SaferPatients

Value Based Purchasing (VBP) is here.

VBP is a control scheme introduced by CMS to reduce the cost of health care. Under VBP, providers will be reimbursed for care given to Medicare patients based on patient satisfaction and the ability to get good scores on CMS core measures.

Medicare has been very clear about the impact to hospital bottom lines. Average performers won’t break even. If you have average core measures, and average patient satisfaction your institution will lose money.

The way to maximize your reimbursement and protect your budget is to have high performance compared to national benchmarks with other hospitals across the country, and to make  dramatic improvement against your own baseline scores. Either way, you must improve.

If you add the reduced reimbursements to an additional 20.4 million Medicare patients over the next decade, and then add the effect of productivity adjustments, 15 percent more institutional providers will go bankrupt by 2019, according to the former administrator of CMS.

What is the solution to value-based purchasing?

• increased use and adherence to protocols,
• real-time monitoring and feedback,
• focused scorecards, and
• better training for doctors and nurses on patient communication techniques.

You must be better than average, or you will be worse off financially next year. But how to get better?

If you are depending on individual clinicians to spectacularly rise to the challenge on their own, you will fail. Sustained results will only come from a systems approach that hard-wires daily habits all of personnel. if you don’t know how to do this, it might be time to get some help.

Watch a three-minute movie about LifeWings.

A Boston surgeon who performed the wrong procedure on the hand of an elderly woman has disclosed the excruciating details of his error in one of the nation’s most prominent medical journals.

As usual this case had all of the classic error-inducing factors: 1) The procedure was done at the end of a long day; 2) Stress was high because several other surgeons were behind schedule. When surgeons are stressed, the surgical team is stressed; 3) The patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment; 4) The surgeon didn’t have a habit of leading or actively participating in the Time Out (seeing them as an unnecessary burden); 5) There were communication issues as the patient didn’t speak English.

The surgeon did speak Spanish and spoke to the patient in that language. This exchange in Spanish was mistakenly interpreted by the Circulator in the room as a “Time Out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred.

While admittedly I wasn’t there for this event, I have personally observed many other OR situations like this one, and I have no doubt that the nurse did an internal debate with herself about whether she should speak up and question the surgeon about the Time Out and the need to do it in English for the benefit of the team. For whatever reasons, including the stress she felt from the surgeon and the fact that the surgeon didn’t typically lead, or get actively involved in the Time Out, she decided it was okay to let it slide.

If the surgeon had always made it a habit of leading the Time Out, and of making a safety statement at the end of it encouraging his team to speak up if they saw something not in the patient’’s best interest, it would have made it easier for the nurse to speak up.

A classic, effective, stop-the-line assertive statement by the circulating nurse at that moment would have changed everything.

He didn’t, and she didn’t. The result was the surgeon performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure.

What did the surgeon learn? “I no longer see these protocols (the Time Out) as a burden. That is the lesson,” he said.

It is unfortunate that so many see the proper execution of a Time Out as an unnecessary time waster until “it” happens to them.

Experience is a great teacher, but she sends in terrific bills.

Watch a three-minute movie about LifeWings.

By now almost everyone involved in health care quality improvement has heard of the checklist used to insert central lines that was developed Peter Pronovost, MD, professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine. The checklist has made Dr. Pronovost famous.

That checklist has long been known to reduce bloodstream infections when used correctly. It has now been proven to reduce patient deaths in Michigan hospitals by 10%.

The British Medical Journal (BMJ) studied the use of the checklist and discovered  a drop in patient mortality in Michigan hospitals. Though previous studies found a reduction in infections, this is the first to link the checklist program with reduced mortality.

“It’s breathtaking,” Pronovost told The Baltimore Sun. “With our program, patients are alive who wouldn’t be if they were outside Michigan.”

The results are so dramatic that the average ICU in Michigan now has better infection numbers than 95% of the ICUs in the remainder of the country.

While checklists must be well-designed, and getting staff to use them correctly can be tricky, with results like these, why isn’t every hospital using the same checklist program?

Watch a three-minute movie about LifeWings

At Brigham & Women’s Hospital in Boston, team-based inpatient care has resulted in dramatic reductions in inpatient mortality, significantly lower lengths of stay, and higher satisfaction for physicians and nurses.

