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Emergency Department Inpatient Practice Medical Economics Operating Room

How Hospitals Get Blood For Transfusion

When the average person thinks of donating blood, the first words that come to mind are “Red Cross”. However, the American Red Cross only supplies about 40% of transfused blood in the United States. What most people don’t realize is that the U.S. uses a free-market approach to maintain its blood supply with the result that there are dozens of different blood suppliers for our nation’s hospitals and they compete with each other.

Every day, 35,000 units of packed red blood cells, 7,000 units of platelets, and 10,000 units of plasma are transfused in the United States. In order to meet the needs, there has to be a continuous flow of donated blood into the country’s blood banking system because blood has a short self-life: 42 days for red blood cells and 5 days for platelets. However, red blood cells can be frozen for up to 10 years.

Most countries use a single, government-directed supplier for the blood supply but the U.S. utilizes a network of non-profit blood services that are overseen by federal regulations. As of 2016, there were 786 registered blood establishments that collect blood plus 725 hospital and non-hospital blood banks. Blood centers account for 93% of all collected blood and hospital blood banks account for 7% of collected blood.

We do not transfuse as much blood as we used to. Lower transfusion thresholds (from previous thresholds of 8-9 g/dL hemoglobin to current thresholds of 7 g/dL), a trend toward less-invasive surgeries, the increased use of erythropoietin, hospital blood management programs, and improved medical technology have led to a reduced utilization of blood; the number of units transfused has dropped by 25% since 2008. As the demand for blood has fallen, there has been more competition between the various blood suppliers and many suppliers have gone out of business. So, who are all of these blood suppliers?

  • The American Red Cross. This is the most visible and publicly recognizable blood supplier and accounts for about 40% of the nation’s blood.
  • America’s Blood Centers. This is a network of more than 50 independent, local blood suppliers that supply about 50% of the nation’s blood. Its member organizations manage more than 600 donation sites in 45 states. Two of the largest members are Vitalant (western United States) and Versiti (midwestern United States).
  • The Armed Services Blood Program. This supports the military and their beneficiaries.

Blood is a unique commodity in that it is almost entirely donated for free by volunteers. The cost of blood is therefore primarily due to the expense of processing, storage, and distribution. Hospitals will typically contract with a particularly blood supplier based on (1) per-unit cost to the hospital and (2) quality of service from the blood supplier. Because of the declining demand for blood and because the U.S. has experienced a period of hospital consolidation into large hospital systems that can compete aggressively for blood pricing, the financial margin for most blood centers are razor thin and many operate at an annual financial loss.

Because 92-95% of blood is transfused into hospital inpatients, the cost of blood is absorbed into the hospital’s general expenses rather than being passed directly to the consumer (i.e., the patient). This is because hospitals are paid by a DRG price that is fixed based on an inpatient’s diagnosis and the hospital gets paid the same whether 1 unit of blood is transfused or 20 units of blood is transfused. Most blood is sold on a consignment model – the hospital stores blood but only charges the blood centers for the units actually transfused; therefore, the blood centers bear the cost of outdated units. The net result is that the blood suppliers are happy when more blood is transfused and the hospitals are happy when less blood is transfused. The average price paid from hospitals to blood centers in 2013 was $225 per unit.

About 38% of the U.S. population is eligible to donate blood but only a fraction of eligible persons actually donate. All blood is subject to testing for communicable diseases including:

  • Hepatitis B surface antigen (HBsAg)
  • Hepatitis B core antibody (anti-HBc)
  • Hepatitis C virus antibody (anti-HCV)
  • HIV-1 and HIV-2 antibody (anti-HIV-1 and anti-HIV-2)
  • HTLV-I and HTLV-II antibody (anti-HTLV-I and anti-HTLV-II)
  • Serologic test for syphilis
  • Nucleic acid amplification testing (NAT) for HIV-1 ribonucleic acid (RNA), HCV RNA and WNV RNA
  • Nucleic acid amplification testing (NAT) for HBV deoxyribonucleic acid
  • Antibody test for Trypanosoma cruzi, the agent of Chagas disease

The most common blood type is O+ followed by A+. People with type O- blood are known as universal donors because anyone can received type O- red blood cells. Persons with type AB+ are known as universal recipients because they can receive blood of any type. Like 9% of Americans, I’m B+ so I can receive blood from people with blood types B+, B-, O+, and O- (in other words, 59% of of the population); I can donate blood to people with blood types B+ and AB+ (in other words, 13% of the population). There are differences in blood types between countries and between racial/ethnic groups. For example, 11% of South Koreans are AB+ (universal recipients) whereas only 0.5% of Ecuadorians are AB+. On the other hand, only 0.1% of South Koreans are O- (universal donors) whereas 11% of people in the United Kingdom are O-.

