhere are seeking solutions to keep their patients healthier and away from hospital. Any doctor practicing at the frontlines will be able to tell you what a big issue this is right now. We regularly see the same patients on something of a merry-go-round of frequent hospital admissions, often with the same illness.

Why does this happen? This issue is complex. In my experience as a hospital medicine doctor, there are number of factors in play, falling into different categories according to the type of illness, availability of definitive treatment, and the social circumstances of the patient.

Severity of illness. Certain chronic conditions, such as congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), when in their advanced stages, are very labile and prone to exacerbations. As much as doctors try to control these with medications, it’s a very difficult task, as it only takes a slight precipitant such as a minor infection or dietary indiscretion to push somebody over the edge. By their very nature chronic diseases tend to get worse over time. And with an aging population, these conditions are increasing in prevalence. Unless we find definitive cures, hospitalizations are always unfortunately a possibility.

Social situation. Patients who have inadequate family support tend to be admitted to hospital more frequently for a couple of reasons. Firstly, their threshold for being able to cope at home with their illness is much lower. Secondly, they will not be able to co-ordinate their regular follow up care so easily. We see the effects of this all the time at the frontlines — two patients with the same level of illness severity; one will be managed at home, the other will require hospital admission for several days.

Lack of follow-up. Many studies have shown that lack of follow-up with a primary care physician in the weeks after discharge can lead to a higher likelihood of re-hospitalization. Seeing a doctor quickly post discharge allows for any potential problems to be “nipped in the bud”. It also allows for care co-ordination and medication reconciliation. Sadly, a large number of patients do not have a regular primary care doctor (mostly for insurance reasons). They therefore tend to use the emergency room as their first point of contact when they feel unwell again.

Suboptimal discharge process. By its’ very nature, the process of discharging a complicated patient from hospital is one that is fraught with possible problems. The discharge process needs to be thorough, seamless and diligent. Areas for improvement in most hospitals include medication reconciliation, clarifying follow-up appointments, follow-up laboratory tests, and making sure that the patient and family is clear about these instructions. Too often, this process is rushed and glossed over. Nothing beats having the doctor sit down with the patient and their family, spending time reviewing all the pertinent information.

Low health literacy. Many patients are not fully educated and informed about the nature of their illness and how best to manage it at home. This can be dealt with by regular reinforcement and utilizing home nursing services to keep on checking in with the patient post-discharge.

Certain very obvious patterns do exist in how patients tend to be readmitted to hospital. Several initiatives are underway across the country to try and improve the situation. Primary care doctors, specialty clinics, home nursing services, and even social workers are all being utilized as part of a team-based approach. The strategies broadly involve:

  • Identifying high-risk patients early
  • Educating the patient and involving family members
  • Having very close follow-up with a collaborative care team

As part of health care reform, hospitals are also facing financial penalties for consistently high readmission rates. But financial penalties alone aren’t the answer, especially for “safety net” hospitals that struggle more with this problem. It’s important to remember that the drive to reduce readmissions is not just about saving the health care system money, but ultimately about keeping our patients healthier and stronger. Whatever can be done to keep them at home enjoying life as much as possible instead of lying in a hospital bed, can only be a good thing.

Suneel Dhand is an internal medicine physician and author of Thomas Jefferson: Lessons from a Secret Buddha and High Percentage Wellness Steps: Natural, Proven, Everyday Steps to Improve Your Health & Well-being.  He blogs at his self-titled site, Suneel Dhand.

6 strategies hospitals should steal from the airline industry @Medici_Manager @pash22

by Jonathan H. Burroughs

The Institute of Medicine, in its landmark report “Better Care at Lower Cost,” concludes at least $750 billion of the total national healthcare budget of $2.7 trillion represents waste as a result of poor IT infrastructure, supplier- rather than patient-centered reimbursement, lack of quality and transparency, and inefficient operations and flow.

Wasteful operations may include: delays, over-processing, redundant work, poor inventory management, inefficient transport, unnecessary motion, over-production (push instead of pull), and defects that cause harm and re-work.

The airline industry has worked on these problems for decades and although its operations and flow patterns are significantly less complex than healthcare, it has mastered basic elements we can learn from to give us a jump-start on mastering and taming a difficult but necessary component of operational design that will lead to improved outcomes at lower costs.

1: Air traffic control is managed as a system, not a place

Flow through the airport affects and directly result from flow outside the airport, and air traffic control does not make any distinction. We often treat emergency department or intensive care unit flow as an isolated problem whereas every aspect of an individual’s care from inpatient, to post-acute, to ambulatory has a direct impact on the other. As it turns out, what happens to an individual outside of a hospital has a greater effect on length of stay and flow than what happens inside. Thus, we will never master hospital flow until we master the flow of the entire system.

