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DECEMBER 2009

 
 Quote of the Month
 
 
It is not enough to do your best; you must know what to do, and then do your best. 
 

W. Edwards Deming 
 

It's 10 years after the IOM report "To Err is Human" was released.  Do you know where your hospital stands today?
 
Ten years ago many were.shocked by the Institute of Medicine's report telling us that we were killing 100,000 people a year - a 747 jet's worth a day, by subjecting patients to preventable errors.
 
Many hospitals today face a combination of high census, employee layoffs, reduced revenue and ongoing budget cutbacks.  Not generally a formula for success.
 
Perhaps surprisingly, it is possible to keep an eye on the budget while actually improving quality.  Start with an assessment of how your hospital has improved over the past 10 years. 
 
Take an honest look at where you are today verses outside standards and benchmarks.  Then focus all of your hospital's brains and talent on quality and productivity improvement.  You'll be amazed by the results!



Discharged from the hospital without answers; the death of Jane Q. Patient

by Dan Walter
 
We found out that her real name was Cindy Chapman, and that she died alone and afraid.
 
Cindy was a paralegal, an activist and a fighter of lost causes who lived in Worcester, Massachusetts. She was part of an online community called RATEMDs, where she had many soul mates. Her posts on health care were funny and cynical and wise. Her screen name was Jane Q. Patient.
 
My wife, Pam, was especially fond of trading comments and barbs with her. Like others on the forum, Jane Q. was prone to drop off the screen for days or weeks at at time. But she always resurfaced with stories of her battles with the system, her fights for the poor as a paralegal, or her volunteer efforts with the Obama campaign. A few months ago, as the fight for health care reform was reaching a fever pitch, Jane started posting about her own medical complaints. She told of emergency room visits and fights over insurance, and pain, pain, pain. Her postings became erratic, with uncharacteristic typos, misspellings, and fragmented thoughts.
 
When Jane Q. dropped off the screen again, Pam set out to find her. Having traded some private emails, Pam knew Jane's real name and had a general idea of where she lived.
 
After relentless Google searching, Pam hit upon a column by Diane Williamson in the Worcester Telegram. It was the story of Cindy Chapman's final days. The 48 year old native New Yorker lived with her cat in a room off Worcester Common. She had been suffering terrible back pains over the summer and had been taken by ambulance to the University of Massachusetts Memorial Medical Center Emergency Room on four occasions.
 
Each time she was discharged with some pain killers, but no answers.

 
The last time she went there she refused to be discharged and the hospital called the police to eject her from the ER on the grounds that she was exhibiting drug seeking behavior. She was put in a cab and sent home. She called one of the few people she knew in the neighborhood. She said that she was in terrible pain and that she was scared and she didn't know what to do.
 
Her neighbor called six primary care physicians before finding one who would accept Medicare and could see her without waiting a year. This doctor found that Cindy Chapman had end stage cancer of the lungs, liver and spine. Two weeks later she was dead.
 
As the Senate prepares to take up the health care bill, The New York Times quotes one analyst as saying that "All industries stand to gain from this legislation." But the real question we need to be asking ourselves is whether the Cindy Chapmans of the world stand to gain anything from our new approach.
 
We'd better hope so. After all, there was a reason she called herself Jane Q. Patient.
 
Dan Walter is a writer based in Deale, MD.
 


 

 
More
Quotes
 
"He is not only dull himself, he is the cause of dullness in others." -
Samuel Johnson
 


 "Judge a man by his questions rather than his answers."
 
 Voltaire
 
 
  
    Quality as the #1Focus 
Hospital Focus 5 is built upon a foundation of the five factors necessary for a well run, successful, safe healthcare organization.  Number one on that list is quality.  Clinical quality and customer service quality must be the cornerstones of everything everyone does every day on every shift.
 
Quality, who in your organization could possibility be against it?  Openly against quality?  Probably not, but that doesn't mean that resistance isn't all around you, just under the surface and something you can't afford if you want to be part of a great, world-class organization..
 
First, the bad news: humans will resist things they are in favor of and things they agree with.  People resist change because it is an interruption in their expectations.  And, unlike things that at are "safe" to disagree with, they will resist quality improvement in more quite, less open ways.
 
