As always, the big picture counts

Making Health Care Better, a piece by David Leonhardt in today's New York Times magazine, is simply a must-read for understanding the complex relationships that shape healthcare quality.

Here is an illustration, based on Don Berwick's "Level of Interest," that often helps me identify players, understand where they're seated, and anticipate where (and why) to expect push-back.


Berwick wrote the piece this slide is drawn from as a "user's guide" for people who would be leading improvement efforts in the aftermath of the IOM report "Crossing the Quality Chasm."

It's worth considering where the elements (drivers; incentives; methodologies) described and critiqued in the Intermountain system fit into Berwick's original construct. (This a case where the expression "same stuff, different decade" is not a slam, but rather a chance to see the evolution of welcome change.)

A better case for a system-approach to healthcare improvement cannot be made than what you'll find in the New York Times piece.

Read it. More importantly, learn from it.

God is great, beer is good, and people are crazy

Insanity is doing the same thing over and over again and expecting different results.
- Albert Einstein

Results from a multi-center nursing "time and motion" study show that nurses in acute care settings spend about 35% of their time documenting care, 17% on responsibilities related to medication administration and monitoring, and 21% coordinating care. I've heard Marilyn Chow, one of this study's lead authors present these data before, and she included them in a presentation given last week in an IOM webinar on the Future of Nursing.

I don't think anyone is particularly happy with these statistics. (Although it remains unclear what patients actually think since high profile evaluations, like this one from US News and World Report, measure nursing care by how mom-like the experience of being cared for is.) Real patients--that is, those who have had the experience of being hospitalized and understand that the circumstances that land them there necessitate far more than a chipper smile and a well-timed fist-bump--might be able to evaluate nursing care using different metrics. But, for now, it appears we're living with "% of patients whose nurses were ALWAYS polite and communicative." Sigh. (Can I just say that when I'm an inpatient, I appreciate polite and communicative behavior on the part of all of my caregivers?)

It's hard to look at Chow's data and not be struck by a significant mismatch between intention and outcome. Surely this is not the best use of valuable, high cost resources.

But what makes Chow's presentation worth studying is that, beyond Slide 4, she gets out of the box, tossing out fresh ideas about how nurses will nurse in the future. And why they should. Plus who will benefit. And how technology will enable it. Review the 11 slides in this presentation for inspiration.

If you think I'm crazy, remember what Einstein said.

David Axelrod on Healthcare Insurance Reform

Flo & Bo haven't yet taken advantage of guest bloggers, and this piece on healthcare insurance reform, like the package itself, is a hybrid.

The actual bill is 1,000 pages long, tough reading even for wonky wonks. So I'm passing along some information I received this morning from David Axelrod, a senior adviser to President Obama.

Mr. Axelrod is the father of a 25 year old daughter who suffers from severe epilepsy. Prior to the advent of the newest epilepsy drugs, his daughter experienced daily seizures so severe that she suffered brain damage. She's only now beginning to have stable, quiet brain, and the Axelrods are discovering what her true abilities and potential may be. (This wasn't in Mr. Axelrod's e-mail- it's information I read a few months ago when Newsweek did a special report on epilepsy.) I think it's important information to know because unlike members of Congress and other long-term governmental employees, Mr Axelrod knows first-hand what it means to battle for coverage and live in fear that a family member might not get needed care.

I'm a parent who has faced concerns like these. And while I can't know or understand every single nuanced thing in the healthcare insurance reform bill, I'm very sure that Mr. Axelrods's concerns align very closely with mine. The concerns I worry about, now and in the future, look a lot like the Axelrod's, not because I have a severly handicapped adult child. But because I could. Any one of us could face a catastrophic illness or event that forever changes our ability to secure healthcare in the system we currently have.

You should base your decisions about whether reform measures are good things or bad things for you, your family, and your country based on the changes that are proposed. It's helpful to remember that making healthcare affordable for everyone makes you safer, too. Without vaccines, some members of your Bible Study group will die. Some children in your kid's Girl Scout troops will too. Having basic, affordable healthcare for all citizens is not the same as subsidizing everyone's luxury vacation. Nor does it mean pulling the plug on Grandma.