Team-based care dissolves the hierarchical, traditional structure that exists among nursing, physical therapy, pharmacy and medical staff, social work staff and others to empower individual members of the team to contribute equally to the optimal outcomes for the patients.

At Brigham & Women’s Hospital and its sister Faulkner Hospital, a team-based model of care has been adopted for almost all general medicine units. This system replaces the “chaotic model,” in which residents, attending physicians and interns rotated on different cycles; physicians and nurses did not know one another; and the admissions department assigned patients to whatever beds were available.

Each unit now has a team made up of attending physicians, residents, interns and medical students, pharmacy students and a faculty supervisor, nurses, a social worker, an RN care coordinator and a physical therapist. All members of the team are assigned to work together on a specific unit for at least four weeks at a time.

Two other key changes were instituted: The admissions department assigns a patient to an intensive care unit team only if there is a bed available on its unit and interdisciplinary rounds are structured sequentially by nurse, rather than by room number.

Also, under a team-based care model the expectation is that you don’t discuss a patient until the nurse is present, Another expectation is that before a physician articulates the [patient's care] plan that you get the nurse’s input. The physician team leader will always address the nurse and ask, “Do you have anything to add about this patient?”

The perspective of other team members is equally valued, depending on the patient’s diagnosis and care plan. Sometimes the most important clinician is the physical therapist. The physician may be writing the orders and doing some of the direction, but under the team-based care model the physician does not work alone, but as part of a team.

This approach requires new standardized processes, extensive teamwork and communication training, and strong support and leadership action from top administrators.

Watch a Three-minute movie about LifeWings

Here are six ideas that will help you take on a risky (because it might fail and you might be held accountable) patient safety or quality improvement project:

1. Whenever possible, take on specific projects. Don’t wait to be asked. Commit early. Raise your hand.
   
2. Make detailed promises about what success looks like (what are the measures?) and when it will occur (set a deadline).
3. Engage others in your project. Ask them to be publicly identified with you and the project. Make it clear to them that if you fail, if the project fails, that they will fail with you.
4. Be really clear to yourself and your team about what the true risks are. Ignore the vivid, unlikely and ultimately non-fatal risks that take so much of our focus away.
   
5. Concentrate your energy and will on the elements of the project that you have influence on, ignore external events that you can’t avoid or change.
6. If you should fail (and you might, or it wouldn’t be a risky project ) be clear about it, call it by name and outline specifically what you learned so you won’t make the same mistake twice. People who blame others for failure will never have a “positive failure,” because they’ve never done it.

If this list makes you uncomfortable, it might be time to ask yourself what you are afraid of.

If this list feels like the sort of thing you’d like your staff to adopt when they work on a project for you, then perhaps it’s a plan for your next risky project.

Hat tip: Seth Godin

HealthLeaders recently surveyed health care leaders around the country about their thoughts on improving patient safety. Here’s a recap of what they found:

• 91% of health care leaders rank patient safety among their top 5 priorities

(Which means if you are involved in patient safety your boss thinks the work you do is really important - so important it is one of the top five things on his/her plate. So right now I would be pretty bold with my goals and my actions to reach those goals. If I was ever going to be supported in my work to improve the safety of my patients, now is the time. If I was ever going to get resources and mind share from my boss to make it happen - NOW IS THE TIME.)

• 69% say that important patient care information is sometimes, often, or always lost during shift changes

(If I really wanted support and resources for my work from my boss, I’d be focusing on teamwork and communication training around patient hand-offs between care givers during the course of care and during shift changes. I’d also make sure I had great checklists or briefing guides to standardize the way hand-offs are accomplished. My boss has recognized this is an area of weakness and an area of emphasis. Now is the time to get it fixed.) 

• 73% say improved infection control practices are among the new initiatives designed to improve patient safety

(Why is my boss saying this? Because infection rates will affect our reimbursements, and because we can’t give great care if we are giving our patients infections. Again, I’d make sure we have the communications training and standardized processes in place to prevent infections. If I needed to understand how to do this I would look to the Keystone Project in Michigan for guidance.)

