"The current system of reporting patient satisfaction scores is much more difficult for large, urban hospitals than for small, rural hospitals," says one researcher, raising discussion about whether there should be additional adjustments by CMS.
Some predictors of patient satisfaction seem obvious, such as good communication between doctors and patients. But a study published in theJournal of Hospital Medicineshows that there are some less obvious predictors that put certain hospitals at a disadvantage for patient experience scoring and, ultimately, for reimbursement.
Researchers at Mount Sinai Health System in New York City found that bigger hospitals and hospitals where many patients don't speak English as a first language were predictors for poor Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, whereas white patients and ones with higher levels of education were predictors for good HCAHPS scores.
That means large, urban hospitals that serve some of the most vulnerable populations are at a disadvantage when it comes to the current scoring system.
"It's been a long-standing feeling of many people in large academic medical centers that the current system of reporting patient satisfaction scores is much more difficult for those types of hospitals than for small, rural hospitals," says the study's senior author, Randall Holcombe, MD, professor of medicine, hematology, and medical oncology at the Icahn School of Medicine at Mount Sinai, and chief medical officer for cancer for the Mount Sinai Health System. "We wanted to look at this and see if there were any factors that seem to predict patient satisfaction scores."
Randall Holcombe, MD
Initially, Holcombe says he and his co-authors hypothesized that patient satisfaction scores would track with population density, as previous research has suggested. Indeed, they found that "scores were definitely better in the less populous states," he says.
But was population the only predictor?
"We decided to dig deeper and look at lots of different parameters," he says.
The researchers analyzed HCAHPS survey data from 934,800 patient respondents who were seen at 3,907 hospitals across the country, representing more than 95% of the nation's hospitals.
The predictors they identified were so strong that you could actually predict what a hospital's patient satisfaction score would be before any patient even filled out a survey, Holcombe says. The lowest satisfaction scores were from population-dense regions of Washington, DC; New York State; California; Maryland; and New Jersey. The best scores were from Louisiana, South Dakota, Iowa, Maine, and Vermont.
"It provokes discussion about whether there should be some additional adjustments considered by [the Centers for Medicare & Medicaid Services]. They now tie reimbursement to these hospitals to these patient satisfaction rankings," he says. "It's very important that it's a level playing field."
He notes that CMS already adjusts for certain factors when determining scores, such as whether patients filled out the surveys by mail or electronically and the age of the respondents.
"Adjusting scores is not a novel concept. [But] there were still additional factors that they could consider adjusting for," he says. "I've not heard anything from CMS yet, but I'd be happy to talk with them about our findings."
That sentiment is echoed by Sandra Myerson, senior vice president and chief patient experience officer of the Mount Sinai Health System. She responded to questions via email:
"Specialty surgical hospitals that only provide specific, planned, and elective procedures to insured patients who are well enough to undergo surgery realize a significant advantage to medical centers that provide care to every patient regardless of their ability to pay for services or their health status upon unscheduled admission, yet CMS does not adjust for these differences," "It would be great to see additional studies that support these researchers' findings—perhaps then CMS will pay attention."
Sandra Myerson
If CMS does get in touch, the study can also show how adjusting for those other potentially unfair factors does, in fact, level the playing field a bit more for certain hospitals that are disadvantaged by the current scoring. The researchers created a formula to adjust for the biases they discovered and applied it to all of the hospitals in New York State. It did, in fact, readjust the rankings slightly.
"Seven of the hospitals in the top 10 still were" there, Holcombe says. "It didn't really blow up the rankings, it just refined them a little bit."
Whatever the setting, Myerson says the keys to providing a great patient experience "include seamless care coordination, on-time care delivery, and effective, compassionate, and empathetic communication with patients and their family members by nurses and physicians."
Holcombe agrees.
"We don't want to imply that our formula is an excuse for bad patient experience," he says. In fact, it could serve as something of a wake-up call for large urban hospitals to pay more attention to these factors. Does your hospital have adequate signage and translation services for people for whom English is a second language, for instance? It's something that Mount Sinai is keeping in mind, too.
"We've discussed this, and these point to areas where we can focus our efforts," Holcombe says.
Two changes affecting trauma care at a Florida hospital cost nothing to make, but saved the hospital more than $100,000 in costs over nine months.
When a clinician presents hospital administration data showing that its ICU isn't performing as well as the ICU 30 miles up the road, leadership can react one of two ways: by taking offense, or by making changes.
Robyn Farrington, RN, trauma program manager at Broward Health Medical Center in Fort Lauderdale, FL, took the second option when she saw the results of a study in the Journal of Trauma and Acute Care Surgery showing that trauma patients at her mixed ICU had worse outcomes than ones admitted to a dedicated trauma ICU (TICU) at Delray Medical Center in nearby Delray Beach.
Robyn Farrington, RN
Trauma patients are definedby the hospitalas "those suffering from an injury so severe that it could cause death if not attended to within the first 60 minutes."
"An individual could very easily have been almost offended, because we were doing it so long a certain way thinking we were doing a great job," says Farrington. "You have to look at the results objectively and just know that what's there is only there in an effort to improve patient care."
