During the investigation that follows a sentinel event, hospital officials usually discover that somewhere along the line, a key safety step was overlooked or omitted, leading to the error. That step may be verifying a patient's medications, or stopping for a "time out" before the first cut is made. Without these, and others, the chances for error increase significantly. But what happens when a medical error is made, and all protocols were followed?
That's what apparently happened last week at Miriam Hospital, part of the Providence, RI-based Lifespan health system. On Friday, a surgeon at the hospital performed a knee replacement on the wrong side of a patient's body, despite following the necessary safety steps and procedures.
President and CEO Kathleen Hittner, MD, told The Providence Journal that the surgical team correctly went through all of the hospital's required safety checks before surgery, including placing a mark on the knee that required operation. Six members of the surgical team verified the surgery site before the procedure began, Hittner told the newspaper.
Is that possible? Six different medically trained individuals didn't notice that it was the right knee that was draped and prepped for surgery, instead of the left? Six people didn't notice that the skin that was about to be cut wasn't marked with a marker, as was standard procedure? It seems hard to believe, but according to hospital officials, that's the case.
If indeed the surgical team took all of the necessary precautions before surgery, it's a good indicator that policies and procedures alone won't prevent errors from occurring. In that same article from The Providence Journal, The Joint Commission's chief patient safety officer acknowledges that wrong-site surgery "continues at an alarming rate." The Joint Commission has required hospitals to verify patient identity, confirm the surgery being performed, mark the surgery site, and take a time-out before a procedure since 2004, but these rules haven't changed the rate of surgical errors reported each month.
So is medicine doomed to fail at error prevention? It depends. If healthcare keeps relying on policies and procedures as the only safeguard against errors, then the answer is probably. That's why healthcare needs to continue looking for new approaches. Last month, I wrote about a session I attended at the Quality Colloquium at Harvard University that compared healthcare to aviation. In that session, Jim Bouey, former director of safety and airworthiness for Boeing Commercial airplanes, said if we want to overcome the human tendency to err, we must learn the shortcuts the human brain creates and find ways to get around them. That's why on an airplane, for example, all cockpit instruments have standard shapes and meanings.
I wasn't there when six clinicians agreed to operate on the wrong knee, but something tells me that the error that occurred at Miriam Hospital last week was the result of too many brains taking shortcuts. To prevent wrong site surgeries and other sentinel events from occurring, healthcare must go beyond policies and procedures and examine what it is about humans that causes us to err.
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Out of the 25 winners of the 2008 MacArthur Genius grant awards, four of them were physicians—each grant totals $500,000. They include Regina Benjamin, Wafaa El-Sadr, Diane Meier, and Peter Pronovost.
Eli Lilly and Co. will begin disclosing how much money it paid to individual doctors for advice, speeches, and other services. The move was prompted by a push by federal legislators toward transparency, and to ensure that such payments do not improperly influence medical decisions.
A 2006 survey of resident physicians at Massachusetts General Hospital, published in The Joint Commission Journal on Quality and Patient Safety, found that hand-offs often lead to patient harm. More than 80 of the physicians who responded to the survey admitted that at least one of their patients in a month-long span had suffered as a result of flawed hand-offs.
Evaluation and management (E/M) codes are among the major categories of codes that are frequently examined by third-party insurance auditors. Medicare auditors recently have seen many cases in which documentation guidelines are not followed adequately to support a consultation code.
The key reason the documentation is scrutinized is because the reimbursements for consultations are higher than the reimbursement levels for office visits of similar documentation levels. In most instances, if the guidelines were not accurately followed, the consultation was either downcoded or denied. In either case, money is taken back from the practice or the physician.
The office/outpatient consultation codes, 99241-99245, and the inpatient consultation codes, 99251-99255, may be used for either a new patient or an established patient. The inpatient consultation codes may also be used for places of service, such as nursing homes or a rehabilitation facility.
When physicians code a consultation, they should follow the three Rs:
Request. The consulting physician should receive a written request, including the reason for the consultation, from an appropriate source. Be sure it is documented properly and placed in the patient's medical record, as well as in the requesting physician's plan of care. If the physician is documenting in the chart by hand, the notes must be legible. If the notes are not legible, the visit will be treated as though there was no documentation and the visit did not happen, or the physicians will have their money taken back because the visit should not have been paid.
Before the consultation visit takes place, remember to follow this dual-documentation process: The requesting physician as well as the consulting physician should enclose the request and the reason for the consultation and document it in each of their charts.