• 53% are devoting more financial resources to patient safety program

(If I was ever going to get a piece of the budget to fund my safety projects, now is the time. I’d get really good at showing my boss why the initiative I want to do will result in a permanent improvement in safety so I could earn a big part of the financial resources my boss is willing to invest. NOW IS THE TIME TO DREAM BIG.)

• 49% say that lack of communication skills poses the greatest risk to patient safety during handoffs or transition of care

(I now know why my boss thinks we are at risk during transitions and handoffs. I would make sure I had identified the very best communication training available and had a plan to make sure my staff was trained. Selling my boss on this training should be a lot easier than ever before.) 

Bottom line: If I was in charge of patient safety in your organization, I’d realize that my work was a high priority for my boss and take advantage of that fact to dream big, act big, ask for big resources, and make it happen now in a big way.

Crew Resource Management, or team training, is not a new topic in health care. Health care has even adopted its own name for a CRM-based patient safety project - TeamSTEPPS. Whatever you call it, it’s the idea that health care as an industry can learn a lot from the aviation industry - specifically that many of the concepts used in creating a culture of safety in the U.S. commercial airline industry can be used in health care to improve patient outcomes.

The question is often asked “Where is the data that proves this approach?” A study that provides the data to back up this notion is reported in  American Medical News.

The research, published in the  Archives of Surgery, followed caregivers who had taken a course titled “Lessons from the Cockpit,” which attempts to relate errors in aviation with medical errors and teach how to avoid them. After studying 857 participants of the six-hour course since 2003, researchers concluded that teaching health care workers the principles of crew resource management has a positive effect not only on patient care, but on workers’ perception of the culture of safety and self-empowerment.

Some of the most striking results include the use of preoperative checklists (75 % of participants were using them in 2003, and by 2007 100% of participants were using them). Self-initiated incident reports rose from 709 in the first quarter of 2002 to 1,481 in the first quarter of 2008.

You can read more by checking out the American Medical News article.

The Patient Safety and Quality Health Care journal reports that 90% of hospitals include patient safety as an integral part of their strategic plan and, even in this difficult economic climate, 53% plan to spend more money on patient safety initiatives than they did last year.

I wonder, given the data that verifies the CRM approach, how many will invest in training their staff with the teamwork and communication skills used by all high-performance teams?

Here is an interesting blog post from Seth Godin, author of Linchpin and Poke the Box (two of my favorite books). Seth says…

“Thousands of doctors have signed up for a service that, among other things, they can use to try to prohibit patients from posting reviews. You can read a bit about it here.

In Iowa, in a surprisingly similar move, the state government is moving ahead with a law that will make it a crime to take or possess videotapes of factory farming that might harm the commercial interests of the farmer.

In both cases, an organization is trying to maintain power by hiding information from the public. Can you imagine being arrested for possession of a photo of a pig?

It’s easy to argue that from the public’s point of view, laws like this are a bad idea. The public certainly benefits from the outing of bad doctors and from the improved hygiene of factory farms. In that sense, it’s unethical for doctors and legislators to subvert their responsibilities by ordering the un-empowered to shut up.

I think it’s interesting to think about from the doc’s point of view (and the chicken farmer), as well. The temptation is for those in charge to defend the status quo by fighting transparency. This ignores a simple truth:

When book reviews are posted, book sales go up.

Yes, the argument of fairness matters.

(Yet) it turns out that transparency increases profitability.

Here’s the thing: when consumers get used to transparency, they’re also more interested in the quality of what you sell, and are more likely to willingly pay extra. They’ll certainly cross the street to buy from an ethical provider. And once people start moving in that direction, the cost of being an unethical provider gets so high that you either change your ways or fade away.

Inundate us with images of cleanliness and quality instead of blacking us out. Don’t race to the bottom (you might win). Instead, force your competition to race you to the top instead.

[Aside: the same objection happened when we started regulating hygeine in restaurant kitchens. Yes, it got more expensive to clean the pots and kill the rodents, but it was okay, because post-Duncan Hines, demand for quality went up enough to more than pay for it.]

The same argument holds true for doctors. Once information about good doctors becomes widespread, patients will be more willing to seek out those doctors, rewarding the ones who consistently take better care of their patients. The entire profession doesn’t suffer (we’ll still go to a doctor) merely the careless doctors will.