Improving patient care was what Marko Bukur, MD, an attending trauma physician at both hospitals, set out to do when he decided to study the differences in trauma patient outcomes between the two ICUs. His own observations, based on working in both units, led him to hypothesize that outcomes would be better in the dedicated TICU.
He says that care at the dedicated unit was more cohesive, had more organized nurse involvement during rounds, and relied less on consultants than the mixed ICU. "I've seen things always ran smoother at the dedicated trauma unit."
'Striking Differences' Between ICU Types So Bukur and his co-authors conducted a retrospective review of the ICUs that are both Level I trauma centers and covered by a single group of surgical intensivists. The researchers examined outcomes for 3,833 patients over five years.
"There were pretty striking differences in the amount of ICU complications that occurred," Bukur says. Specifically, the researchers found:
Overall complications were significantly higher in trauma patients admitted to the mixed ICU (27.5% vs. 17%)
Failure to rescue was higher in trauma patients admitted to the mixed ICU (3.7% vs. 1.8%)
Trauma patients admitted to the dedicated TICU had significantly lower chances of developing post-injury complications
Overall mortality was lower among patients in the TICU
"It's the same physicians providing care," Bukur says. It was "just the infrastructure in place at the [dedicated trauma] ICU that was likely accounting for the vast majority of the difference."
Two Major Changes
When Farrington saw the study results, she knew they had to act. "We made some fundamental changes within our ICU," she says.
Specifically, two major changes were made. Both took only about two months to implement and cost nothing, but already have improved patient outcomes since they were implemented almost a year ago.
First, the placement of trauma beds was changed simply by reassigning where on the unit trauma patient beds were located.
Previously, "trauma patients could really be scattered anywhere within those 24 beds," Farrington says. Now, the higher number beds—about 8 to 12 of them—are designated for trauma patients, so that all trauma patients are geographically near each other on the unit.
The other big change was assigning a core group of ICU nurses to work as dedicated trauma nurses. "The nurse manager engaged the staff to determine those nurses who really wanted to work the trauma patients," Farrington says.
As a result, trauma patients are now cohorted together and cared for by a dedicated nursing staff, creating a "closed" unit without physically closing it off, putting up walls, or doing any construction.
Some flexibility remains. The number of trauma patients might fluctuate, and the designated trauma beds might sometimes get some overflow, but for the most part, those beds are for trauma patients. The nurses also participate in daily rounds at certain times of day using a designated trauma checklist.
Nursing Leaders Supported Changes In addition to reassigning the beds, the nurse manager reached out to the nursing staff to determine who would be part of the new trauma team, and to ensure that they had their Trauma Nursing Core Course (TNCC) certifications up to date and current. After that, it was simply a matter of creating new schedules.
Farrington credits the nurse manager for taking the lead and making these changes.
"It was very easy to implement; the key was the buy-in of the nursing leadership team in the ICU," she says.
Importantly, no one was assigned the trauma nurse role against his or her will; instead the nurse manager put out the call to her staff, and willing nurses volunteered.
"We have a good core that stepped up and said, this is something we want to do," Farrington says. "There has to be a willingness to do it, as well" as having the knowledge and skill base of trauma nurses.
Results
The changes have resulted in cost reductions and patient outcome improvements within the ICU, Farrington says. She later said via email that since its inception in August 2014, the changes have so far led to the following improvements:
Decreased length-of-stays have led to a savings of just over $100,000
Fewer pneumonias: Prior to implementation there were nine or ten cases per quarter. In the final quarter 2014, there were four cases; and in the first quarter of 2015, there has been only one case of pneumonia
Fewer CLABSIs: Four CLABSIs were documented in the eight months before the change went live; for the past nine months, just one CLABSI has been reported within in the trauma population
"The more than you do something, the more likely you'll excel at it," Bukur says of the dedicated trauma nurses.
"This is free," Farrington says. "A couple months with no real investment, other than time and energy."
A study of 153 existing clinical registries found "there's no governing body, there's no standards, [and] there's no official central clearinghouse," says one researcher.
Of the clinical registries that exist in the United States, only a handful are up to snuff, and a lot of care isn't being tracked at all, according to a study published in the Journal for Healthcare Quality.
It not only found that most U.S. clinical registries that collect data on patient outcomes are substandard, but also that the vast majority of recognized medical specialties in the United States have no national clinical registry.
"One fifth of the US economy [is] largely unmeasured in terms of patient outcomes," says Martin A. Makary MD, MPH, surgeon and professor of health policy and management Johns Hopkins and senior author of the study. "This effort has been underrecognized, underappreciated, and underfunded."
Clinical registries—defined by the researchers as databases of patient outcomes developed and maintained by medical organizations and medical specialty groups—are neglected, and "there's no governing body, there's no standards, there's no official central clearinghouse," Makary says.
