Thursday, February 04, 2016

There is no billing code for compassion

I am borrowing a line from Dr. Amy Ship, the 2009 recipient of the Campassionate Caregiver Award from the Schwartz Center, to remind folks that nominations are now open for this coming year's award. The award recognizes health care professionals who display extraordinary devotion and compassion in caring for patients and families.  It is open to health care professionals who work in any U.S. health care setting. The nomination deadline is March 31, 2016. Here's the link.

There's no better way to express your appreciation to a friend, colleague, or caregiver than to nominate them for this honor.

Wednesday, February 03, 2016

Plus ça change

I mean no disrespect to my Australian hosts when I say that I've seen this all before.  The details differ, but the same underlying themes emerge. And when stories are placed side by side, it can be confusing to the public.

In Australia, the government strongly encourages private health insurance coverage for a portion of the population, a policy that was designed to reduce overcrowding in the public hospitals.  There are a whole series of regulations that influence both corporate and individual behavior in this arena.  These rules have essentially created the private health insurance market in the country.

As noted just a few days ago, the private hospitals in the country want to assure their investors that the demand for health care services will not diminish over the next several years.  They cite underlying demographic factors:

In a strident statement Ramsay's Mr Rex said the report failed to consider further utilisation growth linked to the ageing population. "Macquarie's report incorrectly concludes that the modest impact of ageing in the past means that the impact will be minimal in the future," he said. "But it is the future impact of ageing – the baby boomers moving into the 60-70 year bracket - that needs to be considered... We have not yet felt the ageing impact – it is yet to come."

Those who provide private health insurance to cover patients for these services have understandably been increasing premiums to cover the costs.  Look at this chart below:

Private health care costs are rising at about 8%, mostly due to higher utilization of the health care system (both number of visits and procedures per visit) and a bit (about equal to the consumer price index) due to hospital and doctor pricing changes.  So the insurers have actually been able to hold premiums increases to something a bit less than the total cost increase. 

But that doesn't keep government officials from taking a strong stand against the current premium rate filings, saying they demand further review.

The insurers then respond by pointing out that part of the problem stems from the government's own policies. For example, the cost of prosthetic devices in Australia's private health care sector is dramatically above that found in other countries.  Why?  Because the government has made a pricing deal with equipment suppliers to keep the cost of such devices low to the public hospitals, subsidizing those facilities with higher prices to the private hospitals.

Health insurers . . . estimate that up to $800 million could be saved on prosthetics, such as hip and knee replacements, if a reference pricing system with Australian and international benchmarks was introduced.

But let's get past this local detail. Even if it is true--and worthy of attention--it can distract from our overview.  There is an old joke about gravity:  "It's not just a good idea.  It's the law."  So, too, for anti-gravity in the health care world in developed countries.  Those countries face common factors that are driving up costs.  I summarized these back in 2009.  Number 8 doesn't apply here in Australia, but the others do to a greater or lesser extent:

1) Demographics. The huge cohort of baby boomers have now entered the age at which they are seeking hospital care. Meanwhile, their parents are living longer than ever and are coming to the hospital for both acute and chronic care.

2) Entitlement. The first cohort named above expects and demands everything for themselves, and of the insurance products they expect their employer to purchase. For their parents, they often expect extraordinary end-of-life care interventions, paid for by Medicare.

3) New stuff. See #2 above. A knee that previously would have remained sore in the past or be treated by physical therapy becomes a target for arthroscopic surgery.

4) The medical arms race. Physicians and hospitals feel compelled to buy the latest technology, even without proof of enhanced clinical efficacy.

5) Defensive medicine. Yes, the threat of malpractice law suits leads to over-testing and other extra costs.

6) Regional medical mythology. Thanks to Brent James for this insight. Local practice patterns often are just that, with no evidentiary basis.

7) Preventable harm in clinical settings leading to extended hospitalization and bodily injuries.

8) Lack of access itself. If people don't have health insurance and can't get proper early diagnostic and preventative care, they are a more expensive burden on society when they get sick.