Be wary of rumors and ideas that are circulating but are NOT part of the bill before the Congress. The only things that can become law--and affect you and your healthcare--are the items that are addressed in the bill itself.

Snopes.com is a good site for learning what is true, partially true, and not true at all. You should check on the things that don't seem right to you. Be sure any information that concerns you is in context. Beware of short, scary soundbites. Look to see who said it, when, and if it makes sense to you when you have all the facts.

These points explain what will change if the Congress passes the reform measures that are before them. I've used them to evaluate the proposed changes and form my decision to support the bill before Congress.

From Mr. Axelrod's e-mail:

8 ways reform provides security and stability to those with or without coverage

1. Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.

2. Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.

3. Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.

4. Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.

5. Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.

6. Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.

7. Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.

8. Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.

Learn more and get details: http://www.WhiteHouse.gov/health-insurance-consumer-protections/

Patients for a Moment: The cupcake edition

Check out the 5th edition of Patients for a Moment, the bi-weekly blogging carnival by, for, and about patients. You'll find insightful posts, shared by people who have first-hand experience with what's good, bad, and ugly about healthcare.

Here's the post the caused me to look up the correct use of ROTFLMAO: How'd she die? Duncan Cross gets Flo's over-achiever award this week because he managed to pack good, bad, and ugly all in one post!

Americans have been visible in town halls this week sharing, and in some cases shouting, their positions on healthcare insurance reform. I've been surprised that we haven't seen or heard much from business people, like folks in the US auto industry. This would be a good time for a reminder about what happens when an enterprise spends more to insure its workers and retirees than it spends on the raw materials needed to make a car (or a cupcake). And then has to compete in the global economy.

Grand Rounds: The oleaginous armor edition

Grand Rounds is up at The Covert Rationing Blog where you can get a check-up with Dr. Rich, healthcare's Stephen Colbert.

While you may not feel the need to find another source of information about healthcare reform, this one is worth checking out, if only to find out how "oleaginous armor" can be used in a sentence.

Get yourself a bag of Cheetos, mute the cable, put your feet up, and enjoy the read!

Fail!

Today is the first day of school in Georgia for most school systems following a traditional 180 day calendar. This is the 18th time I've sent a student off to school in the dog days of August, making me about as qualified as a parent can be to render this assessment: Fail!

Too early school starts used to occur during the last week in August, a pattern I remember well since it meant my daughter often began school on her birthday. Melting cupcakes only added to what was hot, sticky, and wrong about that. But she's a sample of one, and I guess someone has to start school on their birthday no matter which day is selected.

In Georgia, earlier school year starts have mirrored the introduction of high-stakes student testing as a primary measure of academic quality. When competitive, heavily benchmarked testing occurs in April, school systems that pre-load instructional time are likely to deliver superior results relative to those on the same journey that got a later start. These "wins" are like getting excited when the train with a 9:05 departure beats the scheduled 10:15 run.

Here are my top three "teachable moments" arising from outcomes achieved through gaming:

• Lies, damn lies, and statistics. Discuss!
• Billy Crystal is famous for saying, "It is better to look good than to feel good." Explain how quality markers inform authenticity and shape performance.
• What can people interested in reforming healthcare learn from quality measures and improvement strategies selected by other industries? Compare and contrast measures and outcomes between "commercial aviation" and "public education."

Your time begins now.

Baby steps

Today, Hearst newspapers published a series of reports, Dead by Mistake, about how often people in the United States die as a result of seeking healthcare. It's a big number.

98,000.

The same number--widely seen as an underestimate--that's been floated for the past 10 years when the first comprehensive national report on patient safety was published. Today's Hearst piece added an updated comparison (in the event that comparisons to deaths from AIDS; breast cancer; and auto accidents are insufficient for illustrating the magnitude of the problem). In one month, more people die as a result of medical errors and healthcare acquired infections than died on September 11th. For the record, these iatrogenic events continue to kill more people than AIDS, breast cancer, and auto accidents. Combined.

One article published the Albany Times Union provides an excellent recap of where key improvement measures, recommended nearly a decade ago, stand today. It's worth a read whether you're a seasoned observer of medical misadventures or are just beginning the journey.

I'm in the "seasoned" crowd, and there's something in the Hearst reporting that, while not progress in and of itself, may at last be signaling change, paving the path where progress will ultimately travel.