So he and his team set out to create a "registry of registries" to identify the ones that exist and describe what they're doing—and not doing. They evaluated 153 U.S. clinical registries containing health service and disease outcomes data and found that:
Among the 117 AMA specialty societies, just 16.2% were affiliated with a registry
Government funding was associated with only 26.1% of registries
Only 23.5% of registries risk adjusted outcomes
Only 18.3% of registries audited data
Mandatory public reporting of hospital outcomes for all participating hospitals was associated with just 2% of registries
Martin A. Makary MD, MPH
"What's better than the current standard of care? We don't know because we by and large don't measure it," Makary says. "Ninety-nine percent of care delivered has an outcome that will be untracked." Part of the problem, he adds, is that hospitals are required to track and report massive amounts of data, "including a fair amount of junk."
"In fact, the only outcome that anyone's been able to describe in the value-based healthcare conversation have been the ones that are easy to study and have a minimal impact on quality," Makary says.
"We're talking about patient outcomes here, we're not just talking about patient satisfaction scores and bloodstream infection and central line infection rates… Those are very easy to measure and they are poorly associated with overall hospital quality."
His comments echo those of Deeb N. Salem, MD, physician-in-chief and chairman of the Department of Medicine at Tufts Medical Center in Boston, and first author of the Journal of General Internal Medicine paper "Quantity Over Quality: How the Rise in Quality Measures is Not Producing Quality Results." He told HealthLeaders last month that "we may not be scrutinizing quality measures as well as we should."
Makary says that a measure such as patient satisfaction is important and should be tracked. But "you can have a completely unnecessary surgery and be totally satisfied with it," he says. "We should not fool ourselves into thinking that the easy-to-collect metrics are the ones that are comprehensive and tell the whole story about a medical center's performance."
For all of the untracked care and haphazard and sporadic registries that exist, there are a handful of exemplary researchers say, such as the cystic fibrosis registry, which is "in my opinion, the model of American registries," Makary says. It tracks nearly every patient with cystic fibrosis in the United States and allows scientists to analyze what works, what doesn't work, and ultimately, what's best for patients.
He also points to the organ transplant registry as a success story.
"A huge body of scientific literature has come out of that registry," he says, adding that its data has helped researchers have a better understand science of rejection, transplantation, and immunotherapies, and has also changed laws that govern transplant surgery.
The best registries, Makary says, are not too onerous to use, and have data collection standards that are sound yet feasible.
"So how do you resist the urge to make data collection perfect, when the real goal should be to have something that is very good and generalizable?" he says. "The real goal is finding the sweet spot of what's feasible and yet scientifically sound."
Provider Participation
In addition to sound data collection and adequate funding, registries need participation from hospitals. Makary's team often heard that registries had trouble recruiting hospitals, and cost was the top reason why.
"For a hospital to choose not to measure its performance because there's no business case that's obvious to them represents a conflict between what policy makers and quality leaders talk about when they talk about the importance of moving toward value based healthcare," Makary says.
Since the study was published, Makary says he's had a lot of feedback. "I've had members of Congress contact me and say, 'Hey how can we support registries?'" he says. He tells them to recognize registry participation. If hospitals are paying money for national benchmarking, they should be supported rather than punished financially for trying to evaluate their performance.
In short, registries need more funding, better standards, more attention, and more participation.
"It represents a tremendous opportunity to advance medical science," he says. "It's important work. And it probably represents the greatest uncharted territory in American medicine today."
Hospitals have a broader responsibility to elderly trauma patients than just the time spent within their walls, and should consider updating their strategies to ensure the best outcomes for these patients, research suggests.
Elderly trauma patients are increasingly likely to be discharged to skilled nursing facilities, rather than inpatient rehabilitation facilities (IRF), finds a study in The Journal of Trauma and Acute Care Surgery published in the April issue.
Patricia Ayoung-Chee, MD, MPH
Discharge to skilled nursing facilities for trauma patients has, however, been associated with higher mortality compared with discharge to inpatient rehabilitation facilities or home.
Researchers wanted to "better characterize trends in trauma discharges and compare them with a population that is equally dependent on post-discharge rehabilitation." They not only examined trauma discharges, but also discharges of stroke patients, who have been taking up more inpatient rehabilitation facility beds.
Using data from 2003–2009 data from the National Trauma Data Bank and National Inpatient Sample, the retrospective cohort study found that elderly trauma patients were 34% more likely to be discharged to a skilled nursing facility and 36% less likely to be discharged to an inpatient rehabilitation facility. By comparison, stroke patients were 78% more likely to be discharged to an inpatient rehabilitation facility.
This is despite the findings of a 2011 JAMA study of patients in Washington State showing that "Discharge to a skilled nursing facility at any age following trauma admission was associated with a higher risk of subsequent mortality."
The Journal of Trauma and Acute Care Surgery study notes that "elderly trauma patients are the fastest-growing trauma population," which leads to the question: Where should hospitals be investing their money and time to ensure the best outcomes for these patients?
"I think hospitals should be investing in post-acute care discharge planning," says Patricia Ayoung-Chee, MD, MPH, Assistant Professor, Surgery, NYU School of Medicine, and lead author of the study. "What's the best post-acute care facility for patients? And it may end up needing to be individualized."
She says reimbursement and insurance factors have "played more of a role than anybody sort of thought about" in discharges, rather than what is always necessarily best for patients.