9) The cottage industry problem. The medical profession, both in physician practices and hospitals, has failed to adopt process improvement approaches that are common in other industries, that result in redesign of work flow and systems to derive efficiency, quality, and standardization.

10) A sedentary and malnourished lifestyle for all age groups, leading to obesity and other associated physiological problems that are the precursors to major health issues.

... We can fix some of our inadequacies through legislation, but many components of our problems lie deeper in society.

P.S. While there are pro's and con's of each country's health care systems, similar cost pressures have become evident in much of the rest of the world. Perhaps this suggests that a common organism underlies our problems, homo sapiens and its curious ability to live longer and expect more.

Putting aside the political trading that will inevitably take place, from what I've seen so far, Australia could do a lot by investing in changes to numbers 6, 7, and 9, above--and likely number 10.  Places around the world that have done so have been able to counteract at least part of the anti-gravity tendency of societally driven health care cost increases.

Sunday, January 31, 2016

Mind the step!

One of my "thinker in residence" sponsors here in Australia is VMIA, the Victoria state government insurance agency.  I had just finished having a lovely cup of coffee and conversation with one of the agency's executives, where our topic had been risk assessment and mitigation.

As I started to leave the coffee shop (not a state agency facility!), I stumbled and looked back to see a drop in the floor levels between two parts of the restaurant.  While I can be clumsy (just ask my soccer buddies!), usually I'm pretty adept at walking out of restaurants without suffering harm.  So, I looked back to reconstruct the situation.

Here's the broad scene.  The waiter above has just stepped down into the lower portion of the shop.  And indeed, there is a large sign up and to the right warning patrons of the drop in floor height.

The problem is a that there is a very eye-catching sign to the left, designed to draw your attention as you pass through this area.

So, I didn't notice the warning sign to my right.  Also, the floor area is not well lit, and there is little color difference between the step and the floor below.

Ok, that's the human factors set of circumstances. These are accidents waiting to happen.

Now, let's turn to the people side.  As I stumbled, a clerk behind the counter noticed and smiled knowingly, as if to suggest that I was not the first to have this experience.  I went back to talk with another clerk and point out the problem.  She was very apologetic and asked if I was hurt.  I said I was fine but just wanted to point out the safety hazard.  When she saw me taking pictures, she said, "You're not going to sue us, are you?"  I said no, but I thought the shop might want to devise a better warning system.  She acknowledged that the current arrangement was designed to warn people headed towards the right, i.e., going to the toilet, but not those who might be going to the left.

I left confident that the problem would not be addressed in the future.  Some day, someone will fall and be badly hurt, and the shop may, indeed, be sued.

Think through similar circumstances in health care facilities and other service establishments, as well as industrial settings.  Such patterns are highly prevalent--both in terms of the human factors issues and also in terms of the lack of empowerment felt by the front line staff.

Wednesday, January 27, 2016

A canary in the coal mine?

How should we think about medical malpractice claims against doctors?  Are they indicative of something about those doctors who've been sued? Are they a symptom of underlying quality and safety issues in a hospital, a kind of canary in the coal mine that suggests there might be deeper problems?  These are long-standing questions.

Perhaps part of the answer is provided in a new article in the New England Journal of Medicine, "Prevalence and Characteristics of Physicians Prone to Malpractice Claims," by David Studdert and colleagues.  (The article has a theme that is somewhat consistent to one I discussed a few days ago, which reported that a small group of doctors in Australia accounted for many patient complaints.)

The authors conducted an extensive review of US National Practitioner Data Bank information, analyzing 66,426 claims paid against 54,099 physicians from 2005 through 2014. They found that, over this 10-year period, "a small number of physicians with distinctive characteristics accounted for a disproportionately large number of paid malpractice claims."

Approximately 1% of all physicians accounted for 32% of paid claims. Among physicians with paid claims, 84% incurred only one during the study period (accounting for 68% of all paid claims), 16% had at least two paid claims (accounting for 32% of the claims), and 4% had at least three paid claims (accounting for 12% of the claims). In adjusted analyses, the risk of recurrence increased with the number of previous paid claims. For example, as compared with physicians who had one previous paid claim, the 2160 physicians who had three paid claims had three times the risk of incurring another.