2: Airport operations function 24/7

Airports function 24/7 and so should healthcare systems. Flow should be managed around the clock and utilization managers should be replaced with flow coordinators who hand off their oversight continuously based on time of day and setting of care. For instance, when a plane takes off, airport air traffic control transfers responsibility to regional air traffic control, and oversight of the flight is continually monitored from control station to control station until the flight terminates at another airport.

Similarly, a flow coordinator should orchestrate a patient’s non-emergent arrival, the admission process, the inpatient care, the discharge planning process and then transfer responsibility for the patient to an outpatient flow coordinator to ensure appropriate follow up and continued optimal care. Ideally, the term “discharge” should be replaced with “care transition” so we stop thinking of moving from one environment to another as a beginning or end.

3: All departures are scheduled in advance

The three most common bottle-neck areas in a healthcare organization are the emergency department, the intensive care unit, and the surgical areas (pre- and post-operative). The vast majority of delays in these expensive settings involve the discharge planning process as patients in these areas often have no place available to go, thus backing up operations throughout, delaying treatment for others waiting to come in, reducing patient/staff satisfaction and increasing costs. Ironically, most discharges are predictable to within one hundredth of a day based upon risk and severity-adjusted length-of-stay data bases (e.g., Premier) for each diagnosis-related group.

Therefore, most discharges should be scheduled at least 24 hours to 48 hours in advance (ideally when the patient arrives) with arrangements made for nursing home or ventilator beds, physician appointments, home health on the day of admission in anticipation for discharge. Many healthcare organizations are purchasing or contracting with nursing homes, home health services, psychiatric facilities and physician practices to gain greater control and ease of scheduling by extending the chain of its operations into the outpatient setting.

4: All arrivals are scheduled in advance

One healthcare myth is that emergent arrivals are unexpected. As it turns out, if emergent ED, surgical, or ICU admissions are tracked over time, the vast majority are predictable. For instance, most emergency department admissions arrive between 3 p.m. and 11 p.m. with the fewest arrivals between 4 a.m. and 9 a.m. There will be rare disasters, which require special resources through a disaster planning process; however, these can be managed and illustrate the difference between random (uncontrollable) and non-random (controllable) variation in flow.

Truly random variation can and should be managed by policy whereas non-random variation should be eliminated by standardizing flow to accommodate predictable admissions in a predictable way through optimum staffing, resource allocation (including beds) and standardized admission processes.

5: Flight schedules are smoothed throughout the day and week

An airport only can handle its capacity of arrivals and departures at any point in time and so it manages the schedule to ensure a consistent schedule of flights throughout the week and time of day. Emergency departments, surgical facilities, and intensive care units can be similarly managed so that non-emergent patients who arrive at the ED can be transferred to lower acuity areas during peak hours, elective surgical schedules can be scheduled evenly throughout the week to avoid demand surges, and ICU admissions can be coordinated based upon regional transfer agreements in compliance with EMTALA to ensure appropriate stabilization and safety.

The system needs to be viewed holistically so all of the units and outpatient facilities coordinate flow in a synchronized and synergistic way to accommodate flow throughout the system and not within a unit alone.

6: Delayed flights are taken off of main runways and taxiways

When air traffic control delays a flight, the delayed flight does not block other flights but is directed to another area to await further instruction and movement. Delayed discharges, transfers and admissions should not sit in beds blocking patient flow but should be immediately moved to a comfortable and appropriately supervised holding area where they can be safely managed and not delay the timely diagnosis and treatment of non-stabilized patients.

Most patients waiting for beds are stable and should no longer receive top priority or undermine the overall efficiency and effectiveness of the system. Similar holding areas can be utilized for admissions, transfer, and discharges if beds are interchangeable and staff is cross trained to handle a broad range of diagnoses and conditions.


Although air traffic flow is simpler and easier to manage than healthcare, the industry can offer many lessons that will enable us to treat patient flow systemically as a 24/7, inpatient/outpatient, continuous operation that requires continuous management and oversight to standardize processes, exploit bottle-necks, manage random variation and eliminate non-random variation. By doing so, we can reduce costs, improve quality/safety/service and successfully compete globally for high quality-low costs services.

Jonathan H. Burroughs, MD, MBA, FACHE, FACPE is a certified physician executive and a fellow of the American College of Physician Executives and the American College of Healthcare Executives. He also is president and CEO of The Burroughs Healthcare Consulting Network.

Cost Containment: The Importance of Nurses @Medici_Manager @helenbevan @pash22

by September Wallingford, RN, BSN

Due to ever increasing healthcare costs, stakeholders in the healthcare system rely heavily upon front-line workers to assist in containing costs to help make healthcare more affordable. Since nursing is the largest sector of front-line workers, the field has an opportunity to greatly impact cost containment. Currently, there are 2.7 million nurses in the workforce, with an expected growth rate of 26% over the next decade; however, there has been limited discussion on how nurses can help contain healthcare costs.

Why are nurses not usually integrated into the cost containment discussion? Why have we not been invited to the table? Likely, it is because we don’t have the power to order (or discontinue) tests, labs, or medications, all of which are major factors in the rising costs of care. Even so, a nursing perspective can be important and should be considered when doctors make treatment decisions.

