I have always been amazed by the apparent marketing brilliance of bottled water companies. If someone would have told me years ago I, and many others, would spend three dollars for a bottle of water – something we can all get free from our water faucets – I would have laughed and said they were crazy. Shows you what I know…
That same marketing brilliance came to mind last week while reading an article on the Harvard Business Review (HBR) Blog Network, Fix the Handful of US Hospitals Responsible for Out-of-Control Costs, regarding CMS payments to hospitals for in-patient procedures. Using Medicare Provider Analysis and Review (MEDPAR) data published last spring by CMS, the authors applied a six sigma approach to identify hospitals that were three standard deviations from the average fee paid to hospitals for the most frequently performed 100 in-patient procedures. Their findings forced me to stop and make sure I was reading their conclusions correctly. Their findings:
- Payments to hospitals whose accepted charges were above the national average for those 100 procedures added $5.3 billion dollars in excess cost to CMS.
- Two of the top 100 procedures accounted for more than 10% of the total costs – major joint replacement (6.1%) and septicemia (4.6%). Major joint replacement payments varied between $9,000 – $39,000 per procedure and septicemia payments varied between $7,500 – $44,000 per treatment between hospitals.
- Less than 1% of the over 3,200 hospitals included in the data (32 hospitals) accounted for about 25% of that excess cost – over $1.25 billion dollars. By Six Sigma definition, what they were being paid was three standard deviations from the norm.
How are they doing it, and perhaps a better question is, how are they justifying the difference? I understand and appreciate the issue always raised when data like these become public…”Our patients are sicker than everyone else’s patients” but 5-7 times sicker?
After reading the HBR post, I couldn’t help but stop and think that these 32 hospitals appear to make the bottled water marketing teams look like amateurs.
Humanism in Medicine Essay Contest Winner David Duong On Fear, Trust & the Love That is Patient-Centered CarePosted: November 25, 2013
A recent post on the AAMC blog AM Rounds, 2013 Humanism in Medicine Essay Contest: Caregiving As Good Doctoring, shares a recorded version of David Duong’s essay of the same name. Duong, a third year student at Harvard Medical School, earned 2nd place in the Arnold P. Gold Foundation sponsored contest by responding to the call for essays reflecting on “…the barriers to humanism in medicine today…and…who the ‘good’ doctors are.”
In his essay, Caregiving as Good Doctoring, Duong shares the fortuitous experience of serving as translator by default, being the only Vietnamese speaker available to a family in need of assistance at his training hospital. The patient, Mr. N, was flanked by eight family members all earnestly trying to understand options around end-of-life care for their father succumbing to Stage IV colorectal cancer. It was his job to gently translate details and options given by the attending physician, and as he describes, guide the family through this emotional time.
As Duong retells the story of his time with Mr. N’s family, it is apparent he has learned firsthand the personal and professional ‘benefits’ that result from more intimately participating in the healthcare journey of patients. Following are excerpts, but the full essay is one worth reading in its entirety, as well as shared with caregivers young and old throughout the health sciences. Research may exist that supports empathy to be lost by the third year of medical school, but Duong’s words that follow speak to an awareness and empathy of someone firmly grounded in what it means to “walk with you and yours through this (healthcare) journey”. Enjoy!