Risks also varied widely according to specialty. As compared with the risk of recurrence among internal medicine physicians, the risk of recurrence was approximately double among neurosurgeons, orthopedic surgeons, general surgeons, plastic surgeons, and obstetrician–gynecologists. The lowest risks of recurrence were seen among psychiatrists and pediatricians.

Male physicians had a 38% higher risk of recurrence than female physicians. The risk of recurrence among physicians younger than 35 years of age was approximately one third the risk among their older colleagues. Residents had a lower risk of recurrence than nonresidents, and M.D.s had a lower risk than D.O.s. 

We could stop right there and conclude that the problem lies solely with the high-risk doctors.  But, as the authors point out, these doctors practice in health systems, and those systems have the potential to intervene.

All institutions that handle large numbers of patient complaints and claims should understand the distribution of these events within their own “at risk” populations. In our experience, few do. With notable exceptions, fewer still systematically identify and intervene with practitioners who are at high risk for future claims. Rather, the risk-mitigation initiatives that are in place — such as the educational and premium-discount programs that some malpractice-insurance companies offer — are generally offered en masse. Otherwise, insurers tackle the problem of claim-prone physicians primarily by raising premiums or terminating coverage. These strategies do not directly address the underlying problems that lead to many claims.

In an environment in which a small minority of physicians with multiple claims accounts for a substantial share of all claims, an ability to reliably predict who is at high risk for further claims could be very useful. . . . If reliable prediction proves to be feasible, our hope is that liability insurers and health care organizations would use the information constructively, by collaborating on interventions to address risks posed by claim-prone physicians (e.g., peer counseling, training, and supervision). It could present an exciting opportunity for the liability and risk-management enterprises to join the mainstream of efforts to improve quality.

Tuesday, January 26, 2016

Fostering a non-negotiable safety mindset

Apparently, my recent blog post about preventable medical errors at a Victoria community hospital was widely circulated among the local health care community.  Maybe it's helpful to have an outside observer say things about such a circumstance, but there are also local observers who fully understand the underlying issues and have been working on them for some time.

One is Cathy Balding, who wrote this article on the same situation back in November.  Here are some excerpts that go to the heart of the matter, not just in Djerriwarrh, but more generally through the state of Victoria:

Creating and maintaining consistently safe, high quality care requires an understanding of complexity, and the mix of interconnected organisational factors required: great people supported by great systems, led from the top, based on a relentless pursuit of excellence. But--we haven't yet achieved universal acceptance that this is what it takes. The belief that point of care is fundamentally clinicians' business is buried in our healthcare DNA; an unconscious attitude that drives a hands off approach to clinical governance in still too many health, community and aged care services.

So--There's a step before all the action. And that's the step that many health services miss: fostering a non-negotiable safety mindset that addresses this deeply held belief head on. I see ‘excellence’ everywhere in mission statements and strategic plans. But it doesn't take much to scratch the surface and realise that in too many cases, these words are about image, not substance. The way we'd like to be perceived, rather than the way we really are. As if saying it will somehow make it a reality. But saying it is just the beginning. 

I've addressed a common pyschological reaction of clinicians: everybody likes to think they are doing better than others.  It turns out that boards also fall into this trap.

Marie Bismark summarized this phenomenon in a paper delivered in May 2014: "Almost every respondent believed the overall quality of care their service delivered was as good as, or better than, the typical Victorian health service."  Here's the pertinent graphic from her talk:

I addressed this issue once with regard to US hospitals, noting:

We know that most medical harm does not derive from the individual actions of doctors. It derives from the work patterns and systems that are in place in hospitals. These are not organizational aspects in which most doctors and nurses have been trained. They are trainable with some time, effort, and resources—but those in a position of authority must encourage and demand that it happen. The “those” in this case must be the boards of trustees, the governing bodies of the hospitals. 