For example, I recently treated a patient who had undergone abdominal surgery. Despite uncomplicated post-operative days 1 and 2, on day 3, he developed nausea, vomiting, and an increasingly distended abdomen. I administered intravenous anti-nausea medications, along with back rubs and cool cloths on his forehead. None of the treatments worked. While waiting for the doctor, I sat with the patient and spoke to him about the possibility of receiving a nasogastric tube to alleviate his symptoms. Given an understanding of the process, the patient agreed to this possibility and I paged the doctor once again. The doctor eventually placed the nasogastric tube, the tube was connected to suction, and out came a liter of gastric contents.

I then noticed that the doctor had put in an order for an abdominal x-ray to “check nasogastric tube placement.” Seeing this, I initiated a conversation with the doctor to discuss the patient’s symptomatic improvement as well as his current state of exhaustion. I assured the doctor that nurses would be at the patient’s bedside to monitor for signs and symptoms of tube malfunction. As a result, the doctor cancelled the x-ray, which not only eliminated an unnecessary test for the patient, but also reduced the cost associated with his care.

Situations like these are commonplace to nurses across the country. We witness daily that more is not necessarily better, and we are in a position to help make decisions that lower costs without negatively impacting the patient’s care. Nurses bring a unique perspective to the healthcare cost conversation, so include us in the discussions, give us a seat at the table, and utilize us as active participants in the fight against rising healthcare costs.

September Wallingford is a registered nurse at an academic medical center in Boston, Massachusetts. She is currently completing her graduate nursing education to become an Acute Care Clinical Nurse specialist.

Doing what’s right for patients demands a culture change @muirgray @Medici_Manager @pash22 @helenbevan

We are pleased to announce the dates of our 2013 Lown Conference:
From Avoidable Care to Right Care 

For more information on the 2013 conference, please visit our website:


June 24, 2013   Avoidable Care Admin   

This year’s Lown Conference, From Avoidable Care to Right Care, will take place on December 3-4, 2013 in Boston, MA.

The 2013 invitation only conference will gather clinicians, patient advocates, and civic leaders to deepen our mutual understanding of the cultural, scientific, and ethical issues surrounding the overuse of medical services.

Attendees will leave this meeting with priorities for addressing this pervasive problem, and collaborators who are prepared to begin building bridges to the right care in their communities.

Major themes at this year’s event:

  • fostering a new kind of conversation among clinicians, patients, and civil society
  • envisioning health and health care 25 years from now
  • the global epidemic of overuse

Speakers include:

  • Don Berwick, MD, MPH, Former Administrator, Centers for Medicare and Medicaid Services (invited)
  • Katy Butler, Author of Knocking on Heaven’s Door
  • Bernard Lown, MD, Professor Emeritus, Harvard School of Public Health; Senior Physician (ret.), Brigham and Women’s Hospital, Boston
  • Richard Smith, MD, Former Editor BMJ
  • Rabbi Richard Address, D.Min, Senior Rabbi, Congregation Mkor Shalom

Our working groups for Medical Education, Community Engagement, International Collaboration, and Setting the Research Agenda will convene for a working session on December 5, 2013 following the conference. If you are interested in participating on one of these working groups, please email us for more information

For more information on the conference, including how to register, please visit the Lown Institute website at

Smokers will be asked to quit before undergoing surgery under new medical guidelines @Medici_Manager

Grant McArthur

SMOKERS will be asked to quit before undergoing surgery and be referred for help while on waiting lists under new medical guidelines.

A strengthened smoking policy from the Australian and New Zealand College of Anaesthetists will require all elective surgery patients to be asked if they smoke, and for tobacco users to be given referrals to help them quit before their operations.

The policy will not give practitioners the power to delay or cancel surgery. But ANZCA president Dr Lindy Roberts said the guidelines would offer smokers the best chance to avoid life-threatening complications by providing them with support.

The hope is to convince and help smokers to quit four to six weeks before surgery, while they are already on the waiting list, which can greatly cut the risks of serious complications during recovery.

“Smokers are at greater risk of complications such as pneumonia, heart attacks and wound infections,” Dr Roberts said.

“When you are coming into hospital for something like an operation, it does provide you with an opportunity to think about your health more generally, and the benefits of giving up smoking for your health are in the longer term as well as relating to surgery and anaesthesia.

“It may be that when presented with the risks for a certain procedure that the surgery is delayed to allow somebody to improve their health prior to the surgery.

“From time to time a decision may be made between the anaesthetist, the surgeon and the patient to delay the surgery if there is something that can be improved to make them fitter for surgery.”

The move follows the success of a Frankston Hospital program in which all smokers entering the surgery waiting list were sent a quit pack – prompting 13 per cent to act and contact Quitline. Australian Medical Association Victorian president Victoria president Dr Stephen Parnis said the college’s quit-smoking stance was a positive move, balancing the need to advise patients without discriminating.

