Johns Hopkins Medicine coordinates high-quality care across ambulatory care centers, using a model it says has resulted in improved metrics associated with breast cancer screenings, immunizations, and diabetes management.
Johns Hopkins Medicine's commitment to quality care is evidenced by a governance, oversight, and accountability model that is cascading throughout its ambulatory medicine sites.
"Hopkins has always had an emphasis on quality and safety that was really borne from our inpatient experiences," says Steven Kravet, MD, president of Baltimore, MD-based Johns Hopkins Community Physicians.
Yet how to ensure that the quality of care remains high, even as the organization grows, and in particular, grows on the ambulatory side? Like many health systems and hospital operators, JHM is seeing more growth in its ambulatory services than its inpatient services. And outpatient services are being distributed not only throughout the community, but beyond it.
In the wake of rapid outpatient growth, JHM recognized the need for better ambulatory quality and safety processes to maintain the high-level of care that's become the inpatient standard. So it developed a model to coordinate high-quality care across its ambulatory care centers, which resulted in improvements in metrics pertaining to breast cancer screenings, childhood immunizations, diabetes management, and prenatal care.
Kravet is lead author of a paper in the March issue of Academic Medicine that outlines the JHM model's structure and success.
JHM has two hospital outpatient centers and more than 39 primary and specialty care outpatient sites where nearly two million non-ancillary ambulatory visits are conducted annually across the health system, the paper notes. Often, each ambulatory care practice has its own organizational structure.
To ensure consistent quality, JHM created a governance, oversight, and accountability model that cascades throughout the ambulatory sites. It consists of:
An Ambulatory Leadership Dyad
The dyad consists of a senior physician leader in the role of ambulatory chief quality officer (CQO) and a masters-trained nurse in the role of a senior director for ambulatory quality. The CQO was selected from the Office of Johns Hopkins Physicians (OJHP), which coordinates and oversees ambulatory physicians and staff. CQO dyad organizes and oversees analytics and dashboards for the quality metrics.
The Ambulatory Quality Council
The AQC comprises key leaders from each ambulatory practice setting, the OJHP, and JHM's Armstrong Institute for Patient Safety and Quality. Some of the practices are represented by a physician and an administrative leader, while others are represented by a physician, an administrative leader, and a senior nurse.
"It's created a table to hear what's going on in ambulatory, even when it's distributed throughout the community," Kravet says.
The AQC is also divided into four workgroups which share best practices, and each workgroup is devoted to a different theme:
Performance measures
Value
Patient safety/risk
Patient care/experience
This "cascading accountability model… provided a quality structure for all JHM ambulatory practices. As part of this model, the JHM Quality Board Committee created a quality and safety accountability system, establishing goals and measures for the CQO dyad. The Ambulatory Quality Council then defined its goals, set standards, monitored performance, and reported to the JHM Quality Board," the paper says.
Kravet says this approach brings people together to create an accountability model, set standards, facilitate processes, and distribute knowledge in a practical way. In a way, it's reminiscent of how franchises operate: Each is an independently owned business, but must adhere to the model and standards of the overall organization.
Accountability
"The same measures… are then pushed down to the unit level," Kravet says. "We distribute the dashboards and the expectations."
In addition, the paper says that "if an ambulatory practice continues to report substandard performance metrics, its leaders as well as the ambulatory practice chief quality officer are required to create an action plan and present it to the Board of Trustees."
Since it was implemented in early 2014, the model has resulted in improvements in a dozen government-required performance metrics. "An additional benefit was an improvement in Medicaid value-based purchasing metrics, which are linked to several million dollars of revenue," the paper says.
"It has created a great sense of accountability," Kravet says. It's broken down silos by putting patients at the center of care and encouraged stakeholders to have a voice in shaping and sharing goals.
Moreover, the model is scalable, and the authors believe it can be expanded to "other ambulatory practices within and outside JHM, including to regional and international partners," the paper reports.
"Patient safety is something that everyone can galvanize around," Kravet says. "When people are part of the design, they have greater buy-in into the accountability."
A two-year OpenNotes trial led researchers to a conclusion about transparency: "If you think patient engagement is important to your health system," then sharing the providers' notes "is a no-brainer."
Between 40% and 80% of what a healthcare provider tells patients is immediately forgotten, and half of what they do remember, they get wrong.
"Those are two of the most depressing statistics I've ever heard," says John Mafi, MD, a professor at the David Geffen School of Medicine at UCLA. "We have a big communication problem in our healthcare system, and that's an understatement."
John Mafi, MD
The result of all this miscommunication and forgetfulness, Mafi says, are the very things that are plaguing the healthcare system as a whole: Low patient engagement, poorly managed chronic conditions, prescriptions that go unfilled, medications that lay forgotten in medicine cabinets, bad outcomes, and high costs.
"A lot of these issues stem from poor patient communication," he says. But a new study shows that sharing doctor visit notes with patients—and reminding patients that those notes are available to them—can help keep patients engaged.
OpenNotes, began in 2010, when 105 primary care physicians invited nearly 14,000 of their patients to view their electronic notes about their clinic visits. The initiative was intended to better engage patients in their own care and improve communication between patients and their doctors. It was a success. After the program, patients demonstrated better recall of their medical plans, felt more in control of their care, and were more likely to take their medications.
"Patients felt more in control of their own healthcare. They felt that they understood the language of care much better," Mafi says.
In addition, doctors found that sharing their notes with patients had little negative impact on their workflow. But Mafi said that the program was "totally anticlimactic" with regards to physicians' workflow, and their email volume didn't change.
"The doctors were so worried that this would really interrupt their workflow," Mafi said. "When doctors were offered to opt out, none of them did."
In 2014, a group of nine health systems representing one million patients in the Pacific Northwest announced that it would provide open access to physicians' notes in electronic medical records. Today, more than 5 million patients are participating in OpenNotes, and recently, four nonprofits contributed a total of $10 million to expand the program to 50 million patients.
The success of the program led to other questions, though.
"Who is actually reading these notes in terms of their characteristics?" Mafi says. Also, the program was successful during first year, but are patients really still reading their notes after a couple of years? Finally, how helpful are reminders for patients?
Then, a natural experiment presented itself: A glitch at the Geisinger Health System in Pennsylvania caused electronic invitations alerting patients to signed notes stopped at GHS after year one, Mafi says. They continued at Beth Israel Deaconess Medical Centerin Boston.
Researchers followed about 14,000 OpenNotes trial participants for two years at Beth Israel Deaconess Medical Center and Geisinger Health System.
During the first 12 months, 53.7% of the patients at Beth Israel Deaconess and 60.9% of the patients at Geisinger checked their doctors' notes within 30 days of their becoming available to them. Those percentages stayed consistent throughout the year. During the second year, patients at Beth Israel Deaconess viewed their notes with the same frequency until a slight decline during the final three months.