…In this intimate role as a caregiver, I am reminded of a phrase in Vietnamese that people offer each other at grave moments, when life seems beyond our control, when long-fought battles are lost, or when death takes its final grip: “chia buồn” or “share in the sorrow.” The phrase means that we share in the emotions, the experiences, the bullets that life fires at each of us. The phrase, gently intoned, is intended to ease the burden, to say, “I am here and will walk with you and yours through this journey”…
…What an honor, a privilege, and at times a burden, it is to undertake a profession that constantly invites us to engage and intersect with humanity at its most fragile moments. Therefore, it is our privilege and responsibility as good doctors and medical caregivers—along with our colleagues in social work, chaplaincy, and nursing, among many others—to strive to deliver the best care to our patients. In Dr. Francis Peabody’s statement to the 1925 graduating Harvard Medical School Class, he averred that “the secret of care for the patient is in caring for the patient,” which resonates with our 21st-century mainstream society rhetoric of the “patient-centered” approach. It is not surprising, then, that the highest ideals in medicine have remained constant…
..Throughout my third year of medical school, I have realized that there is no medicine to alleviate fear—the fear of illness, the fear of your body in someone else’s hands, or the fear of dying. But I have also learned that by caring for the patient, by placing the patient at the center of our medical practice, we can establish a trust relationship that just might lessen that fear. By doing so, we humanize our practice, share in the life of our patients and, in return, grow more deeply human…
One-Day Conference to Help Physicians Improve Patient Care and Publish the Results
Join a group of young healthcare innovators at the New York Academy of Medicine
November 23, 2013
CME Credit and Exposure to National Patient Safety Innovators
“QI: Plan. Execute. Publish” is the tagline for the November 23, 2013 conference, jointly sponsored by Albert Einstein College of Medicine (@EinsteinMed) and the CIR Policy and Education Initiative (@CIRSEIU), where resident and faculty physicians in New York-area hospitals will take a leap forward by meeting to empower physicians to conduct scholarly quality improvement (QI) projects. Many of the resident physicians and organizers are Telluride alumni, and we are always excited to watch them carry quality and safety initiatives to the next level.
Saturday’s meeting agenda includes the following faculty:
- Robert Sidlow, MD, MBA, Associate Professor of Clinical Medicine Albert Einstein College of Medicine Interim Chairman of Medicine Jacobi Medical Center and North Central Bronx Hospital, Bronx, NY
- Karyn Baum, MD, MSEd, Associate Chairman for Clinical Improvement
University of Minnesota Medical School Minneapolis, MN
- Gregory S. Ogrinc, MD, MS, Associate Professor of Medicine and Community and Family Medicine, Director, Office of Research and Innovation in Medical Education, Dartmouth Medical School Associate Fellowship Director, White River Junction Veterans Hospital, White River Junction, VT
- Amit S. Tibb, MD, FCCP, Assistant Professor, Department of Medicine, Albert Einstein College of Medicine Director, Medical Intensive Care Unit, Jacobi Medical Center
- Sepideh Sedgh, DO, Pulmonary Critical Care Fellow, Maimonides Medical Center, Brooklyn, NY
National President, Committee of Interns and Residents
- Farbod Raiszadeh, MD, PhD, Committee of Interns and Residents Policy and Education Initiative
- David Eshak, MD, Internal Medicine Resident Jacobi Medical Center, Bronx, NY
New York Regional Vice President, Committee of Interns and Residents
“It is tremendously gratifying to witness the cultural transformation which has taken place in the world of graduate medical education: it is now axiomatic that physicians must be given the skill set to “round on” and “cure” sick systems in addition to sick patients,” said Dr. Robert Sidlow, Associate Professor of Clinical Medicine at Albert Einstein College of Medicine and Interim Chairman of Medicine at Jacobi Medical Center. “Since frontline housestaff are now expected to learn and apply principles of Quality Improvement to their everyday work, it is only natural that we, as educators, teach trainees how to convert their efforts into generalizable, publishable scholarship and communal learning. This conference intends to accomplish just that.”
“As physicians on the frontline, we know our patients and we want the best for them. That’s why we’re leading quality improvement and patient safety endeavors in our hospitals,” said Dr. David Eshak, Telluride alum and an internal medicine resident at Jacobi Medical Center in the Bronx and a regional vice president of the Committee of Interns and Residents. “For us to be effective in QI, we need to work hand-in-hand with all stakeholders and we need to publish our work.”
The program features nationally recognized patient safety and quality improvement innovators Dr. Greg Ogrinc from Dartmouth Medical School and Dr. Karyn Baum from the University of Minnesota. Their hands-on, case-study approach focuses on closing the gap in training in evidence-based methods of process improvement and patient safety.