“This is not about banning people, this is about giving them the best chance to benefit,” Dr Parnis said. “When you weigh into account the procedure they need and their health, if there is a benefit to delaying the procedure then we would do that.”

Five (and a half) lessons I learned at the IHI National Forum @Medici_Manager

Dr Alan Willson, 1000 Lives Plus @dralanwillson –

Several people will be on their way from Wales to the BMJ/IHI International Forum in London next month. While there they’ll see innovation and best practice from around the world. It’s an opportunity to meet experts in quality improvement and patient safety and bring new knowledge back to Wales.

I’ve recently been reflecting on the ideas and examples I heard at the IHI National Forum last December. Here are five (and a half) lessons I learned, recognising a huge debt to Brent James and others who willingly shared their presentations with me so I could fully get to grips with what they were saying.

Lesson 1 – The quality improvement mindset is the opposite of top down management – and that is important

The frontline is where change matters because this is where we interact with patients. To change NHS Wales we need to follow Deming’s principle: Organise everything around value-added processes on the frontline – i.e. focus on the bits that will really make a difference to patients. Change needs to start here to be really effective.

Lesson 2 – Improvement has more to do with left brain than right brain

Innovation is fun. We all like to come up with ideas and then see if they work. But Bellin Health’s ‘High Performance Healthcare’ model indicates that a scientific approach to providing standardised levels of care is important to improving quality.

We don’t always have to do something new – what is more important is making sure the right things are done at the right time, in the right place and to the right people. Then, valuable improvement energy must be focussed on business critical problems and within a clear context of measurement and alignment with what else is happening in the system.

Lesson 3 – Quality and cost saving can and must be delivered together

The evidence from the QUEST initiative in American hospitals shows that improved quality and lower costs (or better control of costs) go together. We’ve also done some work on this, publishing a white paper last year. However, it’s very important that we set out with a focus on quality, not a focus on improving costs – better quality helps reduce costs; just trying to reduce costs won’t improve quality.

Lesson 4 – There is now an evidence base for high performance

The 10 most important elements in high performance have been identified in the QUEST hospitals. In the past we have had intuitive opinions, but now we have evidence-based key features that we should be looking to replicate in NHS Wales. We are fortunate to have Eugene Nelson speaking at the next 1000 Lives Plus National Learning Event on Tuesday 11 June to describe this ground breaking work.

Lesson 5 – Reducing harm from sepsis and surgical site infections are winnable fights

Some healthcare organisations have seen mortality due to sepsis drop by two thirds. Infections after c-sections have been virtually eliminated in many hospitals. It shows that deaths and harmful events can be stopped in Wales – the ways we can make this happen are out there.

 Lesson 5 and a half – We are on the right track with Improving Quality Together (but there is still work to do!)

If we can reach the point in NHS Wales where everyone truly believes that they have two jobs – to do their job and to improve their job – then this will result in improvements being initiated everywhere by everyone.

Improving Quality Together is a way of delivering this mass participation – but we need training, coaching and data for actionable measures to keep track of the improvements taking place and to evaluate them.

Let’s keep talking

I’d be interested to hear your comments on these lessons. Do they reflect what you know about the work going on in NHS Wales? What do you find intriguing? What makes you pause and go ‘hmmm’? Do comment.

Or, if you are at the International Forum next month, 1000 Lives Plus will be running the NHS Wales stand. Please stop by and say hello. If you can’t make it, then we’ll be blogging throughout the week to keep you up-to-date!

Partnering with patients @Medici_Manager @bmj_latest

Fiona Godleeeditor, BMJ

Last month we published a plea from Dave deBronkart (also known as e-Patient Dave) to “let patients help.” As a survivor of stage IV, grade 4 renal cell carcinoma, he described how the online patient community helped save his life (BMJ 2013;346:f1990). His aim is nothing less than to revolutionise the relationship between patients and healthcare providers. “Please,” he wrote, “let patients help improve healthcare. Let patients help steer our decisions, strategic and practical. Let patients help define what value in medicine is.”

This week we hear from another e-Patient, Kelly Young, who tells us why she became “a rheumatoid arthritis warrior” (doi:10.1136/bmj.f2901). Her blog,, was born of the realisation that her doctors were stumped and that she needed to take responsibility for understanding her condition and deciding about her care. The blog now reaches nearly 2% of all patients with rheumatoid disease in the United States and, according to Young, is changing the way doctors as well as patients think about the disease.

The language of revolution and war may seem excessively violent, but it reflects the sense that even internet empowered patients feel they must fight to be heard, to get access to information, and to have their say in treatment decisions.

The BMJ is a journal for doctors. Over the years we have resisted the temptation to widen our sights to include patients among our target readership, although we know that many of our online readers are patients and members of the public. Despite its name, our series of Patient Journey articles is not designed for patients. As recently summarised by the BMJ’s patient editor, Peter Lapsley (BMJ 2013;346:f1988), these articles aim to give our medical readers new insights into patients’ experiences of illness and treatment in order to improve care.