At Geisinger, however, just 13.2% of patients continued viewing their notes once the email reminders ceased.
"Viewership just plummeted," Mafi said. "That was the big finding."
The data also showed that among the Beth Israel Deaconess patients, black and other/multiracial patients continued to view notes, but were overall less likely to view notes compared with whites.
There's a need to reach out those with disadvantaged backgrounds and/or lower health literacy. He points to an effort at a clinic in inner city Atlanta that's showing people with severe mental illness how to log onto the patient portal via their smartphones to get them more involved in their own care.
"It takes extra effort, but if you care about equity in health," the effort is important, Mafi says.
For healthcare executives, Mafi says the larger message is one of transparency.
"For us the message is clear: if you think patient engagement is important to your health system, then sharing the notes is a no-brainer," he says.
As with the first iteration of the OpenNotes study, studying the impact of reminders leads to other questions and research, too. For Mafi, the main question is: "How can we use medical notes and reminders that ping patients to really maximize the chance that the patient is going to be more engaged and lead to better health outcomes?… The next study really needs to do a whole array of different types of engagement techniques."
One way that researchers are doing that is with OurNotes, a new tool that's an extension of OpenNotes. Using a $450,000 grant from The Commonwealth Fund to develop OurNotes, patients at five sites—Beth Israel Deaconess; Geisinger Health System; Harborview Medical Center and Group Health Cooperative, both in Seattle; and Mosaic Life Care in St. Joseph, MO—will be invited to contribute to their own electronic medical records.
"We think that the next phase of all of this will actually have the patient become a coauthor of the note, and we think that will truly be a partnership… patients are more honest with the computer than with the doctor," Mafi says.
"We think this is the first effort in that next phase of really making the patient the center of the entire healthcare system, as opposed to an outside spectator."
"We think this is the way that healthcare is headed: The patient at the center of it all," he says.
Kentucky experienced the most dramatic change in uninsured hospitalizations: a drop of 13.5 percentage points. States that did not expand Medicaid saw very little change in inpatient payer mix.
As state governments continue to wrangle over Medicaid expansion continues, new data confirms that extending coverage has a great effect on the inpatient payer mix.
States that expanded eligibility for Medicaid in 2014 experienced dramatic decreases in uninsured hospital stays and increases in Medicaid-covered stays, a Health Affairs study shows.
Sayah S. Nikpay
States that did not expand Medicaid saw very little change in inpatient payer mix.
"It's really exactly what policy makers expected. In states that expanded Medicaid you see a pretty sharp uptick," whereas non-expansion states stayed flat-lined, says Sayeh S. Nikpay, PhD, MPH, assistant professor, Department of Health Policy, Vanderbilt University School of Medicine. She was a research fellow at the University of Michigan Institute for Healthcare Policy and Innovation when she conducted the study.
"It is nice when policies have their intended effect," she says.
The effect of Medicaid expansion was obvious, the study shows. Researchers used data on trends in payer mix for non-Medicare adult inpatient hospital stays from HCUP Fast Stats, an online database query tool from AHRQ.
They examined 15 states for which data was available through at least the second quarter of 2014: Arizona, California, Colorado, Hawaii, Iowa, Kentucky, Minnesota, New Jersey, and New York, which expanded Medicaid; and Florida, Georgia, Indiana, Missouri, Virginia, and Wisconsin, which did not.
The study found that between the third quarter of 2013 and the second quarter of 2014, "expansion states experienced a 7-percentage-point jump in the Medicaid share and a 6-percentage-point drop in the uninsured share," the study says. The changes represent a 20% increase in Medicaid charges, and a 50% decrease in uninsured discharges.
"It really does shift these uninsured patients to a source of coverage, and those are good changes in payer mix," Nikpay says.
The study also examined state-specific changes. For instance, Kentucky experienced the most dramatic change in uninsured hospitalizations: A drop of 13.5 percentage points.
But one of the biggest surprises for Nikpay was the changes in Wisconsin, which saw a meaningful increase in Medicaid discharges even though it didn't expand coverage. Nikpay points out that Wisconsin already had a generous Medicaid program: All adults in Wisconsin with incomes of up to 100% of the federal poverty level were eligible for Medicaid.
"That is what we call a 'welcome mat' effect," Nikpay says, and likely happened because people who didn't previously know they were eligible for Medicaid enrolled in the program.
No Expansion, No Change Overall, though, in non-expansion states, the changes in Medicaid and uninsured discharges were small?less than one percentage point?and not statistically significant.
"What we're seeing is that really there's not much of a change on average? and they're not seeing a change in uninsured," Nikpay says. "Things are proceeding as they would have before the Affordable Care Act."
For hospital executives, Nikpay says the key takeaway is that hospitals are seeing reductions in the amount of uncompensated care they're providing.
"A Medicaid expansion results in favorable changes in coverage," she says. She notes, however, that there's always the possibility of "crowd-out," in which people drop their private insurance and enroll in Medicaid instead.
"They may actually see some reduction in private revenue," she says of hospitals. Whether that will actually happen, or whether a possible drop in privately insured patients would be balanced out by a bigger increase in Medicaid patients, remains to be seen and is a complex question.
In addition, the study notes that "understanding the impact of Medicaid expansion on hospitals will become even more important as we approach 2017, when hospitals in all states will begin facing increasingly large annual cuts in disproportionate-share hospital payments that subsidize the cost of uncompensated care."
In the meantime, though, Nikpay says she hopes that this study will be another piece of evidence for health policy makers to consider as they debate expanding Medicaid in states that haven't already done so, such as South Dakota, Idaho, and Alabama.
Workarounds are inevitable in complex systems. When there is a disconnect between a system's rigid rules and what its workers feel they must do, leaders should give workers an opportunity to talk about the challenges they face, says a research scholar.
This is part two of a two-part interview.
Nancy Berlinger, PhD, a research scholar at the Hastings Center, an independent research institution focusing on bioethics based in Garrison, NY, puts a shining light on shortcuts, system fixes, and rule-bending in healthcare.
Whatever you call them, she says, workarounds are decisions made, usually quickly and under pressure, "where the situation at hand does not fit the official rules for what you are supposed to do."
Nancy Berlinger, PhD
In part one of a discussion with HealthLeaders Media, Berlinger detailed the ethical questions that arise from the use of workarounds. In part two, she talks about bringing workarounds out of hiding, using them for good, and encouraging innovation in the workplace. The transcript of the interview has been lightly edited.
HealthLeaders Media: It seems like workarounds should be brought to light, and that systems should be open enough for interpretation so that everyone can work together on a problem, rather than having to adhere to a rigid set of rules.
Berlinger: That's a very good way of putting it. It's not to say that everything's up for grabs. We want to take critical thinking seriously. Are we giving people opportunities to comment on whether or not something's worked so we can improve it and then put it into practice as a good set of work rules? Mindful of the fact that healthcare systems are always changing, we're going to have to look at rules every so often.
