Month: March 2008

CMS updates Hospital Compare tool to include patient satisfaction data

On Friday the Center for Medicare and Medicaid Services (CMS) took a big step toward helping patients more-completely compare hospitals. We wait to see if anyone takes advantage of that opportunity.

CMS recently updated and improved the Hospital Compare website. From the release, “For the first time, consumers have the three critical elements — quality information, patient satisfaction survey information, and pricing information for specific procedures — they need to make effective decisions about the quality and value of the health care available to them through local hospitals.”

The Hospital Consumer Assessment of Healthcare Providers and Systems survey collects information from over 2,500 hospitals and allows CMS to report ten measures of patient satisfaction in addition to 26 quality measures with more to come.

This has been well covered in the blogosphere.   Avery Comarow, the editor of U.S. News’s annual Best Hospitals issue, fully explores the HCAHPS survey and the Hospital Compare website:

Here’s how it will work: No more than six weeks after they are discharged, adult patients who spent at least one night in a hospital (omitting those admitted for psychiatric reasons) will be surveyed by mail or phone. Each hospital will need to contact as many patients as needed to generate at least 300 completed responses per year to the 22-item questionnaire. Every month or quarter (it’s up to the hospital), each facility will report its results to the federal Center for Medicare and Medicaid Services. CMS will adjust the responses to correct for patient age, size of the hospital, and other lurking biases. Results will be posted, hospital by hospital, for the most recent four quarters’ worth of data and will include national and state averages and other information to put the numbers into perspective. CMS says it will look closely at the survey responses, make on-site visits, and otherwise try to control hanky-panky. (Hospitals can continue to commission their own surveys and even put the questions on the federal survey, but the federal questions have to be listed first.)

Mr. Comarow also has a very nice review of the website and some tips on using the service.  The Health Care Blog also covers the update.  The Wall Street Journal‘s Health Blog humorously headlines that Hospital Quality Measurement Leaves the ‘Pong Era.’

Not everyone may agree with the utility provided by the updated Hospital Compare website—dare I say some may even be upset that patients are able to compare hospitals on such subjective measures as patient satisfaction?  But this is a good thing—and if a hospital doesn’t like its reported data, the solution is simple: improve patient satisfaction.

11. Evidence-Based Design Matters

Evidence-based medicine.  Evidence-based management.  Evidence-based design.

The thinking makes a lot of sense: do today with what you (and others!) learned yesterday.

The Center for Health Design is the ultimate source on this subject and they provide a much more comprehensive definition:

Evidence-based healthcare designs are used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance, and restorative for workers under stress.

An evidence-based designer, together with an informed client, makes decisions based on the best information available from research and project evaluations. Critical thinking is required to develop an appropriate solution to the design problem; the pool of information will rarely offer a precise fit with a client’s unique situation.

In the last analysis, though, an evidence-based healthcare design should result in demonstrated improvements in the organization’s clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures.

As we plan and build our virtual hospital, our own system is committed to constructing a healing environment through evidence-based design.  The Center even provides a toolkit that will help us:

  • Understand what patients want from the built environment
  • Enhance the design process through consumer involvement
  • Build patient-centered environments
  • Improve design quality and consumer satisfaction

Ulrich and Zimring published a comprehensive literature review/report on hospital evidence-based design in 2004.  The Robert Wood Johnson Foundation has a nice overview/summary of the research.  We can take explicit recommendations from this research and turn them into action:

The Single Room that does it all. “This change alone will help improve patient safety by reducing patient transfers, cut the risk of nosocomial infections, enhance patient privacy, lower stress for patients and their families, and improve staff communication with patients.”

Ventilation Systems and Air Filters. “Several studies have demonstrated that identifying and fixing air-quality problems, in combination with single rooms and scrupulous hand-washing, can substantially lower infection rates at hospitals.”

Noise Reduction. Elements like carpeting and sound-reducing ceiling tiles can lower noise levels.  “Research shows that noise is a major source of stress at hospitals. At hospitals that took steps to cut noise levels, patients were more satisfied with their care, slept better, had lower blood pressure, and were less likely to be re-hospitalized.”

Natural Light. “Looking out at bright light can improve health outcomes, including depression, agitation, sleep, and circadian rest-activity rhythms.”

The “Little Stuff.” “Small changes to room layouts, color scheme, furniture choice and arrangement, floor coverings, and curtains, as well as providing informational material and displays, can improve people’s moods and physiological states.”

