The Future of Nursing

Medicine is excessively hierarchical. That is pretty obvious. While there may have been some benefit to this in the past, (though I am at a loss to think what that might be), clearly healthcare must be seen as a team effort. The role and contribution of nurses in delivering more and more effective healthcare has not been utilized to anything like its full potential. From the Future of Nursing, comes the following recommendations;

1. Nurses should practice to the full extent of their education and training. 
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 
3. Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. 
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.

Reform of Public Service

This is the subject of a special survey in this weeks Economist. While looking at public services generally, criticizing (rightly in my opinion) the growth and low productivity of services worldwide, it has a specific mention of health. Well worth reading.

Amongst the figures given; "McKinsey points out that American spending on this has grown at an annual lick of 4.9% over the past 40 years, whereas GDP per person has grown by just 2.1%. Pessimists are convinced nothing can be done to restrain it. A refreshingly different perspective is provided by Sir John Oldham, a British doctor who is clinical lead for productivity in the National Health Service."
"America, which currently spends 16% of its GDP on health care is theoretically on track to spend 100% of its GDP on health care by 2065."

Spring

A view from St Johns bridge, Kilkenny, Ireland looking north at the River Nore on a glorious Spring day. Check out www.kilkennytourism.ie

What is medical harm?

My favorite definition, from a good friend, (Thanks Peter) is that harm is anything that you would not want happen to you or your family.

Some Thought on Value in Healthcare

Value is a dirty word in healthcare, conjuring up visions of ruthless bean counters, scrabbling for pennies while patients suffer. How different though is the reality? Regardless of location, healthcare costs are rapidly climbing, disease burdens, therapies, diagnostics and expectations are rising faster. Like it or not, hard choices must be made, if not by clinicians, then by the payer, ultimately the taxpayer. How does one align this imperative with the need to ensure quality of care is optimized?
A recent paper by former colleagues of mine brought home the reality of this dilemma. Cruz et al sought to improve compliance with goal directed therapy for children with sepsis. They demonstrated a marked reduction in time to first fluid and antibiotic administration, consistent with guideline recommendations. However, part of the solution was to deploy extra nursing, pharmacy, medical and EMT staff. While this may well have been a beneficial use of this scarce resource, it is unclear if the value increased.
Value can be defined as health outcomes (quality) divided by the cost of achieving those outcomes. So while quality almost certainly increased, it is likely that the cost of achieving this level of quality also increased. The question that must be asked, could better or more health outcomes be achieved for the same expenditure. Unfortunately our measurement systems are as yet unable to answer this question. For a more detailed discussion around this topic, please see Michael Porters website.

Boeing to the Rescue?

A recent piece in JAMA by Pronovost is well worth reading. In it he contrasts the way we design (or rather fail to design) healthcare, especially in relation to equipment, (haphazard, no systems thinking, individuals insisting on their preferred piece of technology etc) versus the way airlines buy planes. They do not buy planes, each of which has different toilets seats, lifebelts etc. They buy a standard plane, for economic as well as safety (reduce variation ) reasons. He suggests in an American context that what is needed is a systems integrator, similar to Boeing. It is interesting that national healthcare systems, despite being in a better position to act in this way, singularly fail to do so.
I have worked in intensive care units where the number of different types of ventilator exceeded the daily census of ventilated children; where the choice of a specific ventilator that a child was placed on depended on which physician was on call. This type of variability is hugely damaging, expensive, a safety risk and results in poor training. Compounding this is a perceived need for hospitals to get the latest new thing, often resulting in a situation where there are insufficient patient numbers to allow all team members to develop the required expertise and experience which are necessary to deliver the best outcomes.
While I agree with his arguments, I think he fails to develop the logical conclusion, in that the entire system, inside and outside hospitals needs to be standardized as much as possible.

Winter

Snow on the Charles River, Cambridge, Massachusetts.

Psst, want to buy a cheap electronic medical record?

Beginning in the 70's, the Veterans Administration developed an in-house electronic medical record, (EMR), now termed VISTA, which has a number of attractive features as outlined. Notably it is free, which given the financial challenges facing this country is not to be sneezed at.

