Posts Tagged ‘Quality’

The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

If the anesthesiologist walked up to the bedside of an elderly, frail patient who is scheduled for a risky operation, and explained bluntly that the patient might die a prolonged and dismal death in the ICU, there would be hell to pay if the patient or the family decided to back out. The preoperative holding area, five minutes before surgery, isn’t the time or place to have that conversation. Yet that’s often when we meet our patients for the first time.

The “risk of death” is always mentioned in the informed consent documentation, but may be framed by physicians and nurses alike as a theoretical concern rather than a real possibility. The surgeon, the anesthesiologist, and the hospital are incentivized to do cases, not to step on the brakes and stop an operation. This is true even when the operation may fix a specific surgical problem but could lead to worse health, more pain, or loss of independence during the last months of life.

“Our goal is not survival at all costs”

One lesson that Dr. Gawande said he has learned from talking to patients is that people have priorities in life other than just survival. The goals will differ from person to person. If we don’t ask patients these difficult questions, Dr. Gawande said, “the care we provide may be out of alignment with their priorities.” That kind of care may cause more suffering than it alleviates.

One patient told Dr. Gawande that he would be okay with his quality of life so long as he could “eat chocolate ice cream and watch football.”  That’s better than any living will in terms of clarity, Dr. Gawande said.

He advised asking a patient, “What’s your understanding of where you are in your illness? What abilities are so critical to your life that you can’t imagine living without them?” Understanding the patient’s goals and fears can help the patient, the family, and the medical team reach the best decision about a plan of care, Dr. Gawande said.

“Our goal is not survival at all costs,” Dr. Gawande asserted. “Nor is our goal a good death. The goal is for our care to match their goals. To deliver the right care, at the right time, every time.”

For this fundamental change in the culture of healthcare to occur, payment models must change too, Dr. Gawande said. “A switch from fee-for-service to fee-for-value is absolutely critical for us to work successfully as teams. We have to be part of driving the reinvention of how we’re paid.” The team’s success should be linked to an outcome that is optimal in the view of the patient and the family, even if the decision is not to do surgery.

Dr. Gawande praised the many contributions of anesthesiology to improving processes of care and promoting patient safety. But he urged the ASA to “move from safety to outcomes as your priority.”

To achieve the best outcome consistent with each patient’s goals, Dr. Gawande said, “we need to work as teams before and after they come to the hospital. We need to be willing to take part in the experiments and drive the experiments so that we are paid as teams for better outcomes.”

Nothing brings out the mama lioness in me more than seeing one of my cubs not being treated as well as I think it should be.

Recently I had the unusual experience of accompanying my oldest daughter into an unfamiliar hospital for a minor surgical procedure. Now this daughter isn’t exactly a cub — she’s a full-fledged adult, with a master’s degree in health care administration, a husband, and two small boys of her own.

But as I watched the OR team prepare her for surgery, I started to feel like an odd combination of a mama lioness and a secret shopper. To the staff members who came in and out of the hospital’s preoperative area, it was clear that I was simply the family member in the corner, and they probably figured I had little clue about what was transpiring. Meanwhile, I was taking in every detail. Some tasks were performed excellently — others, not so much.

The hospital where her surgery took place is a small community hospital on Long Island. It enjoys a location where Jerry Seinfeld, Christie Brinkley, and other wealthy New Yorkers maintain lavish homes for weekend and summer holidays.

My daughter was instructed to arrive at 6:30 a.m. Her procedure involved an initial stop in radiology, to be followed by the actual surgery. As a veteran of hospital life, I questioned whether radiology even opened that early, but we had no way of checking. So we left her house at 5:25, driving carefully on dark, icy roads with fresh snow, and lining up for a 5:40 a.m. ferry ride from her home town so that we could arrive at the hospital by 6:30.

The good news — a valet met us at the hospital door and whisked away the car, so we had only a moment to savor the 20-degree weather and the harsh wind that made it feel colder. My daughter was promptly escorted to a private room to change clothes.

Hurry up and wait

A nurse gave her an insulated paper gown with two openings to connect it to a wall-mounted forced air warming unit. This, I thought, was a wonderful thing. Where I’ve worked, we had forced air warming blankets in the ORs but the hospital wouldn’t spend the money to put them in the preoperative areas. I thought of Tina Fey, playing an immigrant from Albania in a Saturday Night Live spoof of the HBO series “Girls”, and imagined her saying, “In my country, we do not have such things.” Within minutes, my daughter’s gown was hooked up to the warmer and she was feeling much cozier.

Then we waited.