But it is in this arena that we have a public policy lacuna. While trustees often have a statutory responsibility for the quality of care given in their hospitals, they are never held accountable for that care. The history of involvement by lay governing bodies is heavily centered on the social and community aspects of governance. Clinical decisions are left to the clinical staff, as they should be, but oversight of clinical activities by the governing body is often rudimentary at best.

In another article, I offered a suggestion as to how transparency of clinical outcomes could help a board do its job better.

I think the issue is not the unavailability of reliable information on peer performance.  I think the issue is a failure, in the first instance, to even measure one's own performance and to share that with one's own team. After all, the issue is not so much benchmarking.  That only goes so far.  As I've often said, there is no virture in benchmarking to a substandard norm. 

So, the first step is to accurately collect one's own data and make it transparent to your own team. It is that transparency--more than benchmarking--that will establish the creative tension in an organization that will drive people to meet their own stated standard of clinical excellence.  A smart board does not have to apply pressure on its staff by drawing comparisons with others. Rather, they take governance steps to demand transparency, so that the deep sense of purpose that is inherent in the clinical staff is employed to stimulate the team to do better on their own.

In short, the conclusions reached by Dr. Balding, Dr. Bismark, and many other observers must be revisited by the broader community. Victoria, in contrast to, say, New South Wales, has determined that a highly devolved structure of health services best suits it population. That may indeed be the case for a number of reasons, but a necessary condition for such a devolved structure is that the CEOs of local hospitals are given the clear mandate from their boards that quality and safety are the first and highest measures in their performance reviews--and that the boards are given the identical clear mandate from Government.  Yes, access and cost are important factors as well, but if the underlying care delivered by health services is not safe and effective, the public service mission of these organizations has not been achieved.

Monday, January 25, 2016

Nominative determinism

Upon seeing this photo from the town of Koo Wee Rup, Victoria, that I posted on Facebook, our friend Geoffrey Irvin posited that it appeared to be a clear case of nominative determinism, which Wikipedia defines as "the hypothesis that a person's name can have a significant role in determining key aspects of job, profession or even character."  The article notes:

The term nominative determinism had its origin in the 'Feedback' column of the British popular science magazine New Scientist in 1994:

"We recently came across a new book, Pole Positions — The Polar Regions and the Future of the Planet, by Daniel Snowman. Then, a couple of weeks later, we received a copy of London Under London — A Subterranean Guide, one of the authors of which is Richard Trench. So it was interesting to see Jen Hunt of the University of Manchester stating in the October issue of The Psychologist: 

"Authors gravitate to the area of research which fits their surname." Hunt's example is an article on incontinence in the British Journal of Urology by A. J. Splatt and D. Weedon. We feel it's time to open up this whole issue to rigorous scrutiny. You are invited to send in examples of the phenomenon in the fields of science and technology (with references that check out, please) together with any hypotheses you may have on how it comes about. No prizes, other than seeing your name in print and knowing you have contributed to the advance of human knowledge."

What do you say?  Shall we see if our readers here can continue to advance human knowledge and offer other examples, either that support the hypothesis or cast doubt upon it?  Please submit your entries as comments.  Thanks!

Sunday, January 24, 2016

One person's costs is another person's income

What a relief!

According to Jessica Gardner in the Sydney Morning Herald, a recent report suggesting that the growth in utilization of the Australia private health care system might slow down is off base.

Two rival private hospital leaders, Healthscope's Robert Cooke and Ramsay Health Care's Chris Rex, say a research report from Macquarie that warned of a hit to the companies' growth is premature and ignores important trends.

Macquarie's health analyst published a note on Monday warning that a federal government review of the Medicare Benefits Schedule would hit 'utilisation' of services, which is the largest driver of revenue growth for the companies.

Investors were unnerved by the analysis. On Monday Healthscope shares fell 4.8 per cent to $2.36, while Ramsay shares lost 3.2 per cent to $60.65.

In a strident statement Ramsay's Mr Rex said the report failed to consider further utilisation growth linked to the ageing population. "Macquarie's report incorrectly concludes that the modest impact of ageing in the past means that the impact will be minimal in the future," he said. "But it is the future impact of ageing – the baby boomers moving into the 60-70 year bracket - that needs to be considered... We have not yet felt the ageing impact – it is yet to come."