The piece is amply illustrated by the tragic stories of individuals whose lives have been lost or forever changed as a result of medical error. The profound feelings of grief and betrayal experienced by affected individuals hasn't changed, and won't change, until there are no more stories to tell. But what does seem to be changing is a shift in perception about where the opportunities for improvement rightly lie.

When the public demands and institutions support the notion that individuals can be made to perform flawlessly, progress--in any endeavor--is stymied. Individuals can never be flawless, and from a mathematical standpoint, the performance of individuals organized within a system can't be made flawless either. But the odds of disaster when individuals work within well-constructed systems can be reduced to a near-negligible point. This is a guiding principle in industries, such as commercial aviation and nuclear power, that reliably produce an intended, and expected, result.

The Hearst report is rife with criticisms, rightly centered on infrastructure and process defects. High-end individual performance by front line clinicians can only be predicted to occur, and reoccur, when seated within work processes designed to, well, work. The report is noteworthy in its mention of such things as:

• negative consequences arising from a decade-long failure to establish a comprehensive, nationwide error-reporting system
• how a lack of organizational transparency hamstrings patients, as pure consumers of care and in the aftermath of an adverse event
• the consequences when hospitals make full adoption of NQF's Safe Practices a low-priority item

Focusing on system weaknesses means giving up the idea that a Sam Smith, RN or a Jo Jones, MD killed someone (and 97,999 other someones every year). It looks instead at what's available when one Sam or one Jo isn't up-to-snuff, up-to-speed, or up-to-date, and builds a system that allows patients to survive when human fallibility is unmasked.

If a journey of a million miles begins with a single step, we may have seen the first one taken this morning in the Albany Times Union. And we'll soon see if the baby really can walk when we see how patient safety is prioritized in the healthcare reform we're about enact.

It's all in the numbers

I just read something written by a young woman who has lupus and blogs about how her life is complicated by this frustrating disease. She titled the post Everyone Wants to be a 10, But No One Wants to be a 710. (710 is the code providers use to hook "lupus" with the payment they receive for treating patients with the condition.)

I'm not a healthcare economist. And I really don't know what stories told by individual patients mean. I suspect that taken as a whole, individual stories help explain why Americans are spending 19% of our gross domestic product on healthcare. It seems sad that a young grad student would have such intimate knowledge of diagnostic coding--a key component of healthcare's error-prone, tit-for-tat bookkeeping system--when she faces so many other complex, inexplicable things.

I wish she didn't have to worry, as my college-age, cochlear-implant using daughter soon will, "Who will insure me when I get kicked off of my parents' health insurance plan?"

I don't like the way healthcare in the US is designed to treat "parts," not "people." I don't like that so many are denied access to basic care. And I don't like the fact that patchy, poorly coordinated care costs so much. So maybe there's something to be gained from sharing one more story.

It's a short story with a built-in fix, one that I first shared on Twitter. (Conveniently, it fit into one tweet, Twitter's 140 character micro-blogging constraint.)

Why I'm 4 e-docs: $40 copay 4 last real-time dx of "ovarian cyst." Never took my pants off.

Here's the rest of the story:

I saw my family doctor because I had right-sided pain that seemed an awful lot like the same pain I had on a previous occasion, when I was found to have endometriosis-induced ovarian cysts. (My OB/GYN had relocated, and I thought seeking care from, well, my family doctor might be a good idea.)

The family doctor listened to my symptoms, reviewed my history, and, as I recall, said the following,

"I'm not the girl for this."

"You're too complicated for me."

"See a specialist."

"I'm not insured to take care of people like you."

These statements are all valid points, reflecting sad realities of care that neither of us made but both of us face.

But they're points that could have been communicated without a face-to-face visit, saving my time and the doctor's. (Not only did I not take my pants off, I never even sat on the exam table. And the only touching that occurred was a handshake.)

I would have been happy to find out that the doctor had nothing to offer me via an e-mail exchange or a video chat, and I'd be happy to pay the going rate for e-consultation. Whether I had an ovarian cyst or a bad case of gas in December, 2008 will never be known. (The pain resolved before I could schedule a visit with a specialist.) And I don't mind not knowing.