Render an opinion or advice. The consulting physician must then render his or her opinion or advice concerning the patient's problem and document it in the patient's medical record.
Report information in a shared record. If the consulting physician does not share the patient's medical record with the requesting physician, then a letter must be sent to the requesting provider. In the case that the consulting physician does share the patient's medical record with the requesting provider, the report should be put into a shared record. The report should always include a thank-you letter for the consultation request and state exactly what the consultant's opinion is concerning the patient's medical problem.
Editor's Note: This article was adapted from one that originally appeared in the September 2008 issue of The Doctor's Office, a HealthLeaders Media publication.
For some time, we have speculated that America's health system is sliding towards a financial crisis that could spill over into the general economy and bring it down.
The logic goes like this: explosive growth in the cost of healthcare is pricing rank-and-file Americans out of the coverage market and reducing the system's (inflation-adjusted) available revenues. All the while, service demands have continued to increase, creating a mounting resource-demand mismatch.
We can see this already on the system's edges, in the crises or shutdowns at the nation?s safety net health systems—Martin Luther King in Los Angeles, Women's Hospital in Philadelphia, Grady Hospital in Atlanta—where demands for care simply outstripped the resources required to provide it. Because healthcare is one-seventh of the economy and one-eleventh of its jobs, a meltdown that starts at healthcare's edges and then spreads throughout the industry might cascade to all other sectors as well, wreaking havoc throughout the economy.
Now we believe it could happen the other way around, with the collapse of financial institutions sinking healthcare markets. Consider what might happen, for example, if the many health systems whose margins have been kept afloat through investment income, suddenly lost that revenue stream. The ability to provide care, or to purchase goods and services from others in the health industry, would be dramatically compromised.
Market-based, not policy-based reforms
As the largest part of the economy, America's health system will be sorely tested by the financial markets' turmoil. The challenges posed by diminished resources and the tightening of credit will intensify the pressure on healthcare professionals and organizations that have long resisted major structural changes—like the re-empowerment of primary care, pricing and performance transparency, and payments linked to results—that can finally check rampant cost growth and re-establish stability and sustainability to the industry. If they suddenly share in our pain, they're more likely to be receptive.
Despite the current wisdom, the major levers for reform aren't likely to come from the federal government. In 2007, members of Congress accepted $445 million from the healthcare industry, about 16% of all the lobbying contributions accepted from special interests in exchange for influence over policy. They're hardly likely to disappoint their benefactors by passing laws that would drive out the significant healthcare waste that is an important portion of revenues and margin.
And even if they were interested in addressing the problem, and even if healthcare hadn't fallen off the political radar screen compared to the economy, gas prices, food prices, the current economic turmoil and mounting budget deficits would trump Congress' ability to focus dollars on fixing healthcare.
No, it won't be big government, but big business that drives change. Business is finally apoplectic about healthcare's excesses—the cost, the questionable quality, the lack of demonstrable value, and the employee dissatisfaction—and fed up with its excuses. They want results right now. They don't know why health plans—supposedly their surrogates to insure good care at reasonable cost—and the health industry as a whole aren't cooperating.
Businesses' own growth and economic health depends on its ability to compete globally. Now, in a new push, business leaders appear to be coming together and mobilizing decisively to change the ways the system. They are mad as hell, and they're tired of haggling. They're not going to take it any more, and they're giving notice of their intentions. They are in a mood to demand cooperation, and if it is not there, to seek their own solutions.
Two facets of a primary care initiative by business
Given this backdrop of economic turmoil, increasing pressure on the industry, and business' dissatisfaction with healthcare, let's examine two major events—worksite clinics and primary care re-empowerment—that underscore business' determination to transform the system, and in the process, cut costs, insure quality, and satisfy their employees. Both are focused on "the medical home," though the worksite clinic model is, at this point, the most fully realized by far.
Worksite clinics
The uptake of worksite clinics by mid-sized and large corporations is so rapid that it is hard to understand it in any terms but transformative. Walgreens estimates that America has about 7,600 corporate campuses with 1,000 or more employees (that would generally mean about 2,200 or more lives). About half of all Fortune firms are expected to have clinics by 2010. Because a properly configured clinic is scalable and provides a platform for very proactive management of care both inside the clinic and downstream, on the network, the trend is spreading like wildfire to smaller firms with as few as 250 employees. They're also being bundled with high deductible plans and becoming available to coalitions of smaller employers as well.
Large clinic firms, like Walgreens' subsidiary Take Care, and smaller ones like Orlando-based WeCare TLC and Atlanta-based Worksite Rx, are actively catering to the rush of employers who see this model as a way to dramatically improve care while reducing cost.