Features

VISTA includes computerized order entering, barcode administration, electronic prescribing and clinical guidelines. UPTODATE can be accessed from within the system. It also allows (at least for the Veteran population) patients to access their own medical records, similar to the KP system. Vista Imaging allows integration of PACS, pathology, EKG etc. the VISTA system has been used in conjunction with telemedicine to provide surgical care to rural Western States.

Achievements

VA claims a pharmacy prescription accuracy rate of 99.997%, and the VA outperforms the vast majority of public hospitals, supposedly based on its EMR implementation. There are only three hospital systems in the US, which have achieved HIMSS stage 7, (the highest level of IT implementation), one of which is the VA. A non-VA hospital using VISTA is one of only 42 US hospitals to achieve HIMS level 6.

Implementation

Approximately 50% of US hospitals with a full EMR implementation are VA hospitals using Vista. It has also been implemented worldwide, including Finland, Germany, and Denmark as well as developing nations.

Cost

As it is open source, the license is free. Obviously there are large costs relating to localization, hardware, training, and implementation. I have found one reference to implementation of VISTA over 8 hospitals in one state costing $9 million, as compared to a commercial installation over the same number of hospitals costing $90 million.

See here and here for more information.

Sunset, Discovery Park, Seattle

Sunset looking west over the Olympic Peninsula from Discovery Park, Seattle.

Suicide

A very moving post by Anna Roth on her blog about the suicide of her brother in law. She has previously written about suicide, but not this powerfully. The statistics are terrifying, one of the most common causes of death in the 25-44 year old age group, worldwide! Incidence has increased worldwide by 60% over the last few decades. Most common methods are hanging, ingestion, (usually herbicides) and gun shots.
It is estimated that there are 30,000 suicides annually in the US. The most recent data I have seen for Ireland suggest that there are almost 600 reported deaths by suicide annually, a rate substantially higher than the US. The WHO report that the rate in Ireland (11.6 deaths/ 100,000 inhabitants) was 10-15% greater than the average rate in the EU-27.
Can anything be done, an especially pertinent question given our economic collapse and the likely toll that this will cause? While the HSE has a suicide office and a prevention strategy, I have no expertise with which to judge its efficacy. However there are healthcare delivery systems that have shown what can be achieved. The Henry Ford system in Detroit shows what can be achieved. In the first 4 years of the groups suicide prevention program, the rate decreased from 89 to 22 deaths/ 100,000 population. In the most recent analysis the rate over the previous two years had dropped further to zero deaths!
For details, click here. This in a city that has been battered economically over the last decade.
There is another very emotional piece in this weeks JAMA, again an account of suicide from the perspective of a family member. In a future piece, I hope to write about the risks of suicide amongst physicians and ways to reduce this risk.

Optimizing Patient Flow to enhance productivity and safety, Part 2

Coincidentally, following on from my recent post about patient flow, (March 16th) comes  a paper which again demonstrates the critical need to optimize patient flow, not just to improve productivity, but more importantly, to reduce mortality.
Just published this week is a very important paper in the NEJM, here. The authors looked at the effect of nurse staffing numbers on in-hospital mortality in a large academic hospital. It shows that peaks in patient flow (turnovers) are an even greater cause of mortality than patient per nurse staffing ratio. The authors state,
"We also found that the risk of death among patients increased with increasing exposure to shifts with high turnover of patients. Staffing projection models rarely account for the effect on workload of admissions, discharges, and transfers. Our results suggest that both target and actual staffing should be adjusted to account for the effect of turnover. In light of the potential importance of turnover on patient outcomes, research is needed to improve the management of turnover and institute workflows that mitigate the effect of this fluctuation."
The basis of this is simple. Elective admissions are hugely variable, and dependent almost entirely on doctor choice. Because these admissions occur without any reference to the other needs of the hospital, they cause huge peaks and troughs in patient numbers, e.g. not many elective patient will be admitted Friday.
One of the worlds leading experts in patient safety, Peter Pronovost, has also made clear his view that optimizing patient flow is essential for reducing in hospital mortality, see this recent paper.
There are huge opportunities to be had.