On my 16th birthday, the first thing I did the day I got my driver’s license was to drive to the American Red Cross blood donation center to give blood. Except for a few years during residency and fellowship (when I was regularly exposed to HIV secretions and blood in the ICU), I gave blood every 2-4 months for the next 40 years. About 3 years ago, the Red Cross raised the minimum hemoglobin necessary to donate blood and I found myself too anemic to donate. After anemia tests showed iron deficiency and a work-up for GI bleeding was negative, the conclusion was that I donated too frequently and didn’t eat enough meat. So, I started taking iron supplements for a week before and after blood donations, cut back my donation frequency to every 4 months, and learned to love grilled ribeyes again.

The average donor is male, married, college-educated, with an above-average income, white, and between the ages of 30-50. However, 45% of donors are over age 50. So there is a great need to recruit younger people into the donation pool as the current donor pool ages out. In addition, given the ethnic and racial differences in blood types, there is a need to ensure that our nation’s blood donor demographics more closely represents the nation’s ethnic and racial demographics  so that tomorrow’s blood supply optimally meets tomorrow’s blood demands. We need to eliminate the current disparities that exist in blood donation.

Our nation’s blood supply is a business but a business that is a unique hybrid of volunteers and commercial enterprises that is like no other business in the world. The dynamics of our blood supply is changing based on changes in healthcare financing and some healthcare experts believe that the blood supply system as we currently know it is in peril. But regardless of the changes in economics, patients will still need blood and volunteer donors will still be the ultimate suppliers of that blood. So what am I going to do about it? I do what I’ve always done. I’ll take iron supplements for the next few days and then donate a pint.

May 8, 2019

Categories
Inpatient Practice Operating Room

Why Are Pulmonologists So Happy?

As an intern, the one specialty I was sure I did not want to go into was pulmonary. The inpatients all had either COPD or lung cancer brought on by the bad life choice of smoking, the sputum they brought up was gross, and there didn’t seem like there was anything we could do for them. So, back in 1987, I decided to do a critical care fellowship and pulmonary was just the necessary appendage to a critical care fellowship. I was a bit surprised when I read the 2018 Medscape Physician Compensation Report that reported that pulmonologists appear to be among the most satisfied of physicians. The report is the compilation of 20,239 physicians in 29 specialties who responded to the annual Medscape survey.

Although the main focus of the report is about monetary compensation, there are several other questions that to me are more interesting than salary One question asked is “If you were to do it all over, would you choose medicine again?” Pulmonologists were more likely than any other speciality to respond that yes, they would choose medicine again at 88% of respondents, with cardiologists a very close second. In a previous blog post, I have commented on the fact that fewer physicians are choosing infectious disease and nephrology and this is reflected by the the low percentage of nephrologists (66%) and infectious disease specialists (68%) who would choose medicine again.

So, could it be salary that makes pulmonologists so happy? Probably not. All physicians make an extraordinary income compare to the rest of Americans. But pulmonologists are in the middle of the pack when it comes to earnings and earnings do not correlate very well with whether or not a respondent would choose medicine again. In fact, physicians in the highest earning specialties were just about as likely as the lowest earning specialties to report that they would go into medicine again. Plastic surgeons at 80% choosing to go into medicine as a career and orthopedic surgeons at 75% are the highest earners (note that neurosurgeons were not reported in the Medscape survey) where as pediatricians (79%) and endocrinologists (78%) are the lowest earners. So, it does not appear that income determines career satisfaction. However, in the Medscape survey, a separate question asked “If you had to do it over again and went into medicine, would you pick the same specialty?” In this case, earnings correlated with whether the physician would choose the same specialty with 98% of orthopedic surgeons and 97% of plastic surgeons choosing the same specialty again.

What about how the physicians feel about their compensation? The pediatrician knows that he or she is going to make a lot less than an orthopedic surgeon before starting residency. But does career satisfaction correlate to how appropriately the doctor believes that he or she is