For example, to be classified for payment under Medicare's IRF prospective payment system, at least 60% of all cases at inpatient rehab facilities must have at least one of 13 conditions that CMS has determined typically require intensive rehabilitation therapy, such as stroke and hip fracture.
"I think the unintended consequence is that we may be discharging patients to the best post-acute care setting, but we also may not be," Ayoung-Chee said by email, and that question "is only now being looked at in-depth."
She says hospitals should think about truly appropriate discharge planning upfront.
Proactive Hospitals
For instance, at admission, hospitals can find out who the patient lives with, or what their social support system is like. If they have a broken dominant hand after a fall, will they be able to get help with their groceries? Do they live alone? Will they be able to use the bathroom?
Caring for patients also doesn't end when patients leave the hospital, she adds. Hence the study's title: "Beyond the Hospital Doors: Improving Long-term Outcomes for Elderly Trauma Patients."
Ayoung-Chee says the next step in her research is to look at a more longitudinal picture, following individual patients to see what factors play into their function or lack of function.
But hospitals can do some of that work on a smaller scale, with internal audits to determine which facilities have the best post-acute care outcomes. For instance, they could spend time examining which facilities had fewer readmissions compared to others, as well as how long it took patients to get home and their how satisfied they were with their care.
Other research is also trying to determine which facilities are best for elderly trauma patients. For instance, a second study, also published in The Journal of Trauma and Acute Care Surgery, shows that geriatric trauma patients have improved outcomes when they are treated at centers that manage a higher proportion of older patients.
One of the overarching takeaways from Ayoung-Chee's research is the idea that hospitals have a broader responsibility to patients than just the time spent within their walls.
"What we do doesn't just end upon patient discharge. If we truly want to get the biggest bang from our buck, we're going to have to think about the entire continuum," she says.
That could range from working to prevent falls that can cause elderly trauma, to seeing patients through all of the appropriate care needed to expect a good functional outcome. Good healthcare for elderly trauma patients should extend beyond the parameters of morbidity and mortality, and toward returning patients to their original functional status and, ultimately, independence, says Ayoung-Chee.
"Our long-lasting effect as healthcare providers isn't just what we do in the hospital," she says. "And we have to start thinking outside."
Researchers find a "very strong relationship between [physician] satisfaction and burnout and the leadership behaviors of physician supervisors" in large healthcare organizations.
Physician burnout is prevalent throughout the U.S. healthcare system—experienced by nearly half (46%) of physicians, according to data published in JAMA last year. But effective leadership appears to alleviate it, according to new research from Mayo Clinic and published in the April issue of Mayo Clinic Proceedings.
In 2013, nearly 3,000 physicians and scientists across Mayo Clinic's three campuses in Arizona, Florida, and Minnesota responded to a survey about their wellbeing in the workplace. They were asked not only to rate themselves on burnout and satisfaction, but also to evaluate their immediate supervisors, who were physicians and scientists themselves, in 12 specific dimensions of leadership.
Tait Shanafelt, MD
Not only did 40% of respondents report at least one symptom of burnout, but researchers were able to link burnout rates to how well the physicians rated their leaders.
For every one-point improvement in the 60-point leadership score, there was a 3.3% decrease in likelihood of burnout and a 9% increase in satisfaction. Scores were adjusted for age, gender, length of employment, and specialty area.
The leadership factor was also pronounced at the work group-level, with 11% of the variation in burnout and a whopping 50% of the variation in satisfaction among physicians explained by the supervisors' average leadership score.
"There was this very strong relationship between satisfaction and burnout and the leadership behaviors of physician supervisors," says Tait Shanafelt, MD, professor of medicine at Mayo Clinic and first author of the study. "At a high level, the most important point is that leadership behaviors matter."
Teachable Behaviors Shanafelt says the specific leadership behaviors he and his team evaluated could be boiled down into how well the supervisors informed, engaged, and empowered those that they led. He points out that all of the leadership behaviors measured were actionable, ones that can be learned or developed.
"Part of what this tells us is that healthcare organizations probably need to invest more thought and energy both into how they select and also how they develop and train effective physician leaders," he says.
Traditionally, physician leaders have been selected based on being good doctors or experts in their field, rather than whether they necessarily have the have the skills and qualities of effective leaders, Shanafelt says.
"Those [clinical] qualities, while certainly admirable, may or may not set them up to succeed as a leader," he says. Rather, other qualities, such as being open to new ideas, consensus building, and bringing together diverse opinions, are ones that make good leaders who can bring about change.
Tim Gueramy, MD, a foot and ankle orthopedic surgeon who's experienced burnout, agrees, saying that physicians who rise to leadership roles because of the number of papers they published or how cutting-edge their practice is, don't always make good leaders.
"[Those are] not leaders, those are innovators," he says. "Physician leaders have to do what's best for everyone." They need to ask themselves, "How do I take a big group, and globally make patient care better?"
Ultimately, Gueramy left practice for three years to develop his startup, DocbookMD (he's the CEO), after years spent in the "rat race" of seeing huge volumes of patients and working long hours.
