You are currently browsing the tag archive for the ‘quality improvement’ tag.

9612a6cd64fe89d6efe9734320d136ff

When last we left the village (about 2 weeks ago) whose entire existence was to support pulling babies form the stream, a search party had gone upstream to find out where the babies were coming from. Meanwhile there were still babies coming down the stream. As you may remember, a very sophisticated infrastructure had arisen to pull the babies from the stream. The folks who took the lead, the “baby savers,” took their job very seriously and were valued. They often had to jump in and save babies who were coming down or might have to manipulate the equipment to pluck one from the waterfall. As befits their importance, they were paid very well and had an honored place in the village.

The baby savers executive committee, already threatened by the fear that the search party might find where the babies are coming from and put a stop to it, began looking somewhat critically at the entire operation:

Baby saver president: As you know, we have been looking into the “babies in the stream” issue. We have a lot of folks who care a whole lot about babies and have been giving  there time to make sure the babies are pulled safely from the water. However, it seems there is room for improvement.

Village baby saver: What do you mean improvement, we work our butts off.

Village baby saver 2: Yeah, we are up all night. Often I have to jump in. The water is cold.

Baby saver president: Well, we have started to keep track of your work and, to be honest, we are not doing some of the things we should. As you know, we pay you by the baby.

Village baby saver 3: Your point?

Baby saver president: Not to name names, but I think we should have thought through this more carefully. I’m not going to name names, but one of you pulls out a lot of babies. Many of these babies are blue when they come out and the baby resuscitators are complaining. They say you (not to name names) are too rough and push others out of the way so that you can get the most babies.

Village baby saver 2: They are just jealous.

Baby saver president: And one of you, again I’m not naming names, is just too old to do this. Your eyesight is poor and you don’t swim well. The resuscitators have to jump in and grab your babies but then you take credit.

Village baby saver 3: They need to step back and let me do my job.

Baby saver president: I suspect the search party will be successful and there will be many fewer babies going forward. So we are going to start posting how well you do on the wall over there and it may well be that some of you won’t be able to be baby savers any more. From now on, everyone will know how many babies you catch, what percent are blue, and how many went over the waterfall that you should have saved.

Village baby savers (talking at once): wait, that isn’t fair. How is it my problem if they come down too fast? What if more than 2 people are on a shift? I have a wife and kids to feed. Those resuscitators can kiss my…

If you want to see how hospitals do in regards to preventable mortality and certain procedures and use that to pick your hospital, the government’s hospital compare website is for you (go to this site). If you want to see if your hospital or surgeon has an unusual number of complications or just doesn’t do a lot of the procedures that you need, Propublica has a tool that compares individual surgeons (go to this site). If you want to float along and let a random person pull you out of the water and hope they do a good job, enjoy the ride and I hope you avoid the waterfall.

Advertisements

cartoon9I have to remember that I’m an officer and when I give a Marine an order they will obey no matter what. When I use the tonometer and say “don’t blink” I had better remember to follow up with “blink” before they get dry eyes.

Conversation with a Navy Optometrist

I remember fondly my time being a doctor to the Marines. Wet behind the ears, eager to hone my craft, suddenly given superhuman abilities such that with only an internship I could function independently in a remote setting…oh, wait, that last part didn’t happen. Fortunately there was, on the base with me, a wizened old doc (I think his name was Wenzel) who had practiced in rural Kentucky prior to going back and studying pediatrics. His counsel was always wise and when distilled down often ended up being “When in doubt, turf it out.”

We were at a fairly busy ambulatory clinic and urgent care center in Kaneohe, Hawaii. All of us took call. I remember making multiple trips to the civilian hospitals to transport patients. The active duty dependent and military retiree patients had to pay quite a bit out-of-pocket if they used the civilian facilities without consulting us first. We used to get folks driving PAST the civilian hospital to come to our ambulatory dispensary having heart attacks (I can remember one dying on the H-3 while in the car, wife driving 80 miles an hour) and  respiratory arrests (one of the most harrowing ambulance rides of my life, ever) in addition to the assorted 21-year-old Marines who never failed to learn the lesson that alcohol renders no one invincible. The lessons I learned there about the limits of an ambulatory practice setting, the triage and transport of sick people, as well as the health risks folks will take as they try to save a buck,  have stayed with me for 25 years.

I also learned some very concrete lessons on practice organization and care delivery. First, we had a very robust quality assurance program and worked hard to create a culture of quality and safety before it was fashionable. Second, against the wishes of the base commanding officer who wanted to have “his own hospital,” any attempt to be who we were not (a small ambulatory presence designed to get folks the care they need when they need it) was resisted by folks above my pay grade. Third, the Navy was experimenting with nurses in charge of practices such as this and I was extremely fortunate to work with several very good Nurse Corps OICs and learned to work as a member of a care team.

The military is a unique practice environment. The emphasis on readiness as well as wellness provides lessons for all of us in healthcare. Unfortunately, military medicine may be in trouble. The remote locations, providers who may not be invested with tours of only 3 to 5 years, and inexperienced physicians who are moved rapidly up in rank based on medical training apparently has led to problems.  The New York Times has recently published a story highlighting the downside that is worth a read. I was most struck by the quality and safety problems highlighted in the article. Physicians are apparently being placed in small hospitals with skills ill-suited for the location and/or patient population and attempting to provide care comparable to what they learned in their training. In addition, data aggregation techniques now used in the civilian world to assess quality and improve care are not in common use in the military hospitals. Leadership positions are being given to physicians who have a high rank by virtue of their residency training but limited real world or even military experience. The military is not entirely to blame. When they try to consolidate hospitals or provide care in a different fashion they are obstructed by the community, who uses their congressperson to keep the jobs local.

Our troops and their families as well as those who have retired from active duty have the expectation of high quality and safe healthcare, as does the general public. We need to equip all physicians with the skills necessary to practice in the environment in which they find themselves. Surgeons in isolated areas need to focus on doing small procedures well and leave the complex cases for hospitals with teams to provide care, whether on a military base or in rural Alabama. We need to teach how to assess and incorporate meaningful quality and safety practices starting at day one of medical school and not assume competency by virtue of a residency training certificate. The Milestone project seems to be a good start at making sure this happens at the residency level. Lastly, we need to teach leadership. Physicians are expected to be leaders. It’s time we give them the tools to do it.

Ok, so a follower sent me an article from the New York Times that I feel compelled to share. CMS (the folks that run Medicare) have gotten some data regarding CT scans of the chest done in 2008. The radiology experts feel that there is little to no reason to do a CT scan of the chest at the same institution twice in one day and to bill for both studies. They are now using the power of shame to improve patient care. The list has been made available to the general public (and the NYT has put it in a neat interactive graphics package found here) to allow you to look up your hospital and see how they are doing. Remember, there may be a perfectly good explanation but, on the other hand, better to seek out quality at every opportunity.

Archives

Advertisements