This seems like a good time to talk about hospitals. So I talked to a colleague, Cambridge Management Group Senior Adviser Jennifer Daley, M.D., who has held senior executive positions at Tenet Healthcare, Partners Community Healthcare and the University of Massachusetts Memorial Medical Center. She was director of the Center for Health Systems Design and Evaluation at Massachusetts General Hospital/Partners HealthCare, Boston; co-chair and director of research for the National Surgical Quality Improvement Program at the U.S. Department of Veterans Affairs; and vice president and medical director for health-care quality at Beth Israel Deaconess Hospital, Boston.
I chatted with her the other day about various things but focused on hospital-patient safety, on which she is an authority.
Dr. Daley said that while there have been heartening "inroads'' in this area, much more needs to be done to prevent potentially lethal problems, especially avoidable hospital-acquired infections such as bloodstream infections, urinary-tract infections, surgical-wound infections, sepsis and pneumonia acquired from being on a ventilator. We also discussed how inadequate cross-checking by doctors and nurses can lead to perilous drug mistakes, such as with chemotherapy and anti-coagulants.
She said that not enough hospitals follow the protocols needed to dramatically reduce patient-safety issues. "Multidisciplinary groups'' of physicians and nurses must rally around efforts in hospitals to address these problems. Tools include check-off lists and mandatory frequent repetition of oral questions, e.g., asking doctors "Have you washed your hands'' and "Are we about to do surgery on the right side?" and asking patients "What are your allergic to? What's your date of birth?" (Patient-ID error, of course, can lead to disaster.) And patients and their families, she said, must be further empowered to monitor their treatment and speak up when they sense that something might be wrong. She noted that particularly problematical times are when patients are "handed off'' to other physicians and nurses during shift changes, when crucial information might fall between the boards.
She observed, meanwhile, that, "The Baby Boomers [whose rapidly aging ranks are now flooding into the acute-care system] are more active in monitoring their own care'' than older people (the "Silent Generation''), with younger patients (heavy-laden with electronic communication devices useful in communicating with health care providers) presumably to be even more involved in this ever-more connected world. But while patients, as they are admitted into hospitals, receive printed and oral information about their rights, all too often they are too sick and/or exhausted to fully understand this information. Thus, Dr. Daley suggested that patients' family members and other caregivers be given stronger encouragement to "speak up" and ask questions.
A major problem is that "you often don't have the bench strength'' of doctors, nurses and administrators in many hospitals, especially smaller community institutions, compared to academic medical centers, to ensure that more rigorous patient-safety protocols are quickly established, implemented and improved over time.
Dr. Daley said that the "Joint Commission has taken the lead'' in patient-safety goal setting. That has helped bring along smaller hospitals. The commission, after all, has the sword of certification revocation to get their attention. She also singled out for praise the National Patient Safety Foundation and the American Medical Association.
And, she emphasized, mistakes must be brought out into the open so that providers can understand and prevent their repetition. "Everyone must be transparent about errors.''
What other powerful weapons do patient-safety advocates have besides moral duty, the fear of license revocation and litigation?
Dr. Daley noted that, payers, most notably the Centers for Medicare and Medicaid Services, are beginning to withhold payments from hospitals with bad outcomes.
Still, the prospect of declining insurance reimbursements because of health insurance reform and other factors may discourage many hospital senior executives from spending more, mostly on personnel and new safer technologies, to reduce patient-care errors. They want to protect their institutions' operating margins.
So, as Dr. Daley said, patient-safety advocates must frequently remind them that the (not very) long-term costs of failing to implement stronger patient-safety measures could be much larger than the short-term expenses of imposing more rigorous patient-safety protocols. After all, hospital-acquired illnesses and injuries do cause life-threatening illnesses and injuries.
Dr. Daley told of how at one hospital, the CFO and his colleagues were shown pictures of infected bed sores that could have been easily prevented by oversight and check-off lists. "They quickly changed their minds about the short-term cost being more than worth it.''
In any event, she noted rather drolly that new medications, technology and health-system organizational changes make it easier to keep patients out of the hospital, offsetting to some extent the expected flood of hospital-bound aging Baby Boomers. The less time that they spend in the hospital, of course, the less likely they are to get infections and other avoidable errors.
Finally, we asked her what she thought of the care-delay-and-cover up scandal at some Department of Veterans Affairs hospitals, with which she is very familiar. (See above.)
"I'm mad,'' she said, noting, "a kind of civil service mentality'' that seems to imply to some incompetent VA managers that, "you can't fire me.'' She noted that legislation in Congress would help address that problem by making it easier to dismiss problematic senior personnel. And she said the VA system clearly needs many more primary care doctors -- and higher pay for them and those running the hospitals.