Peter Pronovost is a liar. He must be.

Click to toggle image sizePeter Pronovost and his subversive friends are at it again.  Imagine, first they assert that implementation of a standard protocol and checklist could reduce the rate of central line associated bloodstream infections.

“It wouldn’t work here.  Our patients are sicker.”

Then, to make matters worse, they go and contend that reducing the rate of central line infections saves money.  Here’s the abstract from the American Journal of Medical Quality:

This study calculates the costs and benefits of a patient safety program in intensive care units in 6 hospitals that were part of the Michigan Keystone ICU Patient Safety Program. On average, 29.9 catheter-related bloodstream infections and 18.0 cases of ventilator-associated pneumonia were averted per hospital on an annual basis. The average cost of the intervention is $3375 per infection averted, measured in 2007 dollars. The cost of the intervention is substantially less than estimates of the additional health care costs associated with these infections, which range from $12,208 to $56,167 per infection episode. These results do not take into account the additional effect of the Michigan Keystone program in terms of reducing cases of sepsis or its effects in terms of preventing mortality, improving teamwork, and reducing nurse turnover.

“No, it can’t work that way unless we get rid of fee-for-service payments and go to capitation.  We all know that nobody will act to reduce infections because they will get paid less.”

Continue reading “Peter Pronovost is a liar. He must be.”

Twenty-Four Seven

Bradley Flansbaum

First posted 8/07/11 on The Hospitalist Leader

Two recent articles, one from The New York Times, the other from The Hospitalist,initiated some 24/7 staffing issue rumination on my behalf.  It stems originally from a recent op-ed by Lucian Leape:

“Given the accrediting council’s reluctance to act, the federal government needs to get tougher. If we are serious about curbing the tide of injuries stemming from medical errors, Medicare should make its funding of graduate medical education contingent on hospitals’ limiting work hours. We can’t afford to wait another 40 years.”

How do the aforementioned pieces resonate with the above quote?

The NYT article, well written, examines pediatric training, errors that stem from doctor “fatigue,” and the root causes behind these errors—presumably due to burdensome hours and the legacy of educational norms of decades past.  The author, chief of pediatric cardiology at UMass Medical School, cites the evidence before and after implementation of trainee work hour restrictions in 2003 (not overwhelmingly positive incidentally), and concludes that it may not be the stretch worked—although this is a factor, but how information is communicated doc to doc, and shift to shift.  This is not news to hospitalists.

Continue reading “Twenty-Four Seven”

Seeing Things Clearly in the Netherlands

Paul Levy

First posted 6/30/11 on Not Running A Hospital


In the post below, I summarize a conference held today at Jeroen Bosch Hospital in ‘s-Hertogenbosch (den Bosch), in the Netherlands, entitled “Quality and Transparency in Care and Training.” In addition to the conference, today was a significant day in that a new website was launched by the hospital to present quality and safety data to the public and to the hospital’s staff.

As explained by Dr. Marjo Jager, patient quality specialist, Jeroen Bosch has a strong commitment to transparency as a key element of process improvement in the hospital. The leadership of the hospital views transparency as the most powerful way to reduce preventable injuries, but also as essential to successful and ethical responses to patients and to safeguard employees.

Marjo noted that preconditions for successful implementation of transparency are a culture of learning rather than blaming and judging; ownership by those who deliver care; significant participation by physicians in designing new care regimes and setting an example; and strong support from the board.

At right you see an action shot of the moment of truth, as staffers Miriam Casarotto and Bart Deijkers prepare to push the “activate” button on the new website.

Beyond the website, the hospital is also posting clinical data on patient care floors for all to see. They are experimenting with locations and topics, and this is all bound to change with experience, but the commitment to openness is evident, even when the numbers indicate a need for improvement.

Here, for example, is the current scoresheet with regard to pain management on one of the floors. The hospital clearly indicates a result less favorable than they would like, accompanied visually with a cartoon face that is not smiling.

