Barbara Kaplowe, MHSA, CPHQ, Quality Improvement, MidState Medical Center, Meriden, CT
Because I was recently a hospital patient myself let me offer the following thoughts:
We have come a long way in learning to learn from each other in healthcare... which helps to speed up adoption of practices that work. However, if you spend one day in a a patient bed, you will note some of the following:
- Nurses spend way too much time looking for things - equipment, supplies, etc. We need a Japanese lean approach to this.
- We have done little to critically examine workflow. My nurse needed at least 15 minutes to change my dressing. She wore a hands-free wireless communication device with voice recognition that allowed her to respond to any calls from anyone looking for her. Sometimes it was an aide saying another patient needed meds, sometimes it was the unit secretary saying another patient needed something. It was nice that she could instantly answer and say where she was, but what good does that do the patient in the other room that needs the pain med? Frankly, I was wishing she was not so distracted when working on me! Again, there has to be a better way to organize work.
- Today, I waited 5 hours for my home health nurse to show up to change my dressing as scheduled. When I did not hear by afternoon, I called them and they said, no, the nurse had me on the list for tomorrow - no reason why not today as scheduled. My thought was that I would be getting much more reliable service if I was having a mattress delivered. They would be calling me about any changes and, in fact, they would rarely have any changes to their schedule.
- There is something fundamentally wrong with how we pay for healthcare. It is disconnected from the care process and is counter productive. Although a wound vac will cut in half the time it will take for me to recover, the insurance company did not want to pay for it. It took 3 or 4 people dozens of phone calls, etc. to get it turned around. Our payment methodology sucks valuable energy from the system. Energy needed for improvement.
- It's a sad commentary that if I take a can of peas off the shelf at my local supermarket and go through the register with it, that industry automatically updates inventory, vendors, my buying profile and is available within minutes of the transaction. But if my doctor changes a vital medication, it's a shot in the dark if it will be communicated to anybody who needs to know!
Gretchen Frederick, RN, Director of Patient Care & Quality, Buffalo Hospital, Buffalo, MN - a part of the Allina Health System, Minneapolis, MN
1) I do think quality has improved - I think things have become more patient centered and transparent over the last 15 years.
2) Roadblocks include some of the frustrating regulations that we continue to be accountable for, things that have not changed with the times. An example is an OR log - this was a regulation put in years ago so that we could trend data. However, with the implementation of an electronic medical record, reports can be written to trend any data, yet we still are required to have an OR log. We also, in smaller hospitals, are required to have the same regulations as larger hospitals and some of these requirements are resource intensive, like Core Measures.
3) I think one of the biggest success stories are the work around Patient Safety and Team communication. This is something that has been in place in other industries for some time and I think it has real merit in health care.
4) I believe organizations must elevate quality to the senior level. It should be on every board, medical staff and staff meeting agenda as are financials and volumes. Quality must be resourced in an organization so that the coaching and mentoring can occur at all levels.
Illinois Hospital Director of Security
Yes, I believe quality has improved in the past 15 years. I feel that unions in healthcare can be a roadblock to quality. They are concerned with money and jobs for union members.
Leaders must WANT to improve quality. There needs to be a combined effort on the part of the entire leadership team.
Robert Bonhag, DMD, MBA, Consultant, Michigan
I am embarrassed with the progress that has been made in the last 15 or even 30 years. We instituted automated medical records at Duke in 1974 and we used it to measure the quality of care provided against defined disease protocols, particularly to measure our residents' quality of care. Not surprisingly, in retrospect, the major violators of the protocols were the senior clinical staff who had developed the protocols. In practice they found justified reasons to deviate (and were able to explain their reasons). So from my perspective, the last 30 years has been a catch up with what was already possible.
The news now is about the number of deaths that are caused by the health system itself. There is nothing new here. Errors have occurred for years: errors in diagnosis, medication, treatment, hospital caused illness and lack of technology supporting medical care. Now, HIPAA is being used as the latest reason that medical care cannot be better.
We need solutions not excuses. Yes, privacy of medical information is important, but as a patient myself from time to time, I want each of my providers of care or medication to know everything about what I have going on now and in the past, including my risk factors.
We have the technology to provide an integrated care system, why are we not doing it? We had that capacity 30 years ago, why is it not in place? How many people must suffer because there is no integrated medical records sharing?
Every organization wants to develop their own approach to an automated medical record. As a result the doctor's office cannot talk with the hospital or to other doctors or to the pharmacy or even to the patient. No wonder patients cannot manage their own health because they have to fight to get the information about themselves.
Minnesota Long Term Care Administrator
I think there have been improvements with how to treat certain problems. I also think technology has made surgery less invasive. However, I think that the cost of care - the 3rd party payers are in the way, is a roadblock.
There have been successes like same day surgeries and some improvements in drugs and safety. As far as failures, I still think it is standards in the industry - they just are not there. Another failure is the overall cost of healthcare and the fact that we have less and less workers as our country ages. Organizations committed to quality standards will be farther along than others.
Board Member of a 501c-3 Community Hospital/Clinic
Quality has improved. The real question is how much has it improved and how many Americans have been able to take advantage of the improvements? In this regard we still have a largely imperfect "system" especially as it relates to the uninsured. Traditional hospitals with 24/7 emergency rooms have become the point of contact and service for many without insurance or the ability to pay. This in spite of the fact that the ER is a very expensive venue for service delivery.