I'm on a hospital ethics committee, and I remember years ago that there was a particular resource allocation decision that was happening in a particular unit, and no approach to it was working in a very satisfactory way.
Finally, they came up with a set of rules that might be acceptable, but one of the doctors said, 'Now we have to let the nurses put that into practice, because ultimately, if they reject this it's not going to work. If they feel that there's something wrong with this, or it's unfair, or it puts them into an odd situation, it's just going to be put to one side.'
It was taking a critical look, rather than simply imposing rules on people.
Hospitals are very complex environments, and medical practices are very complex environments, and it can be hard to prioritize what… things we're going to focus on.
If people feel as though their system is letting them down… You always know that when you're in that [kind of] organization versus an organization where people can say, 'This is a very challenging job, but I feel that the organization has my back and I feel that they listen to people.'
People can tell you that about their workplace, or they can tell you when they're feeling a sense of uncertainly in times of system-level change, if there's a merger going on [for instance].
[Employees might think] they don't know what the values of the organization are going to be from now on because there are new people in charge. So people need the opportunity to communicate during those times as well.
HLM: And people want to make sure that they're not punished for speaking up.
Berlinger: Oh, absolutely. That's incredibly important. Because there are so many ways that one could be well-meaning and say, 'We want to set up a way to talk.' But if people feel as though this is a one-way conversation, or it's really just a way to… lay down the law, or they're going to be viewed as complainers… [it won't work].
Because of the emphasis on consumer satisfaction, healthcare workers—doctors and nurses on the floor—are very motivated to avoid complaints, and they do not necessarily want to be viewed as complainers either.
They would, I think, like to be viewed as sources of constructive information about how work is actually proceeding and the needs of the patient population. But setting that up has to be done in a very thoughtful way so it doesn't trigger the idea that this is just a flavor-of-the-month, or they just want to figure out how they can make us do more work.
Know that even if you're going out with the best intentions, people may have had a bad prior experience, either in this organization or in a previous job. So approaching that very thoughtfully is important.
HLM: I know this is a very slippery area and that black and white aren't the colors of ethics, but what are some times when workarounds are definitely unethical?
Berlinger: The difficulty is when something is clearly unsafe for patients. That's the bottom line in healthcare.
HLM: The one that's jumping out to me is antibiotic stewardship. Where clinicians feel like they know what's best for their patients, but the hospital is trying to crack down on antibiotic overuse.
Berlinger: This is a good example because antibiotic misuse is a huge problem in this country and other countries. And also, patients and families and doctors have gotten used to antibiotics. And there can be powerful norms on both sides to say, 'Well, the thing that you're going to do is give me an antibiotic, right?'…So clinicians and organizations have to be very clear about…the ultimate goal of keeping an effective drug effective and keeping patients and populations safe so that you can use antibiotics when they're needed.
But it also requires sometimes saying no when someone would prefer you to say yes, or sometimes taking the time for an explanation when it would be so much faster to just write a prescription.
That's a very good example because it shows how that individual—that doctor, that nurse practitioner, that PA—has to be supported by the organization in order to do the safe thing. Otherwise it is very easy just to default to the thing that will keep things moving.
HLM: Can we talk a little bit about nurse "makers" and nurse "hackers?" There was one who was honored at the White House for doing these kinds of creative workarounds for patients. What are some of the ethical concerns around that?
Berlinger: One thing I've heard from a nurse, that I thought made perfect sense, was that a workaround is often the first draft of an innovation.
Every innovation starts with a workaround. You're seeing a situation where the rule, the tool, doesn't match the situation at hand. And if you actually follow the plan rather than the reality in front of you, you could actually wind up doing something very unsafe.
Surgeons can give the example of having a surgical plan but the patient has some sort of anomaly that the surgeon didn't know about… and the plan had to be adjusted on the spot.
What you would want to do in that situation is… share the results of what you did and the outcomes of it. So take a critical approach to it rather than just keep doing this new practice and never telling anyone about it…
So if the nurse hacker is being honored at the White House, it didn't stay at the level of a secret workaround or a semiofficial practice. [It's not] something you maybe told your colleagues about, but didn't tell your supervisor about. So at some point, this nurse must have decided to put this up for a kind of a [quality improvement] QI project, a QI investigation.
Organizations sometimes do have a sort of internal QI mechanism where you can study a different way of doing something. It doesn't mean that you're doing a full-scale research project, but you may say, 'We've come up with something better. We've observed something in our setting, and this would seem to make more sense.'
HLM: It sounds like workarounds need to come out of the closet in order to truly turn into something useful.
Berlinger: That's a good way of putting it because they're an inevitable feature of work in complex systems…which should be differentiated from just saying that healthcare is complicated.
Complex systems are systems that are so big they're not under the control of a single decision maker. Work in the system has to proceed according to rules and protocols, and smaller systems—like IT for example, like medical records—to guide them. Complex systems are always changing.
In healthcare, there are new people coming in the door constantly through the emergency room. And work is always adapting to change. So in situations where work is always adapting, workers are going to be very sensitive to situations where the rules that are supposed to govern work and the actual conditions of work don't match up.
There's constant pressure. And adding to that are the economics of the healthcare system. When you're under constant productivity pressure, it drives these workarounds. Complex systems also have the potential for harm, because they run, often, 24/7.
They can't be shut down to fix problems… it never works that way in a hospital. So workers in these systems face pressures that others may not. And of course their mission is to care for the sick. So they're dealing with an exquisitely vulnerable group of people as those in their care.
It's talking openly about workarounds, asking people to share this in a non-punitive way, while at the same time taking a critical attitude—not criticism—taking a critical look at workarounds and saying which ones are actual first drafts of innovations? Which actually make a system better, and should be more widely shared, not just kept as my personal practice? [Is this] something that could actually be adapted by others?
[It's also important to ask] which ones are problematic and potentially harmful. Their value is unclear and why do people use them anyway? It's almost always because they feel that it saves time.
HLM: So some workarounds exists, not just to do something better for the patient, or solve a moral problem, but to save time.
Berlinger: Very, very often it's about saving time. Someone might think of it in moral terms by saying, 'If I get behind I can't see all of my patients, so I'm going to have to save time here on this case, and this case, and this case, and by the end of the day I have seen everyone.'
Versus, 'If I take all the time this is meant to take, there are people who aren't going to get their meds on time.'
There are these very quick moral calculations that people are making, but they are not all definitely in the interest of making things better for a particular patient—although sometimes they are.
Sometimes they're just simply about, 'How do I get my work done?'
Sometimes these are called 'efficiency-thoroughness tradeoffs.' In systems like healthcare, people tend to get the message that they have to prioritize being efficient over being thorough. At the same time, they're always told that they must be very thorough.
HLM: What would you want C-suite executives to take away from your book?
Berlinger: In the last chapter of my book, most of the recommendations are addressed to leadership because…even when you're describing a front-line problem, it always has something to do with leadership in some way. Leaders set the tone for the environment.