Today physicians have less autonomy than ever before. Shanafelt says that 75% of physicians are now employed by large healthcare organizations, which is a profound change from the solo or small group practices of days gone by.
That remarkable change in practice structure has also brought a change in leadership needs. Shanafelt says effective leaders today, should ask their physicians for their ideas, let the individuals that they're leading identify and develop solutions to local problems, as well as given them the tools to put those solutions into effect.
Physicians are 'Challenging' to Lead "Physicians are inherently critical thinkers who want to solve problems," he says. "The good physician leaders recognize that and sort of engage and empower their physicians to develop their own solutions."
Shanafelt acknowledges that physicians are not always easy to lead.
"Physicians can be a challenging group of individuals to lead because they often bring this very deep understanding of medical practice, they often have developed a healthy degree of skepticism, which is part of the training process," he says. "They're very attentive to detail, want evidence for decision-making, [which] can make it hard to build consensus."
The rise in physicians working in large groups, combined with the perfect storm of burnout factors, makes it more important than ever for healthcare organizations to work on training and developing physicians who can lead in such a challenging environment.
Moreover, improving leadership to reduce physician burnout will have a rippled effect across the organization, since burnout is linked to everything from physician satisfaction and turnover, to quality of care. Shanafelt says some organizations, like Mayo Clinic, have leadership development programs in place, but most don't.
"I think there is an opportunity to expand those efforts," he says. "Good leadership matters and has a profound impact on the satisfaction and burnout rates among the physicians working within large healthcare organizations."
Female RNs continue to earn less than their male counterparts across settings, specialties, and positions, data shows.
The gender pay gap in the United States may vary according to who's measuring it—the White House says women earn 77% of what men earn, while a Pew Research Center survey says women earn 84% of what men earn—but it's always there, even in the female-dominated nursing profession.
In fact, that gap is about $5,148 per year when adjusted for factors such as education and experience. And according to a study, nursing's gender pay gap hasn't narrowed in 25 years.
Ulrike Muench, PhD, RN
"We have been tracking these pay differences in the last few years, and so in some ways were not surprised to see the trend continue," lead author Ulrike Muench, PhD, RN, of the University of California, San Francisco, says via email. "But we didn't expect to see no improvement when looking over a period of 25 years."
Although the lack of men in nursing is often lamented, Muench's research, which was published in JAMA, in March, shows that men who are in nursing out-earn their female counterparts nearly across the board.
"Our study found that female RNs earned less than male RNs even when accounting for work settings, specialty areas, and job positions," she says. "We also adjusted for the number of hours worked, education, and many other factors."
Muench and her team examined salary data from 1988–2013 using the now-discontinued quadrennial National Sample Survey of Registered Nurses (NSSRN) and the American Community Survey (ACS). The NSSRN sample included 87,903 RNs, and the ACS sample included 205,825 RNs. In both samples, 7% of the RNs were male.
"While numerous studies have examined pay differences for physicians, we know surprisingly little about pay differences in nursing, and no study has looked at RN earnings differences over time," Muench said.
The researchers found that the salary gap was $7,678 for ambulatory care and $3,873 for hospital settings. It was also present in all specialties except orthopedics, ranging from $3,792 for chronic care to $6,034 for cardiology. Salary differences also existed by position.
In addition, "No statistically significant changes in male vs female salary were found over time," the study says.
Male nurse leaders don't need to have experienced pay differences themselves to know that a salary gap exists across industries.
"I do think there are disparities in compensation between men and women in all different sectors," Dale Beatty, RN, MSN, RN, NEA-BC, CNO at University of Illinois Hospital and Health Sciences System in Chicago.
Although Beatty says he does not have any direct experience regarding pay differences between men and women, he has seen the literature about it.
"I'd like to say there isn't, but I think there's enough evidence out there to suggest that there is some work that we need to do. I think the bigger issue is if there are differences we should really look to try to understand what they are… It's not a healthy situation if that's occurring."
Muench's study didn't look at why the gender pay gap in nursing exists, and adds that it's "too early to speculate" without additional research. But she does offer a couple of theories of her own.
"It is possible that men gain more experience over time by working longer hours, or that men are more willing to take on additional shifts when the unit is short-staffed," she said. "Assuming all other factors stay the same, a worker with more experience or a more flexible worker earns more."
Muench says healthcare executives have a role to play in correcting the pay gap, and it's a role that starts in their own institutions.
"Healthcare executives are in a great position to examine in their organizations whether pay differences exist between men and women," Muench says.
If pay differences do exist, executives should next try to determine whether those differences are justified.
To get the ball rolling on equal pay, Muench points to the U.S. Department of Labor, "which suggests introducing open pay policies that help with transparency around compensation and has produced an employer's guide to equal pay that has some useful tips," she says.
For instance, a Department of Labor equal pay guide not only includes suggestions for employers such as implementing an open-pay policy, but also for regularly monitoring and evaluating pay policies and listening for red-flag statements from employees and managers, such as "It is not our fault if they are bad negotiators for their own salaries," and "I'm not exactly sure what was used to decide this salary."