"Think of an employer sitting at the table with his healthcare relationships: brokers, health plans, doctors, hospitals, drug and device companies. Everyone but him wants it to cost more, and they are all in direct control of cost creation. So our model is different. We have two goals: Providing better care for the patient, and being a fiduciary for the purchaser. Everything else is secondary." That's a comment by Lynn Jennings, board chair of WeCare TLC, and it typifies an orientation that caters to this new corporate activism on healthcare.
Worksite clinics offer fully integrated health management platforms, separate from and in front of the health plans. Participation is voluntary, but patients who use the clinic don't need to access the health plan until they leave the clinic. In other words, the model goes around the health plan to achieve savings, quality improvement, and employee satisfaction.
The clinics build in significant incentives for both patients and doctors. Employees using the clinics may get free visits, free drugs and labs. Access to the clinics is convenient, fast, private, and secure. Time spent in the clinic often doesn't count as paid time off.
Staff physicians win as well, often making one-third or more than doctors in private practice, with the luxury of spending more time with patients and, because no money changes hand, focusing on care and not worrying about the practice's business aspects.
The clinicians use a complete complement of informational tools: claims analytics and health risk appraisals to identify patients at risk, electronic medical records with embedded best practice and care gap guidelines, and provider profiles to steer patients needing referrals to high performance specialists and inpatient facilities.
Worksite clinics can have had tremendous impact. The City of Port St. Lucie, FL, reported a 3.1:1 return on investment and an 18% total health plan cost drop in its first year of operations. Returns on occupational health, retention and recruitment and lost productivity, are harder to quantify but probably even higher.
Transforming community primary care practices
Worksite clinics are fine for patients in corporations, but how do we change the thousands of small and mid-sized primary care practices in the field? More importantly, how do we allow them to perform the full range of cognitive medicine services they're capable of? Finally, how do we make it worth their while, get primary care off the gerbil's wheel, and encourage young doctors to become generalists?
Two years ago, Paul Grundy, MD, MPH, IBM's Director of Health Transformation, became concerned that his company could not buy comprehensive coordinated care for its U.S. employees.
He could buy an amputation of a diabetic's leg, but he could not buy prevention services to avoid that amputation. Often, he did not see "value" in the outcomes or patient satisfaction associated with the episodic care that IBM was purchasing. He also worried that many of his employees could not name their personal physicians. He saw American primary care's very existence threatened. He knew from a literature review and from IBM's Denmark experience that primary care-based systems saved about 20% in costs and produced 30% better results with immensely greater satisfaction among patients and physicians.
Grundy and his colleagues act
Working through a multi-constituency, action-oriented organization, the Patient Centered Primary Care Collaborative, Dr. Grundy and his colleagues began to drive a powerful market-based reform initiative.
They assembled leaders of nearly 50 Fortune organizations and seven major health plans to describe their findings. His advice to the plans was to move quickly to a primary care model or risk public confrontation and isolation by the Fortunes.
He gathered medical society representatives-family physicians, internists, pediatricians, and osteopaths-for recommendations to re-empower primary care. The result was a declaration of Joint Principles of a Medical Home. Effectively, they argue that American healthcare can be dramatically improved and its cost crisis largely ameliorated if:
Primary care physicians are paid more to collaborate with specialists on the full continuum management of their patients. This would also reduce the profound income gap between primary care and specialist physicians, and provide reason for medical students to again enter primary care as a career.
Mechanisms can be developed to ensure that primary care physicians have access to the full range of modern patient evaluation and management information technology tools.
The rules of engagement are changed between primary care physicians and specialists, so that they can more easily collaborate on patients' care.
This is not a lone view. MEDPAC, the Medicare Payment Commission has also urged Medicare to use medical homes to get Medicare costs under control. In 26 state legislatures, 108 bills introduce "medical homes," and 20 bills in 10 states define the concept and provide for demonstration projects. A few innovative health systems around the country—the Geisinger Health System in Pennsylvania; the Holston Medical Group in Kingsport, TN; Alabama Medicaid; HealthPartners in Minnesota—are actively proving its value.
So far, the major health plans have mounted a few pilots, but nothing substantive or systemic has changed in the way that primary care physicians around the country treated by health plans or specialists. The jury's still out on whether they'll be willing to drive down total claims costs—remember they make a percentage of the whole—by taking advantage of primary care, the most powerful tool at their command.