First, the C-suite has to acknowledge the complexity of the healthcare environment and acknowledge how important they, themselves, are in setting the tone for what workers will perceive as important or unimportant to the system itself.
All healthcare organizations describe themselves as committed to excellence and to caring. You see that on the website; you see that on the marketing materials, and so on. But if front line workers are demoralized and don't perceive that they have the time or the tools to provide excellent care, those are always leadership concerns and maybe are the result of system-level decisions.
Leaders should acknowledge the foreseeable challenges facing workers in their systems. For example, in systems that rely heavily on Medicare reimbursement, like hospitals, it's foreseeable that many patients will be older, will be experiencing age-associated health problems, and will be facing decisions associated with the last stage of life, because they're on Medicare and they're in the hospital.
In a safety net system, which relies on Medicaid reimbursements and other funds, it's foreseeable that many patients will be uninsured… and workers will face resource allocation challenges regularly.
We have to be upfront about these things because this is what your workforce is seeing. If there's a disconnect between what the C-suite is talking about and what the workers are seeing, it's just a recipe for your workers to be demoralized or some of your workforce to want to leave, or for care to be not as excellent as it might be.
I think one thing we should always be careful about in healthcare is expecting some people to be heroes. The idea of being the person who's going to be the savior of the system…this is obviously a collective enterprise…we ought to give everyone an opportunity to be good at what they do.
As we discussed, leaders need to give workers an opportunity to talk about the challenges they face without [creating a] complaint session or an opportunity to task people to solve problems that are way above their pay grade or their level of responsibility.
They should support QI problems in their own settings… How do we bring workarounds out of the closet? [You do that] by encouraging people to talk about their innovations and say, 'OK. Now let's see whether some of these could have broader applications.'
Also, [let's] help people think critically about situations where they felt pressure to improvise in ways that were not putting patients' interests at first. Not that they meant to do that, but they felt pushed to do that.
Sometimes they are not only about the individual doctor or nurse. These are maybe situations where the rules of admission, for example, of a critical care unit are unclear. So there's a habit of referring a lot of patients to a particular unit just in the interest of their safety.
But then the people who actually work in the unit have way more patients than seems safe to them. So there's a little workaround there: We'll find a reason to get [the patient] in there, and it'll be OK, but we haven't really thought of our colleagues on the other side of the door who are managing the problem…
Sometimes it means looking back at the unglamorous things like staffing ratios: How many patients with this particular condition is it reasonable to imagine one person to take care of safely? That kind of stuff can drive workarounds. It can also be the difference between safer and less-safe conditions.
I think attention during periods of system change is very important because system change introduces new pressures….
One final thought is [that] I think both the C-suite and front line clinicians themselves always have to be thinking about who they view as deserving or difficult or demanding, because that goes to the level of moral intuition.
This is true with respect to the patient population and… with respect to their own workforce. Who are we listening to, and who do we think we should do more for because we think they deserve things? This may be a patient who we like, or a particular unit that produces a lot of reimbursements.
Who do we view as demanding? Is it a particular kind of patient, or a particular profession? But we always have to be alert to that in any kind of work because, as the social psychologists can tell us, it tends to guide what we actually do.
If there's a problem you don't want to deal with—and in healthcare the problem can present itself in the form of a patient—you might want to "turf it," which is physician slang for get rid of it, get it off my turf and onto somebody else's turf.
You may find a way to get rid of that problem by pushing it somewhere else, and just making it someone else's problem. You see it in end-of-life care; you see it in psychiatric care. [These are] situations where patients are just turfed between institutions or turfed between units…
Analyzing these problems is tough. And figuring out how, in organizations that are very busy, you can prioritize problems you're going to work on is challenging. So I'm always interested in how… leaders talk among themselves in their own C-suite. Where do leader learn from? How do different professions talk within their own professions? How are we talking about this?
Not just in economic language, but in moral language. Because healthcare ought to be a moral enterprise, it ought to be a good-seeking enterprise. It's about the care of the sick, and the healing of disease, and the relief of suffering. But it's all of our actions and inactions that actually show whether it is a moral enterprise.
A disconnect between how an organization imagines work is happening and what staff feel they must do puts healthcare workers on potentially ethically shaky ground.
This is part one of a two-part interview.
Shortcuts. System fixes. Bending the rules. Whatever you call them, workarounds are a part of life for healthcare workers. But they can result in ethical concerns and questions.
When, if ever, are workarounds OK? And when are they not?
She says she began thinking about workarounds as she was speaking with healthcare professionals during talks for her first book.
Nancy Berlinger, PhD
"They themselves would talk a lot about workarounds," she says. "Sometimes they would say 'shortcuts' or 'fixes' 'bending the rules,' 'working the system,' 'cutting corners.' You'd hear a big range of things; 'tailoring the chart'…a large range of things. I would say, tell me, what do you mean? Tell me more about that."
In a recent phone interview, Berlinger discussed her research on workarounds: What they are, when they're acceptable and when they're not, and how organizations can harness them to help create positive change. The transcript has been lightly edited.
HLM: What are workarounds and what are some that healthcare workers and leaders would recognize in themselves or their colleagues?
Berlinger: Workarounds are the umbrella term for a decision made, usually fast and under pressure, where the situation at hand does not fit the official rules for what you are supposed to do in that situation. Other phrases that someone might use are 'getting creative,' or 'improvising,' or 'doing it my way.' So there's a whole range of ways that people might characterize these situations.
The reason they're of ethical concern—that there's a concern with regard to questions about right and wrong—is at least twofold.
One is because the system itself is usually the source of the pressure to create the workarounds: The basic disconnect, between [how] the organization imagines work is happening and what people feel that they're actually forced to do, usually under pressure to be efficient, to get the job done, and so on.
[Another is] that sometimes people feel that they have to work around rules that seem unfair. That a patient who needs something cannot get what they need because of a rule that may not be an organization rule, but might be a federal or state policy that makes it hard to provide something to that person.
There's a chapter in the book about access to healthcare for patients who are undocumented. [These] patients inevitably wind up in safety net systems. Because they are ineligible for a range of covered benefits that, ordinarily, low income people would be entitled to, it can put a lot of pressure of staff to say, 'Is there a way that we can possibly get you this even though you're not insured?'
It comes up in psychiatric settings; it comes up settings when people hit Medicare rules. People don't want to commit fraud or they don't want to break laws, but they are in a situation where the needs of the patient are going to be hard to meet because of the lack of some coverage mechanism.
And these are the consequences of policy decisions… made far, far away from the person at hand. Even a small adjustment in the way a doctor or nurse or social worker does their work could be linked to something that happened way upstream and far away from them.
HLM: Can you share some other examples of these workarounds? Do the people doing them feel like they're making a moral decision to do the right thing?