Easy Navigation. “It’s easy to get lost or confused trying to find one’s way in a hospital. Not only is this confusion stressful for visitors, but it also incurs a cost to hospitals.”

Work Environments that help staff do their work. “Nursing stations are hectic and stressful places where too many errors occur while updating charts, filling medication orders, and communicating between shifts.”

One more thing: the Pebble Project.  “The purpose of the work (Pebble Project) is to create a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities whose design has made a difference in the quality of care and financial performance of the institution.”  Just take a look at some of the benefits of great design: staff turnover reduced, occupancy rates increased, patient satisfaction up, etc.  And if you have an extra minute or two, enjoy the great images of proven evidence-based design.

Principle #11: Evidence-based design is beyond important, it’s item number one on the things to do list at our own system. The Center for Health Design will help us get there.

Airlines, Airplanes, Airports and Hospitals

For whatever reason, I’ve read/heard several instances recently of people referring to the hospital and airlines/airplanes/airports/pilots metaphor.

To the best of my Google research, Donald Berwick and Lucian Leape started the trend, in an article published in 1999, by using the safety records of airlines to bring attention to high medical error rates in hospitals.

In the last few days I have seen pilot/doctor comparisons, hospital and airplane capacity comparisons related to financial issues, regulation comparisons of flying and doctoring…

Raise your hand if you have warm feelings toward airlines. Seeing none…

Type “hate airlines” into Google. Spend eight hours in airports to take a two-hour flight. Nickel-and-dime pricing. Canceled flights. Lost luggage. Waiting for hours on the runway. Some of these problems have arisen out of necessary circumstance—that isn’t the argument I want to make here. Believe me because I know, I’ve spent some time working in the airline industry.

The argument I do want to make is this: If we continue to connect hospitals with airlines to explain things, my fear is that patients are going to make the connection themselves, and I’m afraid those connections won’t always (if ever?) be positive. While the comparison may be useful, we should temper its use.

Delivering Consisent Care to Inconsistent Patients in a Changing World

So the effect of Free on health care is not a question of if or when, but more like how much?

And we may be starting to see some real impact.   Are more informed patients going to pay the same for health care services?  We want patients to be involved in their care, will there be price differences for those decide to be more involved? Patients as co-producers of health (!) are going to change the way we deliver health care.

PatientsLikeMe is “a community of patients, doctors, and organizations that inspires, informs, and empowers individuals. We’re committed to providing patients with access to the tools, information, and experiences that they need to take control of their disease.”  They are committed to helping those suffering from disease share information about their treatments, and the community members share a lot of information (way more than HIPAA would allow, which is largely the point).

Thomas Goetz wrote a terrific article titled “Practicing Patients,” it is worth the few minutes it takes to read.  Lots of good stuff.  Mr. Goetz does a great job outlining the difficulties the web presents to health care.

When patients take the reins of their own treatment, what role do doctors play? What’s to keep patients from misinterpreting the streams of data and finding false hope — and what’s stopping them from embarking on unproven and even risky treatments or dosages? And what happens if the real-world information at PatientsLikeMe contradicts the clinically proved protocols of medical science?

The article says PatientsLikeMe allows community members to compare treatment plans and patients are changing their drug regimen, for example, sometimes without the advice of a doctor.

In fact, some PatientsLikeMe members have already started doing pretty much what Ensrud warns against. Last November, the A.L.S. community was abuzz with word that researchers in Italy had found that taking lithium seemed to slow the progression of A.L.S. significantly. The Italian study hadn’t actually been published yet, but that didn’t stop 34 members with A.L.S. from soliciting lithium prescriptions from their doctors and coalescing into an ad-hoc clinical trial. There are now 109 members using lithium and tracking their progress with the data tools on the site. The company has rolled out new features to monitor the group with the hope that they will be able to lend a little credence — or cast a little doubt — on the Italian study in a matter of months.

Jamie insists that PatientsLikeMe isn’t encouraging A.L.S. members to start taking lithium. But he is unmistakably excited by the endeavor. As he sees it, the experiment perfectly illustrates how PatientsLikeMe might complement large-scale and long-term clinical research by conducting observational research “on the fly.” Drawing on the notion of personalized medicine, Jamie calls this “personalized research.” And it has a certain logic: for those who already have A.L.S., traditional science works at far too plodding a pace. “The system is broken for terminally ill patients,” says Hanns Riederer, a music producer in Los Angeles who has joined the group of A.L.S. members taking lithium. “It makes us wait five to seven years for results, when we don’t even have that time. Even if it’s half-true, it’s still groundbreaking. I don’t want to wait for something else. I don’t have time to wait.”