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No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though no data prove that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

The Joint Commission, of course, loves nothing more than to make up new rules, based sometimes on real data and other times on data about as substantial as fairy dust.

A year or two ago, another new rule surfaced, mandating that physicians’ personal items such as briefcases must be placed in containers or plastic trash bags if they are brought into the operating room.  Apparently someone thinks trash bags are cleaner.

Now one anesthesiology department chairman has taken this concept a step further, decreeing that no personal items at all are to be brought into the operating room–except for cell phones and iPods.  That’s right, iPods, not iPads.  This policy (of course) probably won’t be applied uniformly to high-ranking surgeons or to people like the pacemaker technicians who routinely bring entire suitcases of equipment into the OR with them.

What’s particularly irrational about this rule is that cell phones likely are more contaminated with bacteria than briefcases or purses, even if they’re wiped off frequently.  And I have to ask how an iPhone 6+ meets eligibility criteria while the barely-larger iPad mini doesn’t.  Again, please show me the data demonstrating that this will reduce infection rates, unless someone is making it a habit to toss briefcases and iPads onto the sterile surgical field.

Show me the money

I wish I could say that the driving force behind hospitals’ fear of infection is simply the wish for patients to get well. Unfortunately, it’s probably driven as much by financial motives as benevolent ones.  Today, Medicare won’t pay for care related to surgical site infections, and it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge.  In 2014, a record 2610 hospitals–including 223 in California–were penalized, and will receive lower Medicare payments for all patients over the next year, not just those who were readmitted.

What does this mean at the grassroots level?

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The Dark Side of Quality

Nobody stands up to argue against quality and value in healthcare. You might as well argue against motherhood, or puppies. Yet many physicians are inherently skeptical of definitions of “quality” that are imposed from above, whether by outside evaluators like The Joint Commission, or (worse) by the government.

There’s good reason for skepticism. Some of the “evidence” behind “evidence-based medicine” has turned out to be flawed, tainted by financial conflict of interest, or outright fraudulent. Any experienced physician knows that there are fads in healthcare just as there are in fashion, and today’s evidence-based medicine may be tomorrow’s malpractice. Let’s take a closer look at what’s really going on in the world of quality metrics, and why it matters if payments to you and your hospital are increasingly linked to how you score.

Surgical Site Infections

The financial toll of surgical site infections (SSIs) is huge, estimated in the U.S. at more than $10 billion a year.(1)  A recent retrospective review from the Veterans Affairs Surgical Quality Improvement Program showed that the majority of SSIs are diagnosed only after hospital discharge, and that 57% will require hospital readmission within 30 days.(2)  The Centers for Medicare and Medicaid Services (CMS) stopped paying for care related to SSIs in 2008 by designating them as “never events”, or non-reimbursable serious hospital-acquired conditions. Now SSIs are part of a long list of hospital-acquired conditions that can result in reduced CMS payments to hospitals, and will bring further reduction in payments over the next several years with the implementation of “value-based purchasing”. More than 1400 hospitals will see their Medicare payments cut by as much as 1.25% this year–a margin that could spell financial disaster for hospitals already struggling.(3)

You may already be among the more than 50% of anesthesiologists who have been reporting performance metrics to the Physician Quality Reporting System (PQRS), which is administered by CMS. When the system started in 2007, CMS offered a bonus payment of 1.5% for successful participation, but that soon shrank to 0.5% and will be discontinued after 2014. Starting in 2015, CMS will impose a 1.5% payment reduction for physicians who do not participate in PQRS, and will push the pay cut to 2% in 2016.

If you participate in PQRS reporting, you know that two of the measures that anesthesiologists report are directly aimed at SSI prevention: perioperative temperature management, and antibiotic timing. PQRS measure #193 specifies that the patient must receive “active warming” or have a temperature above 36C recorded within 30 minutes before or 15 minutes after anesthesia end time. Measure #30 specifies that prophylactic parenteral antibiotics must be administered within one hour before skin incision. Compliance with these two measures isn’t hard to achieve, though no one seems to question the cost to the American healthcare system of all those forced-air warming blankets and machines, or ask why giving antibiotics 61 minutes instead of 59 minutes before skin incision is an automatic “fail”.

But have CMS threats and PQRS compliance done any good? A just-published editorial in Anesthesiology concluded: “Despite early efficacy literature establishing the value of specific antibiotic timing and active warming, repeated large database analyses have not observed robust effectiveness across hundreds of hospitals.”(4)   Simply put, as many of us have noticed in our own hospitals, SSI rates have remained about the same.

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