Continue reading “Seeing Things Clearly in the Netherlands”

In Health Care, Why It Is Best That We Choose for Ourselves

Wendy Lynch

First posted 6/23/11 on the HHCF Blog

Faced with a difficult medical situation, it is not uncommon for patients to ask doctors for advice.  But asking, “Doctor, what should I do?” is a very different question than, “Doctor, can you help me understand and weigh my options?” It may sound like semantics, but your involvement and participation in making personal health decisions can make a difference in your recovery.

A recent study showed that patients who make their own choices report better recovery than those for whom choices were made by doctors (1).  Regardless of WHAT choice was made, the patients who did their own choosing reported better physical and psychological outcomes; active choice-making had its own healing power.  It may also protect us from unwanted consequences.

Continue reading “In Health Care, Why It Is Best That We Choose for Ourselves”

Rads Are Good For You. Take Twice As Many

Paul Levy

First published 6/19/11 on Not Running A Hospital

Dear Mrs. Smith, I am writing to inform you that we exposed your body to an unnecessary level of radiation during your visit to our hospital. Oh, by the way, that was two years ago. We don’t intend to do anything about this for you. Also, we have known about this problem for a long time, and we don’t expect to change our procedures for future patients. Just wanted you to know. Yours in delivering the best health care in the world, Chief of Radiology and CEO. (Jointly signed.)

That’s the essence of this article by Walt Bogdanich and Jo Craven McGinty in the New York Times. Here are excerpts:

Continue reading “Rads Are Good For You. Take Twice As Many”

Comparing Hospitals on Safety, Quality and Cost

Merrill Goozner

First published 4/25/11 on GoozNews

The Sunlight Foundation today gave us a fascinating first peak at the hospital safety data from the Centers for Medicare and Medicaid Services, which was finally convinced to release the information after years of stonewalling by the American Hospital Association. For the first time, the public can compare less-than-stellar performance at competing local hospitals on key indicators like catheter or urinary tract infections or bed sores.

Continue reading “Comparing Hospitals on Safety, Quality and Cost”

Different Countries, Same Problem

Paul Levy

First published 4/25/11 on [Not] Running A Hospital

recent study* reported in Medscape Today summarized the likely factors leading to medical, medication and laboratory errors in eight countries — Australia, Canada, France, Germany, the Netherlands, New Zealand, the UK and the USA. What is striking is the commonality across jurisdictions, irrespective of the type of health care organizational structure, including this conclusion: “Greater understanding by patients of the risks associated with health care could help to engage patients in participating in error-prevention strategies.” Here are some excerpts from the discussion portion of the article.

Continue reading “Different Countries, Same Problem”

Who’s on First?

Paul Levy

First published 4/18/11 on [Not] Running a Hospital

This story about the Joint Commission in the Boston Globe is disheartening.

The lede: The national organization that accredits hospitals will tackle the failure of medical staff to respond to patient alarms, making it a top priority this year.

But the real story is the failure of the Joint Commission to address this issue in a comprehensive and thorough manner. Indeed, it seems to have dropped the ball:

Continue reading “Who’s on First?”

Book Review: “Overdiagnosed” and the Paradox of Cancer Survivorship

Kenneth Lin

First published 4/12/11 on Common Sense Family Doctor

According to the National Cancer Institute and the Centers for Disease Control and Prevention, the number of cancer survivors in the U.S. has increased dramatically in my lifetime, from 3 million in 1971 to 11.7 million in 2007. From 2001 to 2007 alone, the number of persons living with a cancer diagnosis rose by nearly two million. Most people would probably see these statistics as good news: an indication that our cancer treatments are improving and allowing people to live longer, or that earlier diagnoses are giving people a better chance to survive by catching localized cancers before they spread and become impossible to cure.  Continue reading “Book Review: “Overdiagnosed” and the Paradox of Cancer Survivorship”