Berlinger: Yeah, exactly. People who work in safety net settings… know that many of the patients who they're caring for are low income, and yet they constantly face the consequences of some patients having no access to insurance or very limited access.
Let's say you were in a state where your system could get reimbursed for something or the patient could get coverage for something if the problem is an emergency—because there are rules like EMTALA, [the Emergency Medical Treatment and Active Labor Act,] there's emergency Medicaid that provides reimbursement for emergency situations or that gives people access to emergency medical care.
But let's say it's really a chronic problem that a patient has. This happens very commonly when a patient has kidney disorder, for example. The route to treatment would be transplant or dialysis.
And yet, as the patient is undocumented, they are very unlikely to have access to transplants and often don't have access to scheduled dialysis. So what you have to keep doing is admitting them as an emergency patient over and over and over again. And this causes a lot of ethical uncertainty and distress for people who care for this population because it doesn't look like a good way to manage the disease.
And sometimes the hospital might simply admit the patient. They'll say, 'OK we'll admit them into the hospital; they're sick, and then we'll just start the dialysis from here because we can't get them into the outpatient clinic.'
Sometimes this happens with psychiatric patients where you'd like to be able to admit the patient to a psychiatric bed but you don't have enough [beds]. So you look for a medical reason to at least get them into some safer setting.
People often talk about this with respect to, ironically, patient safety. Since the IOM's 1999 report, To Err is Human, drew attention to the problem of medical error in the US healthcare system, there was a big push to make healthcare safer. So what you started seeing was a lot more rules and lists that people should follow.
At the same time, there has been research on how many rules people can follow before they start selectively using rules, because it's just simply too many [rules] to keep in mind, or it's taking too much time.
Workers in healthcare systems are under tremendous time pressures to complete tasks, and keep moving, and complete rounds and clock out by a certain point, and so on. So when more rules are added in the name of patient safety it can, paradoxically, make safety less certain because you're putting people under pressure to reduce and condense those rules in some way.
That was one of the great lessons—and there's attention to this in the book—of Peter Pronovost's work on checklists [for preventing bloodstream infections from central venous catheters used in intensive care units]…What his great insight was, was not that you just handed the list back to people and say here follow them.
You had to completely remake the way people did work in the setting, so that if one person started skipping something, the other person would call them on it. You would ally them in that goal in preventing the infection.
[There's also concern] because people are getting very attached to this idea of checklists as magical solutions… that is just a recipe for setting up more workarounds of checklists. Because the checklist is actually the product of the agreement between the people in patient care to keep the patient safe. And then at the end of it, they say, how exactly does our work proceed?
In [Pronovost's] project, they had many different versions of checklists, but it really has to start with that behavior change, rather than imagining that the rules will change your behavior.
HLM: Are there workarounds that are OK? And which ones are definitely not OK?
Berlinger: That's a very important question, because few things in ethics are up or down. You're always asking for the context in ethics. [It] asks you to think right off the bat, to be a little provocative.
This thing you feel that you have to do to get your job done, to make these little improvisations all day long, is that the right thing to do? Because in healthcare, the right thing to do usually has to do with [the questions]: Is it the right thing to do for your patients? Is this safe? Is this effective?
An example of a workaround that would be appropriate is [when] the plan that you have does not fit the situation at hand in this particular case. So I give an example in the book of a patient whose needs for pain management have clearly changed, but there's no one on hand to actually give the order.
[Maybe] the hospital has a policy for written orders [but] there's no one on the floor who actually has the authority to write the order. So you would either have to do a verbal order, which would be preferable to someone who didn't have the adequate knowledge of the situation trying to just improvise. You don't want people who are less experienced or not authorized…to just wing it.
You might have to say, 'OK there are situations where our procedure cannot be followed for some particular reason.' But if that does arise, you would also say, 'Do we also have a staffing issue?' We don't want to put people on the floor in a bind when a patient is in pain, but they may not control their own staffing there, they're unlikely to do that in fact. So how does that go up the line?
You [also] often hear people talk about problems involving getting equipment fixed. Do you say to people, well you should make it work? Or do you say, we need a better system for figuring out how to get repaired equipment back up to the floor so that people aren't forced to use equipment that isn't working properly.
There might be a one-off circumstance [when a workaround is OK]. The problem is when it becomes a new norm, and you're adjusting or adapting to a situation that is more imperfect than it really needs to be.
More complicated ones, and ones that… get you into deeper waters, are when, for example, there's just a rejection of a new system, when you want to stick with the old one. And that can happen when you're putting in a new IT system or an electronic health record system.
The big bottom line is that behavior change is hard.
But if people are rejecting a system in such a way that they are figuring out how to work around it—there are whole presentations in the IT world about this, [on how to] defend your system from the inevitable workaround—sometimes what is needed is not just to punish people for doing that.
[Maybe you should] say, 'Wait a minute, are they actually sort of crowd-sourcing it? Is there a way that people could actually make it better?' And this could be an IT system, forms, other sorts of processes, but you have to be open to…doing quality improvement research your organization, taking that approach.
So that's definitely an issue for leadership: Are we allowing people to give us feedback about how our systems are working in ways that are not dismissed as complaints? Or that we're going to turn it back to this person [and say] 'you are being tasked with fixing the problem' when they've drawn a system-level problem to our attention.
How do we keep this responsive? If people feel as though if they speak up they're just going to be called a complainer, or [that they'll] be given some new responsibility, they'll just keep quiet about their workarounds. They'll just keep doing it their way.
That's always a little tipoff: If you are doing something but feel that you shouldn't tell anyone about it, that's a tip that it's on potentially ethically shaky ground. Secrecy goes with lying or concealment.
Treating Clostridium difficile adds about $7,285 in hospital costs per patient, not including readmissions, research finds.
It can be difficult to quantify the exact economic burden of C. diff on hospitals and the health system as a whole. But a recent study puts a dollar amount on the cost of C. diff, that number is not only big, but also likely underestimated.
Published in the November issue of the American Journal of Infection Control, the study found that C. diff-associated diarrhea (CDAD) increases hospital costs by 40% per case and puts those infected at high risk for longer hospital stays and readmissions.
Glenn Magee, MBA
Researchers conducted a retrospective analysis of inpatient hospital data, examining 171,586 eligible discharges from between January 2009 and December 2011 from approximately 500 U.S. hospitals in the Premier Healthcare Database.
The 40% increase in costs per case added up to an average of $7,285 in additional costs. Costs were higher for certain high-risk subgroups of patients.
In addition, compared to patients without C. diff, those infected had an estimated:
77% higher chance of being readmitted within 30 days
55% longer hospital stay of nearly five days
13% higher risk of mortality
According to Glenn Magee, MBA, lead author of the study and principal research scientist, Premier Research Services, Premier, Inc., other studies into the cost of C. diff have been limited in both geography and demographics—and sometimes limited to single hospitals—causing some hospital executives to question whether their own hospital would experience the same cost burden.