The demands that patients are placing on medicine today are high.  The co-producing patient is placing pressures (time and otherwise) on providers that is extending already overextended professionals.  This press release from Science Daily,  “Doctor Who? Are Patients Making Clinical Decisions?” reports a study that indicates, “Doctors are adjusting their bedside manner as better informed patients make ever-increasing demands and expect to be listened to, and fully involved, in clinical decisions that directly affect their care.”

Today’s patients do not simply have a medical complaint, they desire a particular operation and sometimes even a particular implant. The doctor is no longer the sole source of medical information. Patients have enough snippets of information to stimulate a dialogue and clearly express their expectations for a particular outcome and technique to achieve that outcome. They are also demanding quicker recovery, return to higher-level sport activity and earlier discharge from the hospital.

Finally, Dr. Jim Yong Kim, a Harvard Medical School professor, has a made a call for the creation of a “new science of healthcare delivery that would systematically evaluate which techniques worked and which didn’t.”  We need it.  The changes above are just a few of the new pressures on our health care system and finding the best ways to deliver care is a must.  “While treatments have multiplied, the operations and processes for delivering those medicines haven’t kept pace, slowing health improvement in developing and developed countries.”

(h/t: TP Wire Service)

Tom Peters on Health Care

I’m a fan of Tom Peters. My dad turned me onto Re-Imagine! early in my undergraduate years; and now, as I look back, I can point to that book and say that it single handedly changed my approach to the world. There have been influences since then to be sure, but that book is solely responsible for my new (at the time!) approach to thinking about, well, everything.

Mr. Peters has been advocating for better health care for as long as I have been reading his blog. But it seems (which is good for us BTW) he has a renewed interest in health care. In fact, he recently spoke at Kindred Healthcare and graciously provided us with his slides from the presentation (find them here). Go check him and his crew out. There is some really good stuff like:

“As unsettling as the prevalence of inappropriate care is the enormous amount of what can only be called ignorant care. A surprising 85% of everyday medical treatments have never been scientifically validated. … For instance, when family practitioners in Washington were queried about treating a simple urinary tract infection, 82 physicians came up with an extraordinary 137 strategies.” Source: Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

And this not by Tom Peters but from Thomas Goetz in the New York Times Magazine as a nice follow-up,

Doctors don’t like to admit it, but “most treatment decisions right now are still based on doctors’ judgments that don’t have real research behind them,” says Jodi Halpern, a physician and bioethicist at the U.C. Berkeley School of Public Health. “But it takes real data to make the right decisions, especially for patients. There’s a powerful improvement in health outcomes, people’s quality of life, when people are better-informed.”

Physicians, of course, have known this for decades; the idea of “evidence-based medicine” — that all decisions should be based on real data — was hatched in the 1980s. But the pace of traditional research is slow, and the number of outstanding questions far exceeds the body of evidence to answer them.”

Price Transparency, stepping in the right direction

From an Associated Press article on MSNBC.com, “You’ve just been diagnosed with cancer, and the doctor is discussing treatment options. Should the cost be a deciding factor?”

Kristen Trusko on The Health Care Blog writes, “If universal coverage mandates that employers provide health insurance or that people secure it themselves, it is highly likely that the majority will choose the lowest cost option, or “low premium” (aka HDHP or high deductible health plan).”  And continues, “Universal coverage could increase HSA projections beyond the current 2012 estimates of more than 20 million new accounts with $200 billion in assets.”

Anyone on a HDHP with a health savings account (HSA) is going to care greatly about the price of care: they are responsible for the first few thousands ($$) paid each year and potentially any co-insurance dollars.  The benefits of HDHPs have been debated. Regardless of your thoughts, the plan’s creation has created an even greater need for price transparency.  And that’s a good thing because we are seeing follow through.

Again from the AP article, “Chemotherapy costs are rising so dramatically that later this year, oncologists will get their first guidelines on how to have a straight talk with patients about the affordability of treatment choices, a topic too often sidestepped.”  And, “It’s a particular issue for patients whose cancer can’t be cured but who are seeking both the longest possible survival and the best quality of life — and may be acutely aware that gaining precious months could mean bankrupting their families.”