Saturday, January 23, 2016

When is a doctor like a bull ant?

In my previous post, I addressed the issue of bullying in Australian hospitals.  In an article published three years ago in BMJ Quality and Safety, Marie Bismark, David Studdert and colleagues addressed a topic that might be correlated in some way with that problem--or might just have importance in it own right.

The authors' objective was: 1) To determine the distribution of formal patient complaints across Australia's medical workforce and (2) to identify characteristics of doctors at high risk of incurring recurrent complaints.

What they found was:

A small group of doctors accounts for half of all patient complaints lodged with Australian Commissions. 

The distribution of complaints among doctors was highly skewed: 3% of Australia’s medical workforce accounted for 49% of complaints and 1% accounted for a quarter of complaints. Short-term risks of recurrence varied significantly among doctors: there was a strong dose-response relationship with number of previous complaints and significant differences by doctor specialty and sex. 

The research suggested:

It is feasible to predict which doctors are at high risk of incurring more complaints in the near future. Widespread use of this approach to identify high-risk doctors and target quality improvement efforts coupled with effective interventions, could help reduce adverse events and patient dissatisfaction in health systems.

The Australian bull ant (seen above) gets you coming and going.  He'll either bite you from the front or sting you from the back. This cadre of doctors do the job even better. They offer the potential of both harming the patient and the institution in which they work.

Thus far, though, "the medico-legal enterprise remains reactive, dealing primarily with the aftermath of adverse events and behaviours that lead to costly disputes." Perhaps the work produced by Bismark, Studdert and colleagues will help the AMA, health services, medical indemnity insurers, and others think more systematically about this issue.  And, as in the bullying case, the input of patients and families could certainly prove valuable in this arena.

Bullying, a multi-legged problem

Notwithstanding Bill Bryson's characterization of this "sunburned country" as a place in which there are dozens of ways to be killed by local fauna*, the chance of actually dying from a spider bite, snake bite, or in other such manner is quite small.  For example, the huntsman above looks pretty ferocious, especially given his 4" (10 cm) span, but he won't kill you.

In contrast, though, Australia shares the unenviable status of other developed countries (US, UK, and the like) in the fact that being a patient in a hospital is a significant risk.  I discussed the situation in one Victoria hospital in a previous blog post.  There, a number of babies died of a result of preventable medical errors.

In the short time I've been in the country, I've heard several people set forth one aspect of the problem, the existence of inappropriate levels of bullying and intimidation by senior members of the medical staff.  Such behavior can directly influence the safety and quality of patient care:

"Most organizations are beginning to understand that this is about patient safety," says Marty Martin, a psychologist based at DePaul University in Chicago. He co-wrote a guide book, Taming Disruptive Behavior [that] details growing evidence linking bad behavior with patient harm.

(Indeed there is reason to believe that such was part of the problem in the aforementioned hospital.)

In a November 21, 2015 article in The Age, reporter Neelima Choahan summarized a day-long summit held by the Australian Medical Association on the topic.

Now comes the question of what to do about it.  Shortly after the article, the AMA issued a position statement on the issue.  The organization's president said:

“Workplace bullying and harassment creates an unsafe and ineffectual work and learning environment due to the continued erosion of confidence, skills and initiative, and can create a negative attitude towards a chosen career.

“The medical profession must take direct responsibility for its culture, reputation, and standard of professionalism. 

“We need comprehensive policy, practices, and education to foster a safe and healthy work and training environment, and we must maintain appropriate standards of patient care.

“Employers and education providers must work closely together to develop a strong response to change the culture in workplaces."

This is a start, but this is a tough problem that has been in existence for decades. Let's hope that the Australian medical profession does indeed "take direct responsibility" for improvement in this arena; but there are important roles for other constituents as well.  In particular, there is a nascent patient advocacy movement occurring in this country. With focus and direction, those engaged patients and families can provide respectful and helpful input about the cultural environment in which they are being treated. There is no mention of this resource in the AMA'a position statement or in the president's comments on the issue.  It would behoove the AMA to join forces with such individuals and groups to help make the statement of position a reality throughout the country.