Knowing that pay differences exist and acknowledging that they might not be justified are important first steps in correcting the gender pay gap. And perhaps this study will serve to alert any remaining skeptics that, even in the female-dominated world of nursing, the gender wage gap is real.
"If it's happening in other sectors," Beatty says, "Why would you believe it wasn't happening for nursing as well?"
Half of the nation's emergency departments have a physician or nurse dedicated to the role of pediatric emergency care coordinator—a three-fold increase since 2003, research shows. But only half have a disaster plan that addresses issues specific to the care of children.
Marianne Gausche-Hill, MD, FACEP, FAAP
Children have different medical needs than adults, and that's also true in emergency situations. That's why Marianne Gausche-Hill, MD, FACEP, FAAP, of the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, says it's "really heartening" that the nation's emergency departments have significantly improved their pediatric readiness in the past several years.
Gausche-Hill is the author of a study published in JAMA Pediatrics this month, which assessed how well EDs are complying with recommendations for pediatric readiness that were issued in 2009by the American Academy of Pediatrics, American College of Emergency Physicians, and Emergency Nurses Association.
Among the resources EDs should have, according to the "Guidelines for Care of Children in the Emergency Department" are:
A physician/nursing coordinator for pediatric emergency medicine
Physicians and nurses who are regularly trained in emergency care for children
A pediatric care review process that's integrated into the hospital's quality improvement plan
The right kind of equipment to care for children
The Physician/nursing Coordinator One of the key factors for pediatric readiness is the role of the pediatric emergency care coordinator, who ensures that staff are appropriately trained, that the ED is prepared with the right equipment, and that the right kinds of policies are in place for caring for children.
This person also looks at data and develops quality indicators to follow; liaisons with others who could have an impact on the care of children, such as the trauma committee, local EMS, or other hospitals within a system; and coordinates regular education updates for nurses.
The study found that half of the nation's EDs currently have a physician or nurse dedicated to this role, which is a three-fold increase since 2003.
Gausche-Hill says the role of the pediatric emergency care coordinator is particularly important because hospitals often don't see enough ill or injured children to realize what policies or equipment they don't have.
"The average number of children that are seen in emergency departments across the country [is fewer than] 13 a day," she says, and most of those children are actually not really very sick or hurt. "The likelihood that it's on somebody's radar on a daily basis is relatively low."
That's why the presence of a pediatric emergency care coordinator, all by itself, is important to pediatric readiness for the entire ED.
"The emergency departments that assign that role are more likely to be compliant with the guidelines," Gausche-Hill says, sometimes as much as four times as compliant. For instance, EDs with a pediatric emergency care coordinator are four times as likely to have a QI plan and twice as likely to have all the policies in place.
There were other bright spots in the assessment, such as the finding that emergency departments have 91% of recommended pediatric equipment readily available.
Photo: American College of Emergency Physicians
Room for Improvement But there are still areas where EDs can improve. For instance, one third of EDs still weigh children in pounds, instead of kilos as is recommended, which can lead to medication dosing errors. In addition, only 47% of respondents had a disaster plan that addresses issues specific to the care of children.
The assessment also found that nearly 81% of respondents reported barriers to complying with the guidelines, such as the cost of training personnel (54%) and lack of educational resources (49%).
But Gausche-Hill says there are lots of ways around those perceived barriers, such as the wide availability of online education and sample policies. She also points to strategies such as shared equipment between low-volume and high-volume hospitals, as well as shared policies, and even shared coordinators between small hospitals.
Building awareness that pediatric readiness is important is also part of the battle, and simply completing the assessment actually helped raise awareness, Gausche-Hill says. The assessment had an 83% response rate, with 4,149 emergency departments taking it, compared with 29% in 2003.
"We are educating as well as assessing," Gausche-Hill says, adding that everyone in the study received a "Pediatric Readiness Score" and a gap analysis report. "This assessment is going to, I hope, stimulate more emergency departments to assign that role."
Gausche-Hill also says that healthcare executives can play a key leadership role in in ensuring pediatric readiness.
"I think they can take a significant role in the development of policies," she says. "When healthcare executives get excited about readiness, it really makes a significant difference."
The data-driven Military Acuity Model aims to determine which tasks are most important to patient care, and which ones cost physicians and patients time and poorer health if they're not completed.
At the Johns Hopkins Kimmel Cancer Center clinic, a multidisciplinary approach to care combined with "military-" style efficiency has resulted in an increase in daily patient volume and a decrease in patient ED visits. It's also freed up physicians to focus more directly on patient care.
Joseph Herman, MD (L)
and Shereef Elnahal, MD (R) Source: Johns Hopkins
Kimmel Cancer Center
According to researchers Shereef Elnahal, MD, and Joseph Herman, MD, the Military Acuity Model (MAM) is a workflow that's similar to the Lean management philosophy, but doesn't focus on physical resources in the same way.
"This method actually focuses on making sure the cognitive resources are in place for your staff," Elnahal says.
MAM aims to determine which tasks are most important to patient care, and which ones cost physicians and patients time and poorer health if they're not completed or if they are done incorrectly.
To make those determinations, MAM uses data mining. The researchers mapped out every task required for care and then looked at a year's worth of clinical data to see whether those tasks were completed. They correlated those tasks with clinical endpoints.