St Patricks Day Parade in Dublin

A great parade, weather perfect, crowd friendly, Dublin at its best. The building in the background is the Rotunda Maternity Hospital, the setting for the birth of the eponymous baby in the book by Roddy Doyle, "The Snapper"

Think outside the box

An interesting blog post from Moss Kanter about innovation. Basically very few organization can shift their way of thinking from business as usual. This is a cause of great frustration for the visionaries and innovators within that organization. Great relevance to healthcare.

Culture eats strategy for lunch

The title of this post refers to an oft quoted piece in business and change literature; to paraphrase, you can have a great plan but if it doesn't take into account the culture of the organization, you will fail. This I think is the crux around which healthcare reform and quality improvement specifically will succeed or fail. This is the great intangible that must be isolated and measured, so that we can truly begin to determine how healthcare providers differ from one another in terms of the quality of the service they deliver. As doctors we believe that the keys to a great service are world class doctors, state of the art facilities, the latest in IT; basically the best that money can buy.

However a study just published in the Annals of Internal Medicine, link here, (subscription required), suggests that this credo is incorrect. Curry et al interviewed 158 staff members from 11 hospitals, which were either in the top or bottom 5% nationally in the US for mortality post heart attack. The factor most highly correlated with outcomes was a cohesive organizational vision that focused on communication and support of all efforts to improve care. In other words, it was the culture, the communication ethos, mutual respect, leadership and desire to improve that should determine where you want to be treated, not all the high tech stuff and big names. This is consistent with my own observations nationally and internationally. All hospitals have problems, the high performers are the ones that seek out the problems and respectfully engage all their staff and leadership to solve them. It is my strongly held belief that one can distinguish between the high and low performers within an hour of visiting them.

Previous studies have suggested that the traditional factors that underpin success include being an academic medical centre, having more beds, and being located in a large city. Curry found that these factors accounted for only 20% of the difference. This is a very significant study, and provides ammunition for those of us who believe the system can be dramatically improved without massive expenditure; the down side is that changing culture can be extremely difficult.

Optimizing Patient Flow to enhance productivity and safety

 What if the healthcare system could introduce a method of improving productivity by 15-20% within months, at no extra cost, but by doing so improve safety dramatically, reduce stress, burnout, absenteeism, patient experience, and all the other good things? There is such a system, with very good evidence behind it. See link here.

1.    Safety:

a.    Arguments around safety in healthcare worldwide usually centre around the need for extra resources, rather than in the first instance optimizing the system in place. By reducing variability in the system, cases can be more closely matched to the available infrastructure and staffing resources, thereby reducing the dramatic peaks and troughs that are seen in every hospital, especially with respect to elective activity. These artificial peaks (due almost entirely to elective activity) may then give rise to the impression that the facility is under-resourced and under-staffed; by reducing this artificial variability the current infrastructure and staffing levels can be utilized to deliver a service that is safer (right patient in the right bed at the right time), and avoid a mismatch between staffing (esp. medical and nursing) and patient numbers.

2.    Efficiency/ productivity:

a.    By utilizing resources as outlined in the previous section, expensive plant such as diagnostics, operating rooms, and intensive care beds can be utilized more effectively and productively. The traditional upper estimate of hospital occupancy has been estimated at 80%; the only rationale for this figure is to provide a surge capacity, a buffer for times of increased demand on the system because no control was placed on how the elective component of demand was managed. By properly managing this demand, it is likely that overall occupancy can reach 90-95% on average safely. One hospital has reported a continuous occupancy rate of 91% since implementing this system. Rather than reducing the number of cases performed, this efficient allocation of a scarce resource allows each individual surgeon to perform more procedures.

3.    Financial benefits:

a.    Obviously, under the current Irish hospital reimbursement scheme, financial benefits are harder to estimate and realize. However, it is clear from point 2 that the return on investment is greater by optimizing hospital flow. Whether this equates to greater revenue as in the US system, or more patients treated for a given budget as in the Irish setting, the end result is greater productivity.