The good news is, with that resistance in mind, you can do some things to anticipate and plan for upcoming changes.  Ask organizational leaders and planners as many questions as possible beginning with their past experience. 
 
Did previous change efforts:

Succeed or fail? (by who's estimate - board, community, physicians, etc.)
Cost more or less than anticipated?
Get implemented on time?
Generate any surprises?
 
Looking ahead:

Where do you expect trouble?
Have you had active, two-way conversations and input from affected parties?
Are you flexible and ready to respond (not over-respond) to the first signs of trouble?
 
New efforts to reduce errors and improve quality will generate fear, starting with "what will this mean to me, my job and my department?"  Don't be caught off-guard, keep in contact with front line managers, employees and medical staff by being there on the front line with them to experience the changes necessary to improve quality.
 
Improving quality won't happen without hard work and it won't be sustained without hard work along with a systematic, organization wide approach.
 
Remember, everyone in health CARE has a duty to "First, do no harm."
 
HAVE A HAPPY HOLIDAY SEASON
 
Let me know your thoughts.  Email me and also follow me on Twitter!   http://twitter.com/HospitalFocus5
 
Ken


 
KGB 2009

Dirty hospital sparks reform call 
BBC News
 
The way hospitals are regulated should be urgently reformed after a report found a catalogue of failings at two hospitals in Essex, a charity has said.
The Patients Association said people had been "appallingly" let down.
 
The independent regulator highlighted an unusually high death rate and poor hygiene, including blood-spattered kit.
 
Basildon and Thurrock NHS trust said concerns were not indicative of wider problems, but a taskforce has been sent in to force through improvements.
 
The Patients Association said the failings were not isolated cases and patients had suffered a lack of monitoring, lack of help with feeding and a lack of dignity.
 
'Not complacent'

Director Katherine Murphy said: "How many times do the public need to keep hearing about this before the government is embarrassed enough to do something about it?
 
"The evidence was there but not acted on. That is completely unacceptable. The system of regulation and supervision needs to be urgently reformed."
The trust, which has two hospitals serving about 300,000 people, said it was "not complacent". 
 
" Our work has uncovered serious failings "
Cynthia Bower Care Quality Commission
Most inpatient care is provided at Basildon University Hospital, which has 777 beds, and outpatient care at Orsett hospital in Grays.
 
Trust chairman Michael Large said: "It is an extremely serious matter and we do not seek to underestimate its gravity.
 
"I want to reassure our local community that the safety and well-being of our patients is our highest priority."
 
The Care Quality Commission (CQC) rated the trust as "good" overall in October.  But a new report from an unannounced inspection team carried out by the CQC found evidence of sub-standard care.
 
The inspectors saw:
  -Floors and curtains stained with blood
· -Blood-splattered on trays used to carry equipment
· -Badly soiled mattresses in the A&E department     with stains soaked through to the foam filling
· -Items that should only be used once still in use
· -Equipment in the resuscitation room that was past the use-by date
· -A children's blood pressure cuff heavily stained with blood
· -Suction machines contaminated with fluid inside and out with what looked like mould growing on the equipment
 
The inspectors criticised a poor care environment in A&E, in particular a lack of privacy for patients.
They also highlighted inadequate arrangements to treat children, with few specialist pediatric staff.
The CQC has asked the regulator of foundation trusts, Monitor, to take action.
 
An expert taskforce will be sent into the trust with a remit to drive rapid improvements in patient care.
Monitor chairman Dr William Moyes said: "We will be reviewing the trust's performance regularly and in detail - if we don't see measurable results quickly, we'll take further action."
 
Death rates
The independent hospital analysis website Dr Foster has found the Essex trust to have a hospital standardised mortality ratio of 136. 
 
This means the rate of death among patients at the trust is a third higher than would be expected by looking at national figures, after adjusting for patients' age and the severity of their illness.
 
This is likely to prompt comparisons with Stafford Hospital where similar concerns were raised about a higher than expected mortality rate.
 
After internal investigations at Stafford failed to find a problem, an independent inspection found serious failings in emergency care. 
 
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Hospital  FOCUS 5

is:
 
A consulting firm that...
 
Believes hands on, down in the trenches, operational experience combined with consulting expertise is vital in obtaining real, lasting results for clients.
 
Has experience in acute care hospitals, health systems, medical schools, CCRCs and other healthcare organizations.