For instance, did patients call the clinic after their visit complaining of symptoms? Did they call because they didn't understand their treatment plan? Did they end up in the ED for an issue that instead could have been addressed during their clinic visit?
After examining the data, the researchers came up with six tasks that were the most critical for patients and workflow. And they discovered something unexpected.
"All of those six high-value tasks could be completed safely by somebody other than the physician," Elnahal says. "That left more time for the physicians and the front-line clinical support staff to do what they do best."
In this particular clinic the six tasks were:
Determining the patient's assumed disease stage prior to clinic
Obtaining or performing necessary imaging studies
Determining which therapies, if any, the patient has received to date
Assessing patients' comorbidities and offering treatment options
Assessing patients' social risk factors and offering treatment options
Assessing and treating patients' pain
Instead of being performed by physicians, those tasks were reallocated to two support staffers: A nurse and a unit coordinator whose main job, previously, consisted mostly of administrative work. Now, according to Herman, the unit coordinator has been "empowered and educated" so that she can organize and assemble information that clinicians need. She also proactively communicates with patients to tell them what to expect and answer their questions.
"Historically hospital networks and systems underutilized their staff," says Herman. But now, the unit coordinator role has evolved into something new. "It's more of a position that I feel like doesn't really exist," he says.
The results of implementing the workflow have been striking. The clinic not only increased its daily patient volume by 31.4%, but in the 30 days after patients' clinic visits, the percentage of patients who needed to call the clinic to discuss unresolved health issues decreased from 34% to 22%.
And the percentage of patients who had to go to the ED after a clinic visit decreased from 9.9% to 7.9%, according to the study, published in the March 2015 issue of the Physician Leadership Journal.
Making sure the six tasks were done and done well streamlined workflow and patient experience, and reassigning them to support staff allowed physician to focus all of their energy on patient care, the researchers conclude.
They note that MAM can be applied anywhere. The only difference is that the "essential tasks" will vary depending on the facility and the care that's provided. And they have to be determined by each individual care team that implements MAM.
"Only they know what tasks are required to treat their patients," Elnahal says. "The people who have the most insight to that are the care teams themselves, so engaging with them upfront is absolutely necessary."
And that insight hits on another important point about implementing MAM: Data isn't enough. "This was a team effort from the beginning. You have to get consensus and buy-in from every single member of care team," Elnahal says. "These data-driven changes in process cannot happen without a holistic approach to the underlying culture of a team."
Now, not only has the Kimmel Cancer Center clinic permanently incorporated MAM into its workflow, but Elnahal and Herman say they are working with VA and military health facilities, such as Wright-Patterson Air Force Base, that are interested in incorporating it, too. In fact, MAM was originally developed by the U.S. Air Force and an outside vendor. Now Elnahal and Herman have adapted the method for outpatient care.
"This method is not limited in any way to a particular setting," Elnahal says. "I think there's definitely huge potential for this to improve care outside of our particular scope."
Evidence-based care models that address the specialized needs of elderly patients exist, but nearly one third of survey respondents say they "frequently" experience age-related discrimination from doctors or hospitals.
Ageism is common in healthcare, and when older adults experience it frequently, they're more likely to develop new or worsened disability, according to a study in the Journal of General Internal Medicine.
Researchers analyzed data from 6,017 Americans older than 50 who took part in the 2008, 2010, and 2012 nationally representative Health and Retirement Study. They found that one out of five of these adults experience discrimination in healthcare settings, and one in 17 experiences it frequently.
Almost one-third of respondents (29%) who reported frequent healthcare discrimination developed new or worsened disability over four years, compared to just 16.8% of those who infrequently experienced it and 14.7 % who never experienced it.
"Ageism in healthcare is very common and experienced by many older adults," says lead author Stephanie Rogers, MD, MPAS, MPH, a clinical geriatric fellow at University of California San Francisco. "People who felt like they were discriminated against had worsened functional status."
She says these people were actually less able to do simple things such as bathing, walking, feeding, and dressing.
Although the study findings are stark, Rogers says she wasn't surprised by them. The surprise actually came during her residency training when she saw how older adults were treated in the healthcare system.
"We seemed to treat them like everyone else," she says. She saw the elderly being treated with the same interventions as people in their 30s and 40s, even though their bodies were much different. For instance, they are much frailer, and they metabolize medicines differently.
Rogers also notes that most research studies exclude older adults, meaning that a huge subsection of the population isn't being included in clinical trials.
"We were treating them the same as younger patients, and it didn't seem quite the right way to do things," she says. "It's just now starting to be recognized that we should be treating older adults differently than we treat younger adults."
Little Interest in Geriatrics
Yet for all of these differences—and for the growing number of seniors in this country—Rogers says there doesn't seem to be much interest in or respect for geriatrics. There are only about 7,000 geriatricians in the United States. "Why would you want to specialize in older adults?" other physicians would ask her.