One more: A leading politician in India is arguing that bribery (in certain transactions) ought to be legalized. Why? Because if the briber feels free to rat out the bureaucrat, bribery goes down.

In all three cases, sunlight is an antiseptic and the marketplace rewards those that behave–and the entire market grows when the standards increase.

Consumers and those that want their admiration ought to reward those in favor of transparency.“

I love Steve Pressfield’s book, Do the Work. It’s a short, simple, incredibly motivating manual on how to overcome the resistance that all great improvement projects meet. Here is a short excerpt on his comments about passion - and passion’s role in overcoming resistance.

“Picasso painted with passion, Mozart composed with it. A child plays with it all day long.

You may think that you’ve lost your passion, or that you can’t identify it, or that you have so much of it, it threatens to overwhelm you. None of these is true.

Fear saps passion.

When we conquer our fears, we discover a boundless, bottomless, inexhaustible well of passion.”

Want to find a way to energize your patient safety or quality improvement program? Find a way to tap into the passion of your staff to heal patients. Isn’t that why they got into health care to begin with?

Nothing is as ever as persuasive to your staff- not your logic, not your cogent arguments, not the peer-reviewed data -  as when your passion for the project connects to their passion for caring for people.

You know you will meet resistance whenever you are trying to effect change. When you meet it, and find yourself hesitant, ask yourself, “What, exactly, would I do here if I wasn’t afraid?” Whatever the answer is - do it. When you conquer your fear of what others will say and do, you’ll find your passion for the task will grow. Others will see it and tap into it. Then you’ll have some momentum.

Go find your passion.

There’s incessant pressure on companies like mine (LifeWings) to get better at selling our services. To put it bluntly, I am on a mission to change the world (or at least the level of safety with which health care is delivered). I really need my team to figure out how to approach, educate, close and support health care facilities to convince them to become our safety partner and use our products and services.

But what about the health care systems, hospitals, clinics, surgical centers, and practice groups that are doing the buying? Business research reveals that the typical organization with more than 1,000 employees has, on average, 21 different people involved in each sale of over $25,000.

The typical big health care facility’s org chart is a mystery, the buying process is a mystery, and there never seems to be an end to the roster of meetings and people. Sometimes it’s almost as though these organizations don’t want to buy anything.

Consultants like LifeWings are not the enemy, and choosing to work with us isn’t charity. The transaction happens because it will benefit both of us.

Unfortunately, the byzantine maze, lack of information, and endless circle is a real barrier to success for both sides.

First, this is exceptionally inefficient. Second, it drives away the great opportunities for sure and permanent improvement in culture and performance. It also leaves health care organizations with only  the sales-focused, ultra-patient consultancies willing to put up with 21 different people and a million meetings. LifeWings is not that consulting company. We don’t even talk about sales revenues - we focus on the number of health care partners we have. I figure that if we help more hospitals next year than we did last year measurably improve their safety and quality, the dollars will ultimately take care of themselves. Besides, I am 56 years old and I am not ultra-patient, my clock is ticking. Patients are suffering now from inadequate safety systems and frankly I don’t think I have time to wait for a million meetings.

If you want to discover new, proven methodologies to increase safety and quality in this era of ACOs, data transparency, and pay for performance, you’re going to need better training partners and consultants. One way to do that is to streamline your buying process and let the folks selling to you know how it works. We’re not the enemy. In fact, companies like LifeWings are your best source for off-the-shelf improvements and innovation you can start using tomorrow.

In this age of health care reform, whoever buys proven innovation the best, wins.

Here are some thoughts on how you can buy better when you are interested in getting help from an outside company:

1. Give them an org chart.

2. Give them an overview of the best way to sell to you.

3. Tell them about successful sales to you and how they were made.

4. Reward your employees when they help a new vendor make a sale that really benefits you.

5. Hassle your employees if they become a roadblock or lie to your vendors.

6. If a vendor asks, “Are you serious about buying from us,” the answer should either be, “Yes,” or “Perhaps, tell me more,” or,  “No, thank you.” Whatever the response - mean what you say.

At LifeWings we want to work with organizations that really want to work with us. Together, we can change the world. Life is too short to have it any other way.