More information on the one-day program CLICK HERE
Anna Quindlen is someone I have long admired. An aspiring journalism undergrad student, I read Living Out Loud almost twenty years ago, and was inspired by her need to share ‘the story’, as well as her ability to make a successful career out of doing so. Now, a well-known and respected Pulitzer Prize winning journalist and repeat best-selling author, Quindlen recently shared her wisdom and words with healthcare leaders–young and old–at the annual AAMC meeting in Philadelphia. It comes as no surprise that the accolades and tears shared in the Storify snapshot of tweets from her talk show organizers made an excellent choice by inviting her to speak. (Click image to go to Storify page if interested).
For those who missed her talk, Quindlen has given permission to the Arnold P. Gold Foundation to make the full text of her speech available until December 3rd, and it can be found here. Having read the transcript, I wanted to share some of the highlights in the event the tyranny of the daily takes priority and prevents the well-meaning click-through before 12/3.
Per her transcript, Quindlen shared the following:
- The story of a repeat surgery she recently underwent, along with the differences in the care she received from her anesthesiologists. Do you know who I am? is the takeaway for providers listening in, as the care team who understood her needs, values, preferences and goals knew who she was–someone who did not want a general anesthetic–and that made all the difference.
- The similarities between healthcare and journalism, and how in this day and age of technological advancement and depersonalization it is still the ability to hold the gaze of a fearful patient that makes the greatest impact.
- The story of the care her father, the patient, and she, the patient advocate, both received as they navigated and negotiated his stay on a burn unit. This story alone is worth the time for the click-through above, but in short, her father’s care team acknowledged and appreciated the knowledge she brought into the room, and as a result her father’s care plan was developed with the family’s needs, values, preferences and goals as the foundation. And while she says that the care he received was best-in-class, it was the social worker who stopped in to ask how they were doing, the nurse who played music for her father when she could not be present, the doctor who expressed three times his understanding of how hard it was to make the choice for palliative care, and the sympathy card she received from the staff, that stay with her now. But perhaps most important of all, she shares that her father’s care team:
…gave me a sense of power and control in a situation in which I was bound to feel powerless…they put a human face, a series of human faces, on my father’s care.
- And finally, she shared four “simple” takeaways for the audience: 1) Try to be present and in the moment 2) Acknowledge uncertainty 3) Practice empathy 4) Try to be kind
As news outlets continue to talk about patient harm, pushing for accountability and bantering about frequency, a more subtle form of harm occurs more frequently and is not meaningfully measured. That harm is steeped in the missed opportunity to know the patient. Providers fail patients on a human level because care providers are human, and humans caring for humans is far from a perfect science. Maybe it’s also about patients resetting expectations and not setting themselves up to be disappointed by, as Quindlen refers to, MDietys that are in fact just people like them. The four simple truths or takeaways she mentions are things all of us, patient–provider–caregiver–sister–son–father–boss–administrator, can ascribe to and make any encounter–healthcare or not–a better one.
Thank you, Anna Quindlen, for continuing to inspire others with your words!
In healthcare, we know teamwork is one key to safer care yet the adoption of interdisciplinary healthcare teams remains a work in progress across the country. In the following short clip, a middle school football team in Michigan defines what it truly means to be a team, and shares their short, but inspiring story. With well over 3 million hits, many have already been touched by the Olivet Eagles but please pass it on!