What does this all mean? Business is defending and advancing its own best interests by taking an active, influential role in transforming healthcare. Whether it can bring enough pressure to bear to bring the entrenched healthcare industry along remains to be seen. But its cause may have just received a boost from the nation's economic woes.
Dr. Richard Reece is author of Innovation-Driven Healthcare: 34 Key Concepts for Transformation and is currently at work on a new book with Paul Grundy MD MPH called Primary Solution. He maintains a column at MedInnovation Blog.
Brian Klepper is a healthcare analyst, speaker and commentator whose consulting firm, Healthcare Performance, helps organization understand and negotiate market-based healthcare reforms that are gaining traction now.
If physicians could be characterized solely based on television stereotypes, the difference between today's doctors and yesterday's would be stark. On the one hand is the revered Marcus Welby, whose patient-centered focus and pleasant demeanor still represents the ideal practice style for family and community doctors.
On the other is Gregory House, a brilliant diagnostician known as much for his horrible bedside manner and abruptness with patients as his cleverness at diagnosing rare diseases. One of the show's plot points even involves mandatory shifts at a walk-in clinic as punishment for his bad attitude.
Of course physicians can't all be pigeonholed based on television characters. But there may be some truth in fiction.
If there's one subject that's been on my radar screen more than any other in the last few months it's the troubled state of the doctor-patient relationship. I initially wrote about it last month after the New York Times declared the relationship "on the rocks." And it keeps popping up in story after story.
This week USA Today covered a study of VA physicians that found "cancer specialists and surgeons rarely responded with empathy to patients' concerns." Researchers studied audio recordings of doctor-patient interactions and found that physicians missed nearly every opportunity to show empathy in response to patient comments such as "this is overwhelming" or "I'm fighting it."
In a JAMA submission this month, researchers suggested that medical students may need education in emotional intelligence to become more sensitive to their patients. In the New York Times, Pauline Chen, MD, warns of the "tyranny of diagnosis" that can shift doctors" focus to the disease rather than the patient.
House's response to this type of alarm ringing: "What would you want, a doctor who holds your hand while you die, or a doctor who ignores you while you get better?"
He has a point. Physicians tackle extraordinarily complex problems every day—from patient diagnoses and medical codes to technology implementation and managed care contracts—that can make issues of emotional connection and proper sensitivity pale in comparison.
Even I have a similar aversion to what reporters refer to as "squishy" topics. After writing about emerging hospital-physician business strategies or following a major piece of Medicare legislation, a topic like doctor-patient communication can seem a little soft.
But House doesn't have to worry about payer rankings, losing patients to competitors, or performance-based compensation—all of which can be influenced by poor patient satisfaction. And his plans to cure a patient with his diagnostic skills alone may not be as effective as he thinks—patients are less likely to adhere to medication plans and treatment options when dissatisfied with their doctor.
As the physician shortage intensifies and workloads increase, doctors will have less time for patient interactions and communication will become a bigger challenge during a time when patients are more demanding than ever.
The solution, for the most part, is easy enough. You just have to make it a priority, for yourself and your organization.
That doesn't necessarily mean getting in touch with your sensitive side. Communication skills are in large part about knowing what to say and when to say it. I got the chance recently to edit communication scripts, forms, and checklists for a new book, Physician Entrepreneurs: The Quality Patient Experience, and most of them are straightforward but far too often overlooked engagement strategies—call the patient by name, give your full attention, etc. But they work.
The fact is, Marcus Welby is gone, and today's doctors don't have the time for his approach to patient care. But there's a lot more the Houses of the world can do to keep patients happy in today's hectic healthcare environment.
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Nine hospitals in Southeastern Pennsylvania had higher-than-expected death rates for patients with bloodstream infections last year, according to a statewide report card on care. Experts said the deadly bloodstream infections represented a growing national problem and that local hospitals must do more to prevent them. The infections killed more than 4,200 patients in Pennsylvania last year, representing a 53% rise since 2003, records show.
Health insurance premiums rose 5% this year as coverage gets skimpier, according to the Kaiser Family Foundation and the Health Research and Educational Trust. Overall, premiums increased to $12,680 for coverage of a family of four and premiums for single coverage increased to $4,704. The 5% increase was comparable to last year's jump.
A groundbreaking bill extending hospital discounts to people without health insurance has become law after the Illinois legislature overturned Gov. Rod Blagojevich's amendatory veto. The legislation requires hospitals to offer significant discounts to uninsured Illinoisans. Instead of paying the full sticker price—typically two to three times the actual cost of care—consumers will pay charges based on the actual cost plus a 35% markup.