"It has more things that will kill you than anywhere else. Of the world's ten most poisonous snakes, all are Australian. Five of its creatures - the funnel web spider, box jellyfish, blue-ringed octopus, paralysis tick, and stonefish - are the most lethal of their type in the world."

Tuesday, January 19, 2016

No worries? Not so good.

Every language or region has its colloquial response to "Thank you!"  In Spanish, we say, "De nada."  "It's nothing."

In the United States, we often say, "No problem."

Here in Australia, it's "No worries."

This is fine in casual settings, as among friends.  But, in health care settings, it's the wrong answer.

I addressed this about five years ago in a blog post, noting:

One of the things I learned in my hospital days was how to accept gratitude. A hospital can be an uncomfortable place for patients and family members. It is a strange physical environment, where people are anxious because of feared or actual medical conditions or forthcoming procedures or tests. In that situation, when you do something kind for someone, the person is truly grateful. It can be as simple as offering directions, or picking up a fallen object, or something much more serious.

When I started working in the hospital, when someone would say "Thank you" to me, I would often answer, "It's nothing," or "No problem." Wrong! I was taught that such an answer devalues the gratitude that the other person is feeling. A more appropriate response is, "It is my pleasure," or "I am so pleased I was able to help." That indicates that you understand their feelings.

Over the years, I trained myself to do this. Lo and behold, once I got rid of the "It's nothing" conversation stopper, people would jump in and continue the conversation even further. I was able to learn so much more about people's fears, expectations, experiences, and hopes and then help translate those into improvements in the clinical environment.

So mates, try this out in clinical settings.  You'll respectfully acknowledge a person's appreciation, and you might learn something new that could be helpful to the patient, family, or your own institution.

Negotiating in Geelong

One of the pleasures in my appointment as "Thinker in Residence" at Deakin University is the chance to hold workshops for local folks on topics that might be new and interesting to them.  This week's session was an introduction to strategic negotiation for people from Deakin, GMHBA (the region's largest mutual health insurance company), the Western Victoria Primary Health Network, and Barwon Health.  Beyond learning some new approaches to this field, many folks in attendance also had a chance to meet each other for the first time.

Here are pictures of some of the attendees, responding to other parties or deep in thought as they considered their approach to negotiating some difficult roles in simulations we carried out.

Saturday, January 16, 2016

Facebook: Killing the goose?

None of us who use Facebook are so naive as to think that it is a free service.  The "cost" of playing is that they use all of the data you post to direct advertisements your way.  It is simply how these applications on the Internet are monetized.

But many friends and I have noticed a dramatic upswing in the number of sponsored items on our news feeds, often showing up with the message that one or another of friends has "liked" the link.  In the past, there would have been a few of these, but now they come in a ratio of 1:10 or 1:20 among the feeds on your page.  Here are three examples of what they look like.  (I've omitted the accompanying pictures.)

I searched the web to see if this upswing in such ads is a new deal, but found nothing.  But I did find this "helpful" suggestion on the Facebook "Help Community" from a few months ago:

Alison asked:

How do I stop the bombardment of advertising posts on my newsfeed - almost all totally irrelevant to me, and some against all my principles.

Hailey provided this non-answer:

Alison replied:

I know all about the options not to see ads from particular advertisers, but the bombardment I have been getting recently is beyond belief. And opting out of each on individually takes time which I don't have to spare. I want to be able to opt out of ALL ads and sponsored links. I'd never follow them anyway - I take word of mouth and recommendations from friends as the best advertising, not people who need to pay to advertise.

There was no response. 

So we know that we can delete the ads we don't like, but who wants to spend the time doing that as you scroll through looking for news from your friends?  As my buddy Lyette noted: "I've already found myself checking less often, because I know they don't even show me half of my friends' updates."

So, what do you think?  Is Facebook over-reaching now?  Will it change your viewing habits?