But Young, deBronkart, and others like them are looking for something more than simply more empathetic doctors. They want partnership on an equal footing. And it’s this shift that the BMJ now wants to champion, working with colleagues at the Mayo clinic and others. As several of us ask in an Editorial this week, how better to improve care than to enlist the help of those whom the system is intended to serve?

Achieving such a partnership is a challenge. Years of paternalism have left doctors and patients unprepared for a different type of interaction. Time and other pressures may seem to justify current ways of working. But what if taking steps to bridge the divide between doctors and patients really did result in better, less costly, more effective care? There is a growing evidence base to suggest that it will. Ten years ago, we published a theme issue on partnering with patients (, and other articles published before and since are now gathered in a collection on To encourage further research and thinking in this area, the BMJ plans a call for papers for a conference and theme issue on participatory care next year. More information will follow shortly. Meanwhile, we are recruiting a panel of patients and doctors to help us think about how we can reflect the shift to patient partnership. I’d welcome your thoughts.

Cite this as: BMJ 2013;346:f3153

Reducing medical errors: What we can learn from the Dreamliner @Medici_Manager @kevinmd

 | POLICY | MARCH 9, 2013

If you think that medical errors are a thing of the past, you are mistaken.

It has been 14 years since the Institute of Medicine’s report “To Err Is Human” shattered the myth that most, if not all, physicians are all-knowing practitioners with flawless skills and infallible judgment.

The story of what happened in the report’s wake was predictable:

  • Where the healthcare industry failed to act as it should have, the federal government and accrediting organizations stepped in to set the standards for healthcare quality and safety, establish quality measures, and assure that healthcare delivery entities complied by instituting financial and other penalties for poor performance.
  • Patients who previously felt safe began to question their healthcare providers.
  • We began to see some evidence of improvement in the quality and safety of healthcare services across the U.S.

In light of the foregoing, a recent “trip” to the website for American Medical News, the newspaper of the American Medical Association, left me feeling frustrated and sad.

story by Kevin B. O’Reilly referred to a recent well-referenced article in Surgery, noting that, at the close of last year, “never events” continue to occur in U.S. operating rooms 80 times per week.

In addition to causing temporary or permanent harm to patients, he extrapolated that these events carry a financial burden of almost $1.3 billion over 20 years.

Although surgical “never events” are rare (i.e., one in every ~12,000 procedures), their seriousness should not be diminished — especially when simple checklists and protocols have been shown to reduce the occurrence of such mistakes to near zero.

According to the article, published findings of a review of medical liability settlements and judgments collected in the National Practitioner Data Bank for 1990 to 2010 revealed that surgeons of all ages are involved in “never events” such as inadvertently leaving surgical items in the patient, performing either the wrong procedure or the right procedure on the wrong site, and — most egregious of all — operating on the wrong patient.

Startling as this is, previous studies have found that the 90% of injured patients who do not receive indemnity payments are not even included in the data bank.

Other studies have shown that “never events” can be eliminated — or at least minimized — by intensifying focus on identifying and correcting deficient processes, for example by addressing communication lapses with presurgery briefings and marking operative sites.

To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.

After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.

A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.

Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.

Because patient safety is part and parcel of my daily routine — whether in the hospital, the classroom, or at a national meeting — I ask myself why our industry is not mortified and why, as a nation, we are not appalled.

When I look to the airline industry for analogies, as I often do, the Boeing 787 “Dreamliner” comes to mind.

After only a couple of incidents, the federal government grounded this newest, most technically sophisticated airliner until the problem was fully understood, the deficiency corrected, and the risk to passengers and crew minimized.

Shouldn’t we address surgical “never events”, which affect 4,160 patients each year, with the same urgency and gravity that we address the potential risk to 210-270 passengers of travelling in the “Dreamliner”?

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

Helping patients to die well @Medici_Manager @giovanimedici @specializzandi

Fiona Godleeeditor, BMJ @fgodlee

There is more than one way to die well, say Katherine Sleeman and Emily Collis in their article on caring for dying patients (doi:10.1136/bmj.f2174). The trouble is that far too many people die badly. Whatever your definition of a good death, dying in hospital when you would prefer to die at home, or dying in pain, distress, isolation, or uncertainty will not be part of it. Yet, as the authors explain, over half of all deaths (in the UK at least) occur in hospital, many patients die with unmet needs, and more than half of complaints referred to the Healthcare Commission are about the care of dying people. All of this is despite the growing recognition of the need for good end of life care. And of course the risk of dying badly matters not only to the person who is dying but to their relatives and friends. The authors quote Cicely Saunders, founder of the hospice movement: “how we die remains in the memory of those who live on.”