Improving health care is a moving target with many of the major players striving to protect the status quo and market share.
In our facility Medicare and Medicaid provides over 50% of the care. One company dominates the insured with about 25% of the business with other insurers and self payers contributing the remainder. We are being squeezed from all sides. Federal reimbursements continue to tighten and the insurers are aggressively trying to keep their reimbursement below our requirements to meet the needs and expectations of our patients. This is especially noticed in our community owned integrated clinic and hospital. Our major insurer does not share our vision for integration and our mission of patient centered excellence. They have proposed contracts for in network reimbursement that penalizes the patient with inconvenience and penalizes our facility with lower reimbursements than we require.
Health care could improve if we could determine an effective way to diminish some of the lifestyle choices/diseases such as obesity, tobacco use, poor eating habits, sedentary lifestyles and alcohol consumption. Some experts estimate these factors account for almost half of all insurance dollars spent. Despite this knowledge reimbursement to address these conditions is lagging.
Louise Juliani, RN, MSN, Illinois
I do think quality has improved over the 35 years I have been a nurse. This is mostly due to so many scientific advances both in diagnostic technology and treatment modalities. Medications alone have improved the health of individuals. Also, it is easier to get new information via the internet and 24 hour news. Cost is out of sight and I'm not sure how that can be curbed. The current efforts on the part of insurance companies and the government have become obstacles to quality and accessability. Where hospitals (my only work environment) used to have a "family" feel, they now have a corporate air. The family has been replaced by a "power team". All hospitals are now following the corporate model of productivity. More work with fewer people. This has been stressful to all workers from administration to maintenance. This interferes with giving the best care.
Finances are the biggest obstacle to improving healthcare. Costs are spiraling out of control and it seems efforts to control it just add layers of paperwork and new regulations. They keep cutting payments so the organizations are motivated to cut costs. The cuts come mostly from personnel. In addition, the health care field has become very competitive, draining much needed resources for advertising and marketing.
Networking to get patients to the specialists they need is a major success story in health care. Now, not only do hospitals have networks, but linkage is available over the internet. Clients can be better informed and link up with the latest care available as well as receive support from other individuals. The biggest failure stems from the same sources. There are many inaccurate sources out there and many individuals are overwhelmed with all the information.
Organizations MUST work together to deal with the many problems facing healthcare in the future. In addition to finances, the aging of health care providers, doctors and nurses especially, will be a crisis in the next 25 years.
Gary Burke, Ph.D., Director of Quality, MidState Medical Center, Connecticut
I believe quality has improved at the better hospitals, because leaders are no longer concerned about how much money quality efforts are going to cost them. They realize that good quality, including clinical quality, saves them more money than it costs them. Other factors that have driven improvement in quality have been:
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Some of the initiatives of the Joint Commission, like Core Measures and Sentinel Events Alerts.
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IHI initiatives, like the 100,000 Lives Campaign.
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State and national Baldrige programs.
Some of the roadblocks are:
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Profit motive.
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The amount of wasted energy and resources that are expended in securing justifiable reimbursement for services rendered.
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Shortages in critical staffing, including physicians.
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Rising cost of technology of all types - IT, medical equipment, etc.
The Baldrige healthcare winners are huge success stories. North Mississippi Medical Center, the most recent winner, is an excellent example. They have achieved significant financial strength through attention to clinical quality. Their approach has been to take their top 20 DRGs and improve the systems around them to drive out the waste, especially the waste that causes poor clinical outcomes.
An example we have implemented here is the adoption of the bundle of best practices for the management of Ventilator Associated Pneumonias. In the first year we went from 12 to 2 VAPS. A recent Baldrige winner calculated that a VAP costs them $40K on average. While our true motive was saving lives, which we have also done, this has been a tremendous cost avoidance for us.
The best step that can be taken to improve quality in healthcare would be to take quality improvement activities from the managers and give them to the staff who know best what needs to be fixed and how to fix it.
Nurse Practitioner, Colorado
Where technology is concerned AND for those with health insurance, probably the quality of health care has improved. And, with certain interventions, like computerized prescriptions, probably fewer mistakes are made. For the many, many uninsured or chronically ill, I don't think anything has changed. Poor and/or uninsured people still use the ER for their primary care... what a misspent pool of money.
Roadblocks, we continue to believe that physicians have to be THE dispensers of health care, when in fact nurse practitioner studies have shown over and over that no quality has been sacrificed by a more "appropriately educated" professional to fill that role. We don't need architects to build tree houses. We need to reserve docs for high tech and very complex care and interventions. Also, people need to take more responsibility for their health instead of expecting it to be dispensed to them. Advertising obviously plays some role in inducing people to buy and consume some pretty unhealthful things.
Success stories usually have to do with restoring people to a more functional life with things like cardiac stents, new joints of all types, etc. I don't know the figures, but chemo therapy, especially in children and those with breast cancer, shows promise for some. On the other hand, CPR success has not improved over 30 years and many times we are doing this to people who are not the right candidates. What a travesty.
Organizations need to stop the top dogs in health insurance from making buckets of money at others' expense and get reasonable. Spend that money on quality initiatives like more accessible primary health care. And, of course single payer - keep using the money for positive gains.
West Coast Managed Care Executive