This year’s annual AAMC meeting is in full swing in Philadelphia, and you can join the conversation on Twitter via hashtag #AAMC13 to see highlights. The theme for 2013 is The Change Imperative and the meeting agenda, which runs through Wednesday, includes the following speakers who will without a doubt engage audiences in thought-provoking sessions on what the future of medicine and medical education will look like:
- Darrell Kirch, AAMC President kicked off plenary sessions Saturday, 4pm to discuss Our Moment of Truth
- Ian Morrison, Healthcare futurist and author, shared “his perspective on the rapidly changing landscape of health care, the impact of the Affordable Care Act on academic medicine, and how our community might leverage changes in the marketplace to help shape the future of medicine” on Sunday morning
- Anna Quindlen, Pulitzer Prize winning journalist and author, was scheduled for Sunday morning to discuss, Health Care in an Information Age: How Doctors, Nurses and Consumers Can Make One Another Better
- Daphne Koller, Professor of Computer Science, Stanford University and Co-Founder/Co-CEO, Coursera, discusses Exploring Changes in Education: Is Academic Medicine Ready for MOOCs? (Monday, Nov. 4th, 4pm)
- Adam Grant, Professor, The Wharton School of Business, University of Pennsylvania and author, Give and Take: A Revolutionary Approach to Success, will speak on Embracing Changes in Culture: Driving Organizational Success by Building a Culture of Contributors (Tuesday, Nov. 5th, 4pm)
For final program, click here.
On Tuesday, November 5th, winners of the AAMC “Light-years Beyond Flexner: Academic Medicine in 2033” video contest will also be announced. Medical schools were invited to create a 2-minute video envisioning what US medical schools will look like in 2033. Following is one example from Baylor University who believes three areas of competency physicians of the new age will need to be well versed in are: 1) Network awareness; 2) Information management, and; 3) Digital content creation. Finalists include:
- Eastern Virginia Medical School
- Meharry Medical College
- Temple University School of Medicine
All submissions can be viewed here.
The Doctors Company (TDC) and their Foundation (TDCF) have been committed to medical education for many years. They have been the major supporter of our annual Telluride Patient Safety Summer Camps for medical and nursing students the past four years, providing full scholarships to sixty medical and nursing students last year so they could attend this week-long immersion in safety, quality and transparency.
I have been honored the past two years to be invited to attend TDC Annual Advisory Board Retreat. The retreats have become a favorite meeting of mine, as well as one of the best educational meetings I have attended. One of the presentations I enjoy hearing most is given by Dr. Richard Anderson, the CEO of TDC, who opens the meeting with an update and discussion on the current medical malpractice environment. Dr. Anderson shares claims data along with insightful narrative so that a “novice” to the medical malpractice industry like I am can understand and appreciate the challenges healthcare really faces today.
A couple of numbers he shared this year really hit me:
- The average cost of a claim at TDC is $97,000
- 82% of all claims filed do not result in any payment to the patient and/or family
A couple of things came to mind as I reflected on those two facts. First, where is all that money going? If the $97,000 isn’t going to patients or families, who was it going to? Who was getting all that money? The second thing was the pioneering work done by Rick Boothman, Susan Anderson, Skip Campbell and others at the University of Michigan highlighted in the article entitled Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. After full implementation of a disclosure-with-offer program at the University of Michigan, Boothman and colleagues observed:
- Decreases in the monthly rate of new claims from 7.03 per 100 000 patient encounters to 4.52
- Declines from 232 lawsuits (38.7 per year) to 106 (17.0 per year)
- Declines in median time to claim resolution from 1.36 years to 0.95 year
They also appreciated decreases in monthly costs associated with total liability, patient compensation, and non–compensation-related legal costs. Through an open, honest, timely and effective communication approach to unanticipated outcomes, they were able to successfully start addressing the excessive costs Dr. Anderson referred to associated with liability claims.
Maybe there is a better approach to the “deny and defend” model we have seen used through the years.
One additional figure Dr. Anderson shared also hit me hard this year. The number of claims filed asking for compensation above $10,000,000 has tripled over the last year, with the total claim pool going from $400,000,000 to $1,200,000,000 in total costs in just twelve months. Even gas prices haven’t risen that fast. Has the severity of patient harm suddenly tripled over the past year or are there other factors contributing to this sudden escalation?
If interested, The Doctor’s Company website contains numerous healthcare, patient safety and risk reduction resources. Click here for more information.