But there is good news. While modern medicine often seems to actively promote bad end of life care, doctors can do a great deal to help patients achieve a good death. Early identification of the dying phase, good communication with patients and relatives, sensible prescribing, effective management of physical symptoms, and understanding of the patient’s social, psychological, and spiritual needs must all play their part.

Sleeman and Collis have targeted their advice towards doctors in training. But clinicians at all levels of experience will benefit from reading their article. Senior doctors will, in any case, want to model the highest professionalism and humanity when dealing with dying patients. Knowing that younger doctors will be taking their cues from you provides an additional incentive.

The article usefully tackles some of the misconceptions that have dogged the Liverpool care pathway in recent months. The pathway is a framework, not a treatment, so doesn’t need formal consent, but the decision to start someone on it should be made by a multidisciplinary team and should be discussed with the patient where appropriate and always with the relatives. While on the pathway, patients should be supported to eat and drink; and if the patient’s condition improves, the pathway can be stopped.

Essential to good end of life care is the ability to recognise that a person is dying. Sadly, this is a prognostic skill that doctors are “notoriously poor at,” say the authors. But do patients need to know that they are terminally ill in order to receive good care? The same authors take part in our Head to Head debate this week, arguing that patients should be told, since this knowledge is necessary for informed decisions (doi:10.1136/bmj.f2589). But Leslie Blackwell argues against what she calls “prognostic disclosure” (doi:10.1136/bmj.f2560). This is, she says, “a failed model for medical decision making that creates more suffering than it relieves,” and “for most people the apparent choice between comfort and prolongation of life is a false one.” I’m not convinced, but I would like to hear your views.

Cite this as: BMJ 2013;346:f2656




Antimicrobial resistance—an unfolding catastrophe @Medici_Manager @bmj_latest

Fiona Godlee, editor, BMJ

At the end of the 1960s, the then US surgeon general William H Steward famously declared: “The war against infectious diseases has been won.” His optimism might well have been justified at the time. The discovery of antibiotics and their widespread introduction had transformed both medical practice and life expectancy.

Antibiotics still transform lives, but—as with so many of the world’s resources—we now know that they are not limitless, and that unless we are careful, their beneficial effects will run out. We have become so accustomed to the availability of antibiotics that a world without them is almost inconceivable. Yet this is the world that England’s chief medical officer, Sally Davies, demands we contemplate in the second volume of her annual report (doi:10.1136/bmj.f1597). The causes of this unfolding catastrophe are many: overuse of existing antibiotics, increasing resistance to them, a “discovery void” regarding new drugs, and a change in the types of organisms presenting the greatest threat. “If we don’t get this right we will find ourselves in a health system not dissimilar to the early 19th century,” she says.

Is Davies being overdramatic? Sadly not. Her decision to focus on antimicrobial resistance has been broadly welcomed. And this week we publish a report from Richard Smith and Joanna Coast, long term analysts of the economics of resistance (doi:10.1136/bmj.f1493). They suggest that the picture she paints may even be too rosy. “Resistance is said to present a risk that we will fall back into the pre-antibiotic era,” they say. “However, this is perhaps optimistic.”

Their argument is that we have badly underestimated the cost of resistance. Studies that have tried to estimate the economic impact have looked at the extra cost of treating a resistant infection compared with a susceptible one. But this ignores the bigger picture. The whole of modern healthcare, including invasive surgery and immunosuppressive chemotherapy, is based on the assumption that infections can be prevented or treated. ”Resistance is not just an infectious disease issue,” they say. “It is a surgical issue, a cancer issue, a health system issue.”

Their revised assessment of the economic burden of resistance encompasses the possibility of not having any effective antimicrobial drugs. Under these circumstances they estimate that infection rates after hip replacement would increase from about 1% to 40-50%, and that about a third of people with an infection would die. It seems likely that rates of hip replacement would fall, bringing an increased burden of morbidity from hip pain.

The CMO’s 17 recommendations include better hygiene measures and surveillance, greater efforts to preserve the effectiveness of existing drugs, and encouragement to develop new ones. As Anthony Kessel and Mike Sharland point out, only one or two new antibiotics that target Gram negative organisms are likely to be marketed in the next decade (doi:10.1136/bmj.f1601). Recognising this as a global problem, the CMO’s report also calls for antimicrobial resistance to be put on the national risk register and taken seriously by politicians internationally.

As for the cost of such action, Smith and Coast see it as an essential insurance policy against a catastrophe that we hope will never happen. And they share the CMO’s urgency. “Waiting for the burden to become substantial before taking action may mean waiting until it is too late.”