Compare that with pediatrics, which has its own subspecialists, wards, and dedicated hospitals, and good access to pediatricians, Rogers says. In fact, the American Academy of Pediatrics counts 91,915 pediatric-focused physicians in the United States, and says there's a still shortage of pediatric medical subspecialists in many fields, as well as a shortage of pediatric surgical specialists.
Although her study didn't look at how older adults were discriminated against, Rogers says patients who experience it may have worse communication from doctors or don't believe they're getting enough information from their doctors. In addition, the physical space of a building might not be accommodating for them in some way, or local providers might not offer care for their specific needs.
"They may be feeling they're not respected by the healthcare professional or the healthcare system," Rogers says.
Anecdotal reports reveal that people who are discriminated against often feel voiceless or invisible, but Rogers says that this study "shows that this is actually happening, and we need to figure out ways to fight this discrimination and level the playing field."
There are already proven ways to more effectively care for older adults; hospitals and health systems just aren't using them, Rogers contends.
She points to well-established, evidence-based care models such as Acute Care for the Elderly (ACE) units and the Hospital Elder Life Program(HELP), which aims to prevent delirium. She says implementing programs like these may not only improve patient outcomes, but also save hospitals money and improve satisfaction scores.
"These models exist, but very few hospitals actually use these models," Rogers says. "The hospital systems have not recognized the importance of them or implemented them."
Whatever the reason geriatrics is neglected and older adults are discriminated against, Rogers says it's something that the healthcare system needs to address, and urgently.
"Our nation is aging and we're going to have many, many older patients in our healthcare system. We need to find the models and use the models that exist to care for them better," she says. "This is neglected, and this needs to be a priority."
A paper by the chairman of the Department of Medicine at Tufts Medical Center finds "very little evidence" that the 30-day readmissions measure of quality "has any effect on overall survival." In fact, he says it, "drives a lot of doctors and hospitals crazy."
Deeb N. Salem, MD
Physician-in-Chief,
Chairman, Department of Medicine,
Tufts Medical Center
Not all quality measures are created equal: Some are good, some are head-scratchers, and a handful may even be dangerous to patients.
That's the argument of "Quantity Over Quality: How the Rise in Quality Measures is Not Producing Quality Results," a perspective piece in the Journal of General Internal Medicine.
"All quality measures are not equal, although they're treated as equal… some of them are very importantly backed by science, and some of them are not very well-backed at all," says Deeb N. Salem, MD, physician-in-chief and chairman of the Department of Medicine at Tufts Medical Center in Boston, and first author of the paper. "It raises the fact that we may not be scrutinizing quality measures as well as we should."
According to the paper, quality measures take clinical guidelines a step further, into the realm of a "mandate that affects fiscal compensation and public reputational standing. QMs influence patient care, institutional compliance, and organizational financial well-being."
And that's where things can get cloudy.
For instance, Salem points to 30-day readmissions, the quality measure that he calls the "one I hate the most" and that "drives a lot of doctors and hospitals crazy."
"The 30-day readmissions one is filled with unanswered questions," Salem says. "Why are we using this one? Why has it become something that if we don't do well on, the hospital is going to lose money?"
Salem says he has "no idea" how or why those 30 days were arrived upon in the first place, and sees "very little evidence that this has any effect on overall survival."
Moreover, the paper notes there are multiple factors that lead to readmissions, not all of which are within a hospital's control. The paper cites research showing that readmissions vary by patient population, with some attributed to factors such as poverty, mental illness, and lack of social support, so hospitals serving large numbers of those populations may be unfairly judged.
"There are social factors that may play a big role in that," Salem says. "We're maybe punishing hospitals that are taking care of the kinds of people that can't take care of themselves, and we may be hurting those hospitals more than we're helping anybody."
The paper also includes discussion of two quality measures—both of which have now been eliminated—that not only were eventually shown to be ineffective, but actually ended up being harmful to patients.
The "scariest" example of this, according to Salem, was the widespread use of perioperative beta blockers, a quality measure based on research that was later shown to be fraudulent. In fact, "a meta-analysis published in 2013 with consolidated outcomes of over 10,000 randomized participants showed that initiation of [perioperative beta blockers] before surgery caused a significant increase in mortality," the paper says.
"It took years to figure this out," Salem says, but by then, that faulty quality measure had already been used for a long time.
Other quality measures are flawed in other ways, the paper says. For instance, it states that length of hospital stay isn't positively correlated with quality of care, and patient satisfaction in surgical care has "no association with hospital compliance with surgical quality measures."
The point of this discussion isn't to disparage all quality measures, Salem says. He believes there are valid quality measures that have saved many lives, such as the focus on reducing central line-associated bloodstream infections.
"It sounds like we're trashing the whole system; we're not," Salem says. "We're just saying, 'back up a little bit.'"
Instead of focusing on or prematurely adopting quality measures that may not be useful and that may not differentiate good practices—or worse, actually harm patients in the long-term—Salem believes that there should be a peer-review-type process that thoroughly investigates and vets potential quality measures so health insurers and Medicare don't "jump into them without much proof." Instead, doctors and hospitals should be able to focus on the quality measures that are most effective for improving patient outcomes.
"We need to develop a process of being careful and making sure that there is quality in these measures," Salem says.