But the hospitals in the Premier Healthcare Database are geographically diverse and provide a representative sampling of both teaching and nonteaching hospitals, according to Premier.
"When you have a study that considerers 500 hospitals and estimates these costs, it's a lot more resonant," he said.
In addition, the study's estimates are conservative for the health system as a whole, mainly because they don't factor in the cost of readmissions, and instead, "only considered hospital costs and not physician or treatment costs beyond the index hospitalization," it says.
"The assumption is that a lot of those readmissions are related to treatment for C. diff…the real cost is actually greater than $7,300," says Magee. "The total impact on health systems as a whole is much greater than that."
The study also looked at CDAD-attributable costs for certain high-risk subgroups of patients and found that they're higher, but only slightly, than the costs for the general population. These are patients
With renal impairment ($8,942)
With immunocompromised status ($8,692), and
With concomitant antibiotic exposure ($8,545)
"The surprising thing was that high-risk subgroups had similar results as people who were not high risk," Magee said.
Bimal Shah, MD, MBA
From here, there are many possible takeaways and actions, says Bimal Shah, MD, MBA, service line vice president, Premier Research Services, Premier, Inc. For instance, he says, antimicrobial stewardship programs can work toward more precise treatments and reducing overuse of antibiotics, which often is associated with C. diff infection.
On the research side, Shah says he'd like to see prospective analyses to determine which tools and standard protocols are most effective, as well as to quantify the effect of early identification and treatment on outcomes.
"This is on the radar for everyone," he says. "It's on the top of every [list at every] hospital, hospital administrator and quality person in all of our hospitals."
Magee adds that hospital leaders and other stakeholders within an organization should also work with other nearby facilities, such as skilled-nursing facilities, to monitor and to be proactive about admissions and discharges between and among institutions to ensure optimal care.
"If I were a healthcare executive, I'd want to make sure that my operational leaders were active in this area," Magee says. "Each hospital is going to have their unique challenges. Have we identified those challenges? And what are we doing to meet them?"
How well-meaning and clinically unimportant actions can make or break the patient experience, and how leaders at Cleveland Clinic and Mount Sinai Health System are refocusing efforts.
K. Kelly Hancock
During her hospital's monthly executive leadership rounds, Cleveland Clinic's executive chief nursing officer, K. Kelly Hancock, MSN, RN, NE-BC, met a patient who didn't seem quite happy, despite his insistence that everything was OK.
"We could just tell that he was a bit hesitant in his answers," Hancock says. So before she and her fellow executives left him, they probed a little more, asking, "Are you sure there's nothing else we could do to make your experience better?"
Actually, something was bothering him. Someone had come in to change his gown, and instead of addressing him by name, such as Mr. Smith, they called him "honey" and "sweetie."
"For him, he was offended," Hancock says.
It may have seemed like a small thing, but it really rubbed him the wrong way, and totally colored his experience as a patient. It was clear that it had been bothering him for quite some time.
"You've really got to dig when you're with the patients and the families," Hancock says. "What's important to that patient [is something] you may miss."
Clinicians might check off all of the important clinical boxes when caring for a patient, but it's often the small—perhaps nearly imperceptible—nonclinical elements of a hospital stay that most affect whether a patient has a good experience.
"I think that patients come to us expecting to get really good clinical care," agrees Sandra Myerson, MBA, MS, BSN, RN, senior vice president and chief patient experience officer at New York's Mount Sinai Health System. "The only way they can really judge us is on the rest of it."
With all the effort, money, and attention that's currently being paid to the patient experience, it's important for clinicians to understand how to get to the real heart of how a patient is feeling, and to do it in real-time.
Digging in
Beginning this year, Cleveland Clinic will be starting a program in which providers, such as nurses and physicians, will actually shadow patients during their inpatient stay or outpatient visit to better understand "what their experience is through their lens." Hancock says she's "really excited" about the program and can't wait to start it, adding that they think that "it's important enough that it's clearly worth the investment to take those caregivers offline."
Sandra Myerson
"We know the best feedback is from the patient," Hancock says. "We think it really will lend itself to some great feedback to develop stronger interventions."
Shadowing could also help clinicians develop the empathy they need to really understand what patients are going through, and therefore, what they care about. Hancock says compassionate care is about being present, empathetic, and listening for key words that a patient uses that might clue clinicians into their emotions, and ultimately, their experience.
Use the right language
Hancock says it's important to meet patients where they are, and the shadowing project will very literally do that. By asking something as simple as "What's important to you during this stay?" clinicians might find out that the patient really wants his hair washed or face to be shaved. They're small things that can go a long way in providing dignity and comfort, but that may not be "important" clinically.
"We have to pay attention to those things that are concerning to the patient that we might not even think they should be concerned about," Myerson says. "We tend to be really task oriented."
Hancock says providing a template for talking about these nonclinical topics can help staff drill down into what's really important or worrying to the patient. In addition, engaging in role-playing exercises can help staff ensure that such conversations with patients happen naturally and without sounding scripted.
Myerson adds that training managers and other clinicians to ask certain open-ended questions, rather than yes-or-no questions, can elicit better responses. For instance, clinicians might ask "How did you sleep?" or "What got in the way of you sleeping well?" instead of "Did you sleep well?"
Another question that could be useful, especially if a patient is suffering, is "What's the worst part of this for you?" according to a new essay in JAMA. Asking such a question and "turning toward" suffering, the authors write, helps not only with the patient experience in the moment, but with overall, long-term healing in a way that straightforward diagnosis and treatment may not. It acknowledges that patients are whole human beings. It's also important to remember that clinicians are whole humans, too, and that these non-clinically focused interactions doesn't always come naturally. That's why they need training.
"We're spending a lot of time and effort around coaching people to be really effective communicators because it's not something that we learned in school," Myerson echoes. "It's about the human experience."
Be visible and open
Myerson says patients aren't always comfortable expressing their concerns during their hospital stay, especially if they're unhappy with a particular clinician. Patients may also not know who to complain to in the first place. That's why nurse managers have to be visible and available to patients.
"What we like to do is have the nurse manger round on every patient every day. It is a really great way for the patient know who's in charge of the unit," she says. "At the end of the day the nurse manager is really the CEO for their unit."
Nurse managers at Mt. Sinai also hand out postcards with their name, photo, and contact information—in English on one side, and Spanish on the other—so patients have it handy if they need to get in touch. Nurse managers at Cleveland Clinic also round on new patients and distribute business cards.
"If I know who's in charge I can go right to the boss," Myerson says.
But it's not only the boss who has a role to play in listening to the patient. For instance, Myerson says some of their housekeepers have a great, natural ability to interact and connect with patients, and sometimes patients will confide things in them. When that happens, they're instructed to tell either the charge nurse, nurse manager, or their own supervisor.