But I do mind that the encounter was captured this way:

The diagnosis of "ovarian cyst" is certainly questionable. And where did 491.20, the CPT code for "obstructive chronic bronchitis without exacerbation" come from? Who had that?

A salute to Grands Rounds (and other eye-catching things)

If you're following, or trying to find, reasonable points of view about healthcare reform--opinions that might be useful should you be forming one yourself--you're probably feeling a bit like Richard Gere in an "An Officer and a Gentleman" when Lou Gossett, Jr. hoses him. You've got nowhere else to go!

But wait. Forget that Lou Dobbs has been acting like Lou Gossett, Jr.

Click on over to Grand Rounds where Kim and her Gumby-esque friends share a lot of interesting things, the healthcare reform posts being a real find. You may feel like you're in a Fellini movie.

But if you're looking for the best reads, you've got nowhere else to go!

Truth, like rain, does not care who gets wet

Okay, I'm feeling grumpy today. And my mood didn't improve when, against my better judgement, I opened a "this-is-for-real" chain e-mail and found this:

The actress Natasha Richardson died after falling while skiing in Canada. It took eight hours to drive her to a hospital. If Canada had our healthcare she might be alive today. In the United States, we have medical evacuation helicopters that would have gotten her to the hospital in 30 minutes.

We're fortunate to live in the United States where we're free to form and express opinions. Like whether the healthcare reform measures on the table are, indeed, the right way to go. I'm still working on an opinion, learning more about what's in the package and how it will effect dimensions of care that are important to me. Like, will the changes make healthcare safer? More effective? Timely? Efficient? Patient-centered? Equitable?

It's no secret that I've been dissatisfied, personally and professionally, with the bang we get for the buck under the highly fragmented and hard-to-access system we currently have.

And, no, I'm not going to Canada.

But I do know a thing or two about Canada, being married to an ex-pat Canadian for a quarter-century and all that comes with that.

Canada is relatively easy to find on comparative health outcome rosters (they're usually a goodly number of notches ahead of the U.S. in measures of population health like infant mortality rates and life expectancy). Oh, and Canadians do pretty well in dollars spent, too (in 2005, using 9.9% of their GDP on healthcare relative to the U.S.'s 15.3%).

All citizens in Canada recently got free online access to the Cochrane Library, where credible studies are synthesized and results shared (using both highly technical language that appeals to researchers and with words that make it easy for consumers to understand complex topics). So Canadians understand concepts like "due date" and "hospice care" which is why, perhaps, they spend less money fixing what ain't broke and trying to fix things that can't be fixed. Don't know for sure, just a guess.

Empowering citizens by ensuring they have access to high-end, evidence-based medical information is not particularly sexy or glamorous (especially when compared to the health education we enjoy in the U.S. where advertisements portray middle aged men who can't pee as the next generation of Outward Bound campers).

One pay-off is that with credible information, Canadians--and others who use facts to inform their decisions--increase their ability to make satisfying, even life-preserving, decisions. It's helpful to know, for example, that more than 10% of the U.S. air ambulance helicopter fleet crashed between 1995 and 2000. And that the safety of air evacs, to this day, is below--far, far below--what passengers on craft subject to FAA oversight enjoy.

Because it's big, fast, and glamorous doesn't make it necessary. And making it subject to regulatory oversight doesn't have to diminish its safety or effectiveness. Outcome data are helpful to know, should you have to weigh the risks and benefits of air transport--and other high tech gadgetry--to facilitate the care of someone in your family.

Frankly, just knowing that Canadians have helicopters might be a step in the right direction.

California is full of bad actors

California is full of bad actors. But maybe I should tell you something you don't already know.

In case you missed it last week, California's Governor Schwarzenegger replaced most members of the State Nursing Board. This action followed an LA Times report detailing the board's inability to evaluate and rule on allegations of professional misconduct by registered nurses in a timely fashion. A day or two later, two California state senators announced they were crossing party lines to author legislation that would reform the state's Medical Peer Review process. Both actions were widely reported under headlines forecasting improvements in "patient safety."