4.    Patient satisfaction:

a.    Hospitals that have (in the US) implemented this system have eliminated wait lists, ER waits, cancellation of elective procedures etc.

Evidence base.

1.    The American Hospital Association has identified six priority areas in its efforts to accelerate hospital performance improvement; these include health care acquired infections, health information technology, medication management, patient safety, and of relevance to this document, optimizing patient flow and throughput. The AHA state that “patient safety is negatively impacted when patients do not move through hospitals in a timely and efficient way. The AHA endorses the methodology of the Institute for Healthcare Optimization as a means of improving patient flow.

2.    The Leapfrog Group for Patient Safety is an umbrella group representing some of the largest employers in the US, (IBM, Intel, Toyota, Boeing, Motorola, FedEx). Collectively they represent employers and agencies that purchase care for more than 35 million people in the US. Leapfrog ranks hospitals in the US publicly on a number of patient safety measures. A study by the Commonwealth Fund (June 2008) reported that hospitals publicly reporting their Leapfrog Quality data had a lower mortality rate for Acute Myocardial Infarction and Pneumonia. Participating hospitals are asked if they adhere to the following quality and safety practices:

                                               i.     Computerized Physician Order Entry

                                             ii.     ICU Staffing with intensivists

                                            iii.     Compliance with performance standards for certain high risk treatments

                                            iv.     Leapfrog Safe Practices Score

3.    From 2011, the Leapfrog Group will measure a hospitals policy around flow optimization and safer scheduling, (personal communication). The group states that patient safety can be negatively impacted by a hospitals scheduling policy. The Leapfrog group supports the methodology of the Institute for Healthcare Optimization as a means of improving patient flow and reducing patient risk.

4.    In 2006 the Institute of Medicine (IOM) released “The Future of Emergency Care in the United States Health System”, a series of reports assessing the severe problems facing the nation’s emergency care system and offering recommendations to improve it. The report states "hospitals should reduce crowding by improving hospital efficiency and patient flow and using operations management methods and information technologies."

5.    The Joint Commission, the body responsible for accreditation of US hospitals, endorses a strategy of providing scientifically grounded methods to optimally manage patient flow and reduce variability as part of a policy to improve patient safety. It endorses the methodology of the Institute for Healthcare Optimization.

6.    Don Berwick, the head the Center for Medicare and Medicaid Services (CMS), one of the most powerful positions in American Medicine, has stated that there are two sleeping giants in trying to achieve quality healthcare, patient safety and patient flow.

7.    A number of the largest and most renowned US academic health centers have recently begun work on redesigning their patient flow and throughput, (personal communication). One 212 bed hospital has seen a revenue boost of $50 million annually within one year of implementing this system. Cincinnati Children’s has seen its productivity increase by the equivalent of a 100 million dollar capital rebuild, (100 beds) and its annual revenue increase by $137 million.

8.    A number of Childrens Hospitals including Cincinnati, Lucille Packard, and Great Ormond Street have adopted this approach.

9.    There is emerging evidence in the medical literature that failure to incorporate these principles is associated with serious adverse outcomes. In one study by Pronovost (2009), the odds of being readmitted to an ICU were five times greater when the number of patients admitted to the ICU were above a certain volume. 

Reporting Poor Performance by Doctors

A very concerning piece, but not that surprising to those in practice. A study of >1000 UK doctors found that almost 30% would not report concerns about a colleagues poor performance. The main reason for this was concerns about retribution. It brings to mind a conference I attended 2 years ago in which a keynote speech was by three well known, (non-nmedical) whistleblowers. They made the point that whistleblowers are often motivated by anger or revenge, and that if they were faced with the situation again, they would not reveal their misgivings. This was very sobering; one assumes that whistleblowers (an awful term) are motivated by altruism.