How Veterans Are Winning the (Quality) War

Paul Levy

First published 3/31/11 on [Not] Running A Hospital

At a seminar last night at the Center for Public Leadership at Harvard’s Kennedy School, one of the students asked a question along the lines of, “How do you know when you have done too much with regard to transparency?” My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI’s Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

Continue reading “How Veterans Are Winning the (Quality) War”

Maryland Proceeding Off-Course

Paul Levy

First published 3/21/11 on [Not] Running a Hospital

Maryland, the only state with a hospital rate-setting process, also has an interesting financial incentive program related to quality indicators. It is described here. Some excerpts:

This initiative, which commenced July 1, 2009, links payments to hospital performance on a set of 49 Maryland Hospital Acquired Conditions (MHAC) across all-payers and patients in the State.  Continue reading “Maryland Proceeding Off-Course”

Don Berwick on Patient Centered Health Care

Kenneth Lin

First published 2/14/11 on Common Sense Family Doctor

Brian’s Note: I saw this nice column by Dr. Lin and decided to post it as a complement to another effort that readers may be interested in. Over at Facebook is a page called 100,000 voices for Don Berwick. If you are moved to do so, please check it out and maybe post something on the wall there.

To me it is remarkable that Dr. Berwick, one of the nation’s true examples of servant leadership, has been politically excoriated. Meanwhile, we’ve heard virtually nothing from the leaders of the hospital world, who are, in my experience anyway, overwhelmingly Republicans and who have made the pilgrimages every year for many years to the Institute of Healthcare Improvement meetings, always with enthusiastic support for Dr. Berwick’s vision and activities. So much for conviction and expediency.

I stand with Dr. Lin and Dr. Steuerle below that we get the health care and the government we deserve.

100,000 Voices for Don BerwickI’m a big fan of Don Berwick, the current administrator of the Centers for Medicare and Medicaid Services who last week was on Capitol Hill being grilled by a congressional committee on his views. Although Dr. Berwick (a pediatrician by training) made his reputation in the area of improving patient safety and quality, his views on patient-centered care are what I admire most.

Continue reading “Don Berwick on Patient Centered Health Care”

Hospital Governance Issues in Israel

Paul Levy

First published 3/8/11 on [Not] Running A Hospital

I am currently in Haifa, Israel, addressing a conference being held by the Israel National Institute for Health Policy Research entitled “Governing Hospitals.” Here’s the summary of the program:

As explained here, Israeli hospitals come in several varieties. An excerpt of the context:

Israel has a national health insurance system that provides for universal coverage. Every citizen or permanent resident of Israel is free to choose from among four competing, non- profit-making health plans. The health plans must provide their members with access to a benefits package that is specified within the NHI Law. The system is financed primarily through taxation linked to income (through a combination of earmarked taxes and general revenue). The Government distributes the NHI funds among the health plans according to a capitation formula which takes into account the number of members within each plan and their age mix.

Continue reading “Hospital Governance Issues in Israel”

Heart Failure or System Failure?

Merrill Goozner

First published 3/3/11 on Gooz News

Today’s New England Journal of Medicine reports the results of a government-funded study of two potential approaches to giving emergency diuretics to congestive heart failure patients who show up on emergency room doorsteps gasping for breath. Should it be through a continuous drip or periodic injections? Should physicians prescribe high doses or low doses of these fluid dispersal drugs? Cost isn’t an issue since diuretics are generics. The pressing question was whether high doses caused a greater incidence of renal failure, which had been suggested by a number of smaller trials.

Continue reading “Heart Failure or System Failure?”

2 Kidneys vs. 100,000 Lives


First published on [Not] Running a Hospital

This story about a kidney transplant mix-up in California is bound to get lots of coverage. It is these extraordinary cases that get public attention. I am sure it will lead to a whole new set of national rules designed to keep such a thing from happening.

Of course, such rules already exist, and it was likely a lapse in them that led to this result.

Continue reading “2 Kidneys vs. 100,000 Lives”