These initiatives--and others focusing on the processes used to evaluate and re-evaluate professionals who may be "bad actors"--are indeed part of the fabric that protects the safety of patients. But equating occasional long reaches down a dark foxhole with "patient safety" is a huge disservice, a distraction almost, relative to what the science of patient safety really is and what it takes to get the job done.

Patient safety is really the science of reliability applied to healthcare: How does a system operationalize processes in order to achieve a stated goal? It's not "How to cure cancer?" but rather, "How do we ensure that a patient is not killed by an overdose of chemotherapy while undergoing treatment to be cured of cancer?"

Goals like these rely on competent individuals, but they are not achieved--in a reliable fashion--solely because of them. (Having a sober pilot does not guarantee a safe flight.) Measures that focus on individuals' performance and behavioral choices should not be equated with the full spectrum of activities needed to improve the reliability of healthcare.

As healthcare reform ramps up, patients and professionals should be looking for measures--and funding--to enhance patient safety that are wider than a foxhole and constructed in a way that allows existing tunnels to connect.

My Purple Door

Three of my four grandparents emigrated to the USA from Sweden, and one of the highlights of my adult life has been reconnecting with cousins in the small village where my father's people have lived for hundreds of years. Sweden is a rural country of 9 million people, with a population size that mirrors my home state of Georgia and a land mass similar to California's.

Sweden's bucolic beauty shares elements of the pacific Northwest, coastal New England, and Alaska. Most remarkable, at least to my American eye, is how Sweden's infrastructure complements its natural beauty. No suburban sprawl, no ribbons of strip malls connecting one group of Walmart shoppers to the next, few fast food outlets beckoning always-hungry, rarely-satiated citizens.


Homes in the country, like the one here that belonged to my great, great grandparents, are usually painted wood. They showcase traditional designs and palates, contributing to a landscape that is even more beautiful than the sum of its parts. (If you get a chance to bet on the color of a house in rural Sweden, choose barn red; light gold; or wedgewood blue. You're going to win.)

One night, while drinking with my cousins, it occurred to me to ask about the social customs and constraints that produced such a holistic landscape. "Stefan," I asked, "What if a Swede wanted to paint his house purple? Could he do that?" My cousin paused to be certain he understood the question, explained a little about local zoning, then said, "But a Swede would never want to paint his house purple."

This led to the telling of a story about the desirability, from the Swedish point of view, of being an average citizen, "a middle Svenson," as my cousin explained it. In Sweden, people are discouraged from living or behaving in ways that substantively distinguish them from their peers. This doesn't mean that individuals aren't creative or expressive. It simply means that one's efforts should reflect established norms, building upon principles, traditions, and aesthetics that have withstood the test of time. A person who painted his house purple would invite unwelcome attention, irrespective of how lovely the shade. So would a person who parked a broken washing machine on his porch.

My cousin's insight helped me understand why the Swedish countryside looks the way it does. The explanation helped me understand a little more about rural Georgia, too.

Culture impacts more than paint colors and where old appliances are laid to rest. Take health outcomes for Georgia and Sweden, two locales that share both population size and challenges that come with providing care in rural settings:

• In Sweden, deaths of infants in the first month of life--a statistic that's considered a reliable marker of overall population health--number 2.1 per 1,000 live births.
  
• In pockets of Georgia, where the least healthy and poorest citizens are clustered, the neonatal death rate is 17 per 1,000.
  
• Some of Georgia's citizens do much better, with neonatal mortality rates in the weathiest suburbs at 4.2 per 1,000.

These comparative health outcome data are especially important for Americans, who, like me, can access highest end healthcare and often believe they have something to lose when the subject of healthcare reform is broached. Sweden's best--a best that represents outcomes for all citizens, not just the healthiest and weathiest--is far better than what the most privileged Georgian can expect.

The take-away? No matter how well you think a market-driven healthcare economy works, it's important to remember that you can't buy what doesn't exist.

My husband, an ex-pat Canadian and naturalized American citizen, worries less than I do about identifying an appropriate healthcare model for Americans to emulate. Americans, he says, are not like anyone else, even though we are, in point of fact, a little bit of everyone else. My husband believes that a uniquely American solution, one that accepts our good intentions, bad behaviors, unparalleled diversity, and independent ways will emerge. I hope he's right.

From the looks of our front door, I kind of need him to be.