Progress of the Safety Movement

Some (relatively) disappointing news recently. An analysis of the Safer Patients Initiative was published in the BMJ (here and here). This was a large scale intervention comprising a large number of components of care. Unfortunately, there was no evidence of any difference in outcomes between control and intervention hospitals. What could the possible reasons be? There are a number of hypotheses,

1. hospitals will get safer regardless of interventions, and do not need this type of large scale change, (unlikely)
2. These interventions were too complex, encompassing 43 different interventions, (probable)
3. Management and clinician buy in, expertise, knowledge and support were insufficient to show a difference, (highly likely)
4. The interventions sought has insufficient evidence to underpin their use, (highly likely in some cases)
5. Many hospitals, (both intervention and control) already had high levels of quality in some domains, hence the big effects were less likely to be seen, (likely)

So what lessons can be drawn? I think there are a number.

1. Large scale change is difficult, messy, a long term commitment and often fails
2. Leadership, at management and clinical level is critical
3. Improvement and quality must be seen to be the only way to do business, not an optional extra
4. There must be a better system of measurement; even today measuring mortality is contentious. The ideal measurement system should be one that measures patient outcomes from the perspective of the patient, and reimburses the system, not a provider for optimal outcomes. See Micheal Porters work from Harvard for more on this

Torture and Solitary Confinement

Not strictly medical improvement and certainly not seasonal, but a very powerful piece from Gawande just published in the New Yorker. Well worth a read.

Safety and over the counter medications for children

A paper just published in JAMA provides some fascinating information about a lack of consistency in dosing instructions and measuring devices in over the counter (OTC) medications for children. the results are to say the least disturbing.


Results Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation.


Given that a major contributor to adverse medication events in children relate to dosing/ weight errors, obviously these discrepancies pose a potential risk. Of more importance, though it is not the subject of the paper is the efficacy and side effect profile of many of these therapies.

High Reliability Organizations

There has been a great deal of discussion recently about healthcare adopting the same approaches that have facilitated high reliability organisations to achieve exceptional levels of safety despite operating in high risk high consequence environments. Examples include aircraft carriers, nuclear submarines, the nuclear power industry and aviation.
What are the features of a high reliability organisation? Are these concepts translatable to healthcare? Are there any examples of HROs in healthcare?

There are according to one expert in the field five characteristics of HROs.

•Preoccupation with failure rather than success; this is self explanatory. The HRO almost celebrates failure and actively seeks it out recognising that only by recognising the defects within it's systems can it seek to rectify those defects.
•Reluctance to simplify interpretations; always seeking the explanation especially the explanation that defines the cause of a possible future mistake.
•Sensitivity to operations; To be sensitive to operations, we must monitor a messy reality and respond to the unexpected.
•Commitment to resilience; HROs recognize that not every risk can be mitigated, but anticipate failure and ensure that redundancy is built into the system.
•Deference to expertise; instead of hierarchy structures determining responses, the decision making in a HRO migrates to the persons with most expertise in that area.

The key difference between HROs and other organisations is that they respond differently to what others would consider signals of no significance. Mindfulness is what some have described this aspect, the capability to respond strongly to weak signals and respond strongly to mitigate the potential adverse consequences of such a failure. An example in healthcare might be the test result that is delayed, a routine test of no significance but this is a warning that the system is prone to error, that a time critical result may also be delayed. The HRO responds immediately to address this failure, the Low Reliability Organisation (LRO), effectively all of healthcare, is unlikely to take any action. HROs are constantly looking for evidence of failure or potential failure. Clearly these concepts can be applied to healthcare, though the details are likely to differ. However, it is likely that the only organisation which will successfully make this transition will be those in which the culture is receptive, indeed greedy, to make this change, and in which the leadership see becoming a HRO as the number one priority of the organization. This is such a fundamental shift that it likely that very few organizations will be successful in their attempts to become HROs.

I asked two physicians recently, world experts in safety and who lead the safety/ quality efforts in their hospital, which is probably the most advanced hospital in the world in this field, where their institution was on a 1-10 scale in safety. About a 3-4 on a good day they replied. That is the characteristic of a hospital that is striving to be the best and safest in the world, but recognises that despite being the best, it has a long journey ahead.

This book is probably one of the seminal works describing HROs, and I recommend it highly. Weick & Sutcliffe