In fact, everyone on the nonclinical teams receive education about making eye contact with patients, smiling, and introducing themselves. Myerson adds that building services team members have huddles before each shift, and "they talk about patient experience almost every single huddle."
"Everybody has a role in the patient experience," Myerson says.
The year-long effort will focus on safety for healthcare providers, as well as the patients they serve.
The American Nurses Association will spend 2016 promoting its new "Culture of Safety" campaign to champion improved safety for patients and healthcare providers.
But "there's still enormous room for improvement in safety," she says. "Not all organizations have really adopted the best practices."
Organizations should move beyond the "old approach" of safety that revolves around chasing numbers on a scorecard.
"The new approach is that safety has to be a way of life," Cipriano says. Moreover, it has to trump all other goals, because when an organization has a true culture of safely, "all of the other improvements follow.
"We really need to emphasize that learning within healthcare," she says. "It's sort of a clarion call across all organizations that it's really time to live this set of activities and values."
Cipriano says that the campaign aims to make sure organizations and their leaders—as well as employees—are not only adopting a culture of safety but actually demonstrating one.
"It starts from the belief that leaders absolutely have to set the stage," she says. "For a long time everyone has known what to do but it's really putting it into practice. That's the harder part."
For instance, leaders need to ensure that resources are in place to achieve results, including resources for adequate staffing, equipment, and education. Cipriano also says leaders should adopt and support "a sense of yearning for constant improvement" and allow behaviors to define metrics.
"The staff need to know that if they speak up something will happen," she says, and leaders must respond with transparency, accountability, and actual results.
Leaders must demonstrate that they are receptive to the staff and encourage the reporting of errors and near misses, with assurances that the will be no blame, finger-pointing, or risk of punishment.
"There has to be an acknowledgement that there is no hierarchy," Cipriano says. "Safety doesn't require a hierarchy. It requires empowering every voice."
The campaign will also focus on and tie together issues such as safe staffing levels and skill mix; violence in the workplace; stopping manual patient handling and lifting; and making sure that technology is user friendly and is used appropriately, including EHRs. The health and safety of nurses themselves will also feature in the campaign's efforts, including making sure that nurses get adequate breaks and have a have a quiet area to stop, rest, and eat.
"Nurses tell us that stress is probably the most prominent feature of a work environment," Cipriano says.
With this is mind, ANA is supporting the "quadruple aim," adding the health of the provider to the much-discussed "triple aim" of better care, better health, and lower costs.
ANA says that through the campaign, organizations can access a "culture of safety" logo and toolkit, which includes a:
Fact sheet
Email template
Social media graphics, draft tweets and Facebook posts
Customizable news release
PowerPoint template
Culture of safety theme for 2016 National Nurses Week (May 6-12), with accompanying toolkit
Thematic articles throughout the year in ANA periodicals American Nurse Today and The American Nurse
Monthly Navigate Nursing webinars and two four-part webinar series related to the culture of safety theme
Cipriano says the culture of safety efforts will resemble its approach to 2015's year of ethics campaign, in that it will cluster content and messaging, providing a deep dive on the topic and its resources. And the year-long emphasis underscores the importance of repeating a message again and again to emphasize its significance and how it should be implemented.
"You can't just say something once," says Cipriano, and you have to tie it all together. "We believe that culture of safety is worthy of that kind of attention."
It also places nurses at the forefront of making this kind of change.
"We are expecting them to speak out loudly and often," Cipriano says. "And we want them to be full partners, not just with physicians but with healthcare executives and any leader that is in the space of delivering care."
A real-life look at the CDC's core elements of antimicrobial stewardship in practice at two leading institutions.
The White House, The Joint Commission, and an increasing number of other stakeholders are doubling down on antimicrobial stewardship, saying that the time is now to stem the tide of antibiotic-resistance. Late last month, The Joint Commission released its proposed standard focusing on Antimicrobial Stewardship, which is now open for field review. The proposed standards call for an "antimicrobial stewardship program based on evidence-based national guidelines" in ambulatory healthcare organizations, critical access hospitals, hospitals, nursing care centers, and office-based surgery practices.
"The intent and outcome would be a standard," says Lisa Waldowski, MS, APRN, CIC, infection control specialist for The Joint Commission enterprise.
She says such a standard is a long way off, and is still very much in development: The proposed standards are out for field review through December 30 and will be going through a vetting, development, and approval process all next year. Plus, the Joint Commission would give a long lead time for organizations to have a chance to implement such a standard.
"It will be coming, but I don't think we're going to see this in the next year," she says. Still, "this is not going to come as a surprise ... we're moving toward that future state."
"This is not a new issue. Now it's just being supported at a higher level," Waldowski adds. "We have created this conundrum that we're under now. We really have to say we can't bide anymore time. We really don't have the luxury or the time to spare."
Doing it for patients
It's not just the Joint Commission that could potentially push hospitals and other organizations toward implementing stewardship programs. There's also a push for having antimicrobial stewardship teams in each hospital as a condition for participation in Medicare/Medicaid by end of 2017, notes Mohamad Fakih, MD, national infectious diseases physician leader at Ascension Health in Detroit.
But in the meantime, he says, "I think it's the right thing to do for those we serve …. We're doing this to improve our patients' outcomes."
Antimicrobial stewardship is likewise a priority at Northwestern Memorial Hospital in Chicago, which has had a formalized program since 2002.
"There's been an incredible increased intensity and awareness in our government and regulatory bodies," Sarah Sutton, MD, medical director of the Antimicrobial Stewardship Program at Northwestern Memorial Hospital and assistant professor in the Division of Infectious Disease at Northwestern University Feinberg School of Medicine. "I like to say that gone are the days of cowboy antibiotic use when every prescriber just followed his own rules and his own habits."
CDC recommendations in practice
Despite robust efforts at some organizations, though, there are certainly others that are behind the eight ball in implementing antimicrobial stewardship programs. Waldowski says the CDC's core elements of hospital antibiotic stewardship programs provide excellent guidance for any program.
The CDC's core elements are:
Leadership Commitment: Dedicating necessary human, financial, and information technology resources
Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs shows that a physician leader is effective
Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use
Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (e.g., an "antibiotic time out" after 48 hours)
Tracking: Monitoring antibiotic prescribing and resistance patterns
Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses, and relevant staff
Education: Educating clinicians about resistance and optimal prescribing
The Ascension Health and Northwestern programs embody these elements. Here's how:
Leadership commitment: According to Fakih, Ascension's leaders have made a commitment to support improved antimicrobial use in all of its facilities, and have "created a Center of Excellence for Antimicrobial Stewardship and Infection Prevention for the whole system to optimize antimicrobial use across the care continuum.
"A critical factor to success in most organizations is the commitment from leadership. Until recently, antimicrobial stewardship has not been on the radar screen for most of the U.S. hospitals," he says. "Leadership also helps engage the different stakeholders and have their goals aligned with best practices."