Cite this as: BMJ 2013;346:f1663

Footnotes Follow BMJ Editor Fiona Godlee on Twitter @fgodlee and the BMJ @bmj_latest

Hospital Kaizen: Habit-Building @MikeLombard @Medici_Manager @fabriziofontan2

I’m really liking The Power of Habit:  Why We Do What We Do in Life and Business by Charles Duhigg.  Taken along with the Mike Rother’s Toyota Kata, you have the basics of what it takes to create a continuous improvement culture.
For clarity’s sake, I define a continuous improvement culture as an environment in which we strive to improve every process, every day, with everybody involved.  No improvement is too small, we don’t batch all our improvements into big projects, and anybody in the organization can be an improvement leader.  For more information on this concept applied to healthcare, see Graban & Swartz’ book Healthcare Kaizen.
Anyway, in Duhigg’s book, the habit-building loop is presented.  It has three components:
  1. Trigger:  this is the cue to perform a routine
  2. Routine:  this is the standard steps performed to arrive at the desired result
  3. Reward:  this is the payoff for performing the routine on-cue
When these three elements are in-place and clearly related, a craving eventually forms.  This craving causes the habituated person to anticipate the reward at the trigger point, even before performing the routine.  This phenomenon is the indicator of a well-formed habit (for better or for worse!).
While Duhigg’s book is about the science behind habit-forming, Rother’s book is about the habits needed to drive continuous improvement.  Specifically, he emphasizes two habits (he uses the term ‘kata’):
  • Improvement Kata:  this is a 4-step routine that helps us 1) see the ideal condition to which we strive, 2) study the current condition to see our gaps, 3) set a short-term target condition to pursue that is on the path to the ideal condition, and 4) pursue the target condition using PDSA (another 4-step routine).
  • Coaching Kata:  this is a routine, drawing upon the Socratic Method of teaching (asking questions instead of giving answers), that is designed to reinforce the proper execution of the aforementioned Improvement Kata.
So, how do we put in place the three elements of the habit-building loop for the two kata?  How do we create a craving for the kata?  The routines (element #2 of the habit-building loop) are established by Rother’s book.  The other two elements, triggers and rewards, are TBD for me personally.  Some thoughts:
  • Triggers:  eventually, the ideal would be that the trigger is the detection of a problem/gap/opportunity for improvement, but in the short-term, more artificial triggers may be needed (i.e. require each manager to perform one PDSA cycle per month…not a long-term solution, but can get the ball rolling in the short-term).
  • Rewards:  eventually, the ideal would be that the reward would be the intrinsic motivators of mastery, autonomy, and purpose (see Daniel Pink’s Drive), but in the short-term, more artificial rewards may be needed (i.e. gamification:  badges, achievements, recognition, compliance tracking, small gifts, etc.)
This type of habit-building is tricky business.  Culture change is hard.  It takes a wide range of knowledge, organizational finesse, and a lot of trust and patience on the part of senior leadership.  But the payoff is huge.  A culture of continuous improvement is the best, most sustainable competitive advantage available.

Great article about measurement for judgement versus measurement for improvement @Medici_Manager @helenbevan

More quality measures versus measuring what matters: a call for balance and parsimony

North Mississippi Health Services Malcolm Baldrige National Quality Award 2012 @Medici_Manager

North Mississippi Health Services (NMHS) is a nonprofit, community-owned, and integrated health care delivery system serving 24 rural counties in northeast Mississippi and northwest Alabama. The organization includes six hospitals, four nursing homes, and 34 clinics. It provides preventive and wellness services, hospital-based emergency and acute care services, post-acute care services, and a preferred-provider organization. The NMHS workforce of 6,226 employees and 491 physicians serve at health care facilities located in six Mississippi communities (Tupelo, Baldwyn, Eupora, Iuka, Pontotoc, and West Point) and one Alabama city (Hamilton). Net revenue in 2011 was $730 million.

North Mississippi Medical Center (NMMC), the flagship hospital and referral center in the NMHS system, was honored with a health care category Baldrige Award in 2006.

High Standards = Better Health Outcomes

  • Efforts to create healthier populations in the communities served by NMHS have led to outstanding results. For example, outpatient management of diabetes has met or exceeded the National Committee for Quality Assurance (NCQA) top-decile benchmark since 2008. Colorectal cancer screenings have increased since 2009 and consistently exceed the standard set by the state’s Medicare quality improvement organization. Additionally, data from NMHS’s Community Health Assessment demonstrate that the number of smokers in the region has declined 7 percent since 2004 to 15.6 percent.
  • For 2012, the NMHS flagship hospital, NMMC, has demonstrated performance at the 100 percent level for Joint Commission-accredited hospitals in 26 of 30 Surgical Care Improvement Project core measures. (The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States.)
  • A strong focus on patient safety has led to no central line-associated blood stream infections in its intensive care unit for two years. Slips, trips, and falls are below the National Database for Nursing Quality Indicators mean for both inpatient and long-term care settings across the system in fiscal year 2012.
  • Weighted patient satisfaction results for the NMHS system have been at or above the Press Ganey Associates 90th percentile since 2008. (PGA is a national consulting firm focused on improving health care performance.) Scores from the Hospital Consumer Assessment of Healthcare Providers and Systems survey, a national, standardized, publicly reported poll of patients’ perspectives of hospital care, were at or above the 90th percentile for one or more dimensions at all six NMHS hospitals.