Now onto the price vs. actual charge debate…

Ethical Dilemmas of Reform

The Health Care Blog:

San Francisco surgeon Hootan Roozrokh faces one felony charge of dependent adult abuse, for which the maximum punishment is four years in prison. Roozrokh, 34, has pleaded not guilty and his attorney, M. Gerald Schwartzbach said his client looks forward to clearing his name at trial.

The Roozrokh case has attracted much national attention and raises worrisome questions about whether the transplant community is pressing too hard to increase the nation’s organ supply, thereby creating situations ripe for blurring ethical boundaries, such as this one.

Medicine is full of ethical dilemmas that providers must confront on a daily basis. This case shows what can result as ethical boundaries gradually gray.

While we debate the likelihood of health care reform and the form of which it may take, the most important conversations may take place post-reform decision. We must consider the ethical dilemmas we will be presented with as a result of any cost cutting measures, insurance coverage plans, methods of financing, etc.

Some of the most expensive care in this country occurs at the end of a person’s life. That is to be expected as providers try to save lives. This isn’t the case all the time, however. A 2006 USA Today article:

While researchers are able to show differences in costs, the real question remains how much of those additional hospitalizations, tests and doctor visits resulted in better care or better quality of life? Finding answers to that question is difficult and controversial, but health policy experts say doing so will become increasingly important as the U.S. seeks ways to slow the rapid rise in health care spending.

Any health care reform debates ought to include conversations of the ethical implications. Lowering costs may mean a reduction in actual care provided.  Is that a good thing?  A bad thing?  The warranted answer: It depends.

10. Green as can be

In the kind of prognostication you can only find in a bar like Cheers, serendipity ran me into a know-it-all-end-of-the-bar type several months ago that put our future environmental status in stark perspective: Mother Nature will be just fine. If we, as in humans, don’t change the way we interact with the Earth, it will be us who is disposed of; Mother Nature will have done her job: react to imbalance to ensure stability. Weird and uncomfortable as the situation was, the message resonated.

Making our own system green is a small step we can take “to do our part.” But, for a moment, let us move beyond the environmental benefits of going green and focus on our patients. An article at Building Design and Construction puts it well:

Think about this: If you were asked to identify the one building type that needed the highest-quality indoor air, the lowest levels of toxic off-gassing, the greatest access to daylighting and outdoor views for occupants, the most efficient energy and water usage—in other words, the greenest building—what would you think of first?

Hospitals, right? Sure you would. Hospitals should be leading the way in providing patients, their families, doctors, nurses, technicians, and office staff the ultimate sustainable experience. Sick people should have the greenest buildings of all.

But it’s not the case.  Hospitals have been slow to jump on the green revolution. The U.S. Green Building Council reports that only 74 hospital construction projects have been LEED certified, about 2% of all LEED-registered projects. But, as construction booms, and as we continue to build our virtual hospital, the opportunity to build green facilities is upon us.

National Geographic published an article in 2006 ranking the top 10 green hospitals in the U.S. that also discussed the challenges of building green hospitals, “Infection control requires strict cleaning procedures and frequent air changes, which increase the already-high energy costs of the 24/7 operations and sophisticated medical equipment that make hospitals among the greatest energy consumers of any institution.”

A solution.

The Green Guide to Health Care provides a 400+ page document (go to their site and register for a free download of the document) that is “the healthcare sector’s first quantifiable sustainable design toolkit integrating enhanced environmental and health principles and practices into the planning, design, construction, operations and maintenance of their facilities. This Guide provides the healthcare sector with a voluntary, self-certifying metric toolkit of best practices that designers, owners, and operators can use to guide and evaluate their progress towards high performance healing environments.”

The GGHC combines several resources to come up with their assessment principles including the Green Healthcare Construction Guidance Statement (pdf) by the American Society for Healthcare Engineering, LEED, the U.S. Environmental Protection Agency’s Labs 21 Environmental Performance Criteria, the Green Building Council of Australia’s Green Star Green Building Rating System, among others.

The aforementioned Building Design and Construction article offers 14 steps to greener hospitals and an analysis of GGHC, “This well-conceived set of guidelines goes far beyond LEED in rating hospital projects. GGHC requires integrated design, something LEED only hints at. It covers both construction and operations, and it offers specific health policy reasons for each of its credits. Unlike LEED, however, it is self-compliant: Building Teams rate their own performance, which to some is a shortcoming. Currently, 79 projects are participating in the GGHC pilot program.”

Principle #10: Building green facilities is a must. The best part: aside from being good for the environment, the elements of a green hospital are great for patients.