For instance, the chief medical officer plays a big role; if members of the pharmacy team are working on it, but physicians are not onboard, the program won't work. It needs to be clear that administration is fully supportive, including physician leadership. When hospitals within Ascension's system aren't doing as well with stewardship, they get a call and perhaps also a site visit with their CEO, CMO, physician leaders, laboratory leaders, directors of pharmacy, and all others that will affect the care, so they can hear recommendations directly.
The CEO must also be onboard in action, as well as word.
"The big message that I would give the leadership is that resources need to be provided to the antimicrobial stewardship team," Sutton says. That includes IT resources and having dedicated employees to do the work. "These programs are labor intensive and do need resources."
Accountability and drug expertise: The CDC calls for appointing a single leader who's responsible for program outcomes, preferably a physician, as well as a single pharmacist leader who's responsible for working to improve antibiotic use. The program should create a climate where they work together daily and medications are reviewed daily, Fakih says.
A physician can lead the way in the program, educate colleagues, and work with pharmacy, but the pharmacist leader has to have power, too, especially in challenging a physician's prescribing choices.
"It's not going to be just saying we're committed, we have to do some action. You need to empower the pharmacists," Fakih says.
Implementing at least one recommended action: Sutton says it's important to choose to work on issues that will have early success; programs shouldn't take on the biggest challenges first. Small successes will lead to larger efforts.
Also, Northwestern has chosen a specific issue as their "rallying cry:" reducing Clostridium difficile–associated diarrhea (CDAD).
"For each individual, recent antibiotic use is the strongest risk factor linked to the development of Clostridium difficile diarrhea. In addition, for in-patients within a ward or facility, there is building evidence that the community antibiotic load is also linked with risk of developing CDAD," Sutton said later via email. Northwestern Memorial Hospital's antimicrobial stewardship program "is partnering with the hospital, clinicians, pharmacists, IT, and patients to reduce the in-patient antibiotic load as a means of reducing CDAD."
Tracking and reporting: Sutton says order sets are critical. For instance, Northwestern's CPOE gives prescribers information such as what antibiotics the patient is on now, the dose, the interval, start date, and original indication, as well as past antibiotic use, "so the clinician sees a bigger picture." Order sets also give prescribers a limited number of options, rather than the whole spectrum of antibiotics, so that they're less likely to choose one that's inappropriate.
Waldowski says linking antibiotic usage to defined metrics is also key. For instance: Are costs going down thanks to wiser prescribing? Are there fewer cases of Clostridium difficile? And, as mentioned before, the physician-pharmacist team should be reviewing antibiotic use daily for appropriateness.
Education: Although each of the above is certainly critical to success, educating clinicians and getting them to make change might represent the biggest hurdle.
"Even if you have all the technical stuff mastered … culture can limit your success," Fakih says.
Waldowski agrees, saying, "The easier part is to create the recommendations, create the policies and procedures, write the standards."
But as Sutton says, "Hospitals need to be aware that changing a culture is a really challenging thing to do, and that's what's really indicated to reducing antibiotic overuse."
Sutton says that no matter how much momentum there is behind decreased and smarter antibiotic use, there will always be holdouts who resist change and "feel very strongly with their use of antibiotics," even if it "doesn't fall into line with approaches to modern antibiotic use." Plus, prescribers often learn from their mentors and do what they've been taught, thus perpetuating inappropriate antibiotic use.
For all of these reasons, educating clinicians is critically important. Sutton says clinician education should include providing data in a way that's easily digested, showing them scientific literature, and sharing data about concrete improvements, such as differences in Clostridium difficile rates when the institution is using fewer antibiotics. It's also important to reassure clinicians that they're not putting their patients at risk when they change their antibiotic prescribing.
"Clinicians are really trying to do the best for the patients," she says. "But they need that reassurance that they're going to be OK."
Researchers find serious underreporting of body mass, alcohol abuse, and tobacco use in hospital billing data and recommend two solutions.
The Nationwide Inpatient Sample (NIS), which is derived from billing data, is used for everything from calculating hospitals' risk for readmission or surgical complications to researching things like the effect of health policy changes and access to care.
But there are "glaring flaws" and gaps in the data, thanks to dramatic underreporting of patients' alcohol and tobacco use, as well as their weight and body mass, according to researchers at Johns Hopkins University School of Medicine. The study was published in the journal PLOS ONE.
Susan Hutfless, PhD
"We sort of knew going into it [that] it would be bad. We didn't know how bad," says the study's last and corresponding author Susan Hutfless, PhD.
Just how bad was it? Here's an example: According to the NIS, the United States prevalence of overweight is just 0.21%, and the prevalence of obesity is 9.6%. The researchers compared NIS data to information that's in the Behavioral Risk Factor Surveillance System (BRFSS), a federally sponsored telephone-administered survey where more than 500,000 American adults answer questions about their health. According to BRFSS data, 35.8% of Americans are overweight and 27.4% are obese.
"Why is no one coding overweight at all when it's 33% of the population?" Hutfless says.
Body mass isn't the only place where there's significant underreporting in the NIS. It reports alcohol abuse in just 4.6% of the population, compared to 18.3% in the BRFSS, and tobacco use in 12.2% of the population, versus 20.1% in the BRFSS.
This underreporting can have significant implications for a hospital's bottom line, Hutfless says, since missing data can result in inaccurate risk adjustments, and therefore, unfair reimbursement.
"A very high number of patients are having their risk coded as lower than it actually is," she says.
Yet the information is being collected: Questions about patients' weight, alcohol, and tobacco usage are standard. It's "impossible to find a provider who doesn't ask that," says Elie S. Al Kazzi, MD, MPH, the study's first author.
But critical information about weight, alcohol abuse, and tobacco use that's included in the recorded medical history doesn't usually make it onto a hospital bill, and the NIS is based on billing data.
Elie S. Al Kazzi, MD, MPH
'The Data is There' "When people are coding, they are coding the big-picture conditions," Hutfless says. They're coding myocardial infarction, but not necessarily that the patient is also an overweight smoker. That information would certainly affect the patient's risk of readmission. And "missing information in the database leads to inaccurate health quality assessments and could have a devastating economic impact on hospitals that see the sickest patients," according to a release about the study.
In an accompanying editorial, Hutfless and Al Kazzi write about several possible solutions to the problem. "The data is there. It's just an issue of actually downloading it and transferring it," Al Kazzi says.
One short-term solution would be to merge the databases, data is from HHS's more than "1,800 publicly available databases could be used to complete missing information," the editorial says.
The authors also suggest that "incorporating meaningful use measurements into datasets that comprise billing codes could enhance the completeness without adding additional coding burden." As for possible long-term strategies, they write that "financial incentives in coding, publicly available information on items used to adjust for risk in the existing Medicare products, and random audits" could increase accuracy.
"In my opinion, it's easy" to fix, says Hutfless. "It's administrative fixes, but I don't think that the amount of manpower and brain power is large… especially for the return on investment."