Maximizing Service and Improving Performance

  • NMHS uses a variety of methods to reach various stakeholders and capture their feedback on areas for improvement. These include the “Careline” free phone line, regular leader visits to work areas, face-to-face interviews, Facebook comments received, and surveys. The system’s customer service team reviews the data to identify where changes are needed.
  • NMHS shares performance results with its workforce, partners, patients, and other stakeholders through systematic, well-deployed performance score cards. Performance data and progress toward improvements are reviewed monthly by senior leaders. System-wide collaborative work groups share best practices on a regular basis.
  • NMHS utilizes an innovative “Ideas for Excellence” program to capture improvement suggestions from the workforce. The number of ideas submitted has more than doubled in the past five years to greater than 10,000 in fiscal year 2011, with approximately 40 percent accepted for implementation during that time.
  • Use of NMHS’s Integrated Community Health Record by both employed and affiliated physicians, including remote log-in capability from their homes when on-call, ensures access to needed patient data and information during transitions from home to the Emergency Services Department to inpatient status and back to outpatient status.

 Caring for Caregivers: Employee Satisfaction a Priority

  • The NMHS employee retention rate has been at or above 90 percent since fiscal year 2007, exceeding the Bureau of Labor Statistics’ benchmark for health care organizations by 10 percent.
  • To engage its workforce, NMHS links rewards and recognition to its EXCEL performance management system and the organization’s critical success factors. Survey results show that employee engagement was above 90 percent from 2008 through 2012, and that workers rated their job satisfaction as “best-in-class” in both 2010 and 2012.
  • NMHS’s core competency of “People Who Provide a Caring Culture” recognizes the role that the workforce plays in achieving the organization’s mission to “continuously improve the health of the people of our region.” Through its innovative “grow-our-own” strategy, NMHS employs a full-time career counselor to assist employees in identifying opportunities for career progression and provides tuition reimbursement for advanced education and training that approached $450,000 in fiscal year 2011.
  • Senior managers at NMHS have created a culture that emphasizes “people first” among its critical success factors. This “servant-leadership” philosophy enables managers to model the organization’s values and build trust with employees, sustaining an empowered, accountable, and high-performing workforce. Open communication and recognition are achieved through a “No-Secrets” culture and open-door policy, weekly e-mails from the chief executive officer, and regular rounds by senior leaders throughout the system.
  • NMHS’s physicians serve as key partners who are actively involved in the organization’s business strategy. In collaboration with staff and the administration, employed and independent physicians work together to develop the organization’s strategy, implement and improve its work systems, and accomplish its goals.
  • To support physician leaders in the organization, NMHS has developed an intensive Physician Leadership Institute. Graduates expand their leadership roles as advocates, mentors, and performance improvement champions. Physician leaders share operational responsibilities by participating in annual planning retreats, service line management, and supporting clinics and community hospitals across the system.
  • NMHS’s Live Well Employee Incentive Program educates and rewards employees for healthy and safe behavior choices on and off the job. The program has contributed to a trend where the annual increase in premiums for the employer-sponsored Live Well Health Plan dropped from 12 percent in calendar year 2009 to 2 percent in calendar year 2011.

Sound Management is a Prescription for Financial Health

  • NMHS leads its primary competitor in market share by 13 percent and all other hospitals combined by 8 percent. In addition, for selected procedures (e.g., cardiac catheterizations and open-heart surgeries), NMHS has led all other competing hospitals in market share from 2008 to 2010.
  • Despite its location in what has been called “the nation’s epicenter of poverty,” NMHS is the only health care organization in Mississippi or Alabama with a Standard & Poor’s (S&P) AA credit rating, which it has held for the past 18 years.
  • “Days cash-on-hand,” a financial indicator of available revenues used by organizations to plan future spending, has steadily increased since 2008 to 256 days in 2011, outperforming competitors and other S&P AA-rated organizations.

An Active Commitment to Healthier Communities

  • Dollars spent for charity care at NMHS rose to $80 million per year in 2010 and 2011. Employee contributions to United Way—providing meals, prescriptions, clothing, and utility assistance to the citizens of northeast Mississippi—increased from $475,000 in 2007 to nearly $600,000 in 2011.
  • To address the challenge of maintaining a highly qualified staff, NMHS has financially supported local schools of nursing, a pharmacology program at a local university, and created the Family Medicine Residency Program. NMHS builds relationships with students beginning as early as elementary school and offers a paid Physician Shadowing Program for college students.
  • NMHS community and regional outreach includes obesity prevention services, school health centers that provide nurses to 22 schools in six counties, the free Nurse Link Call Center, and free fairs for preventive screenings and health care promotion, including blood pressure checks, flu shots, and childhood immunizations.

For more information:

Marsha Tapscott
North Mississippi Health Services
830 S. Gloster St.
Tupelo, MS 38801
Telephone: (662) 377-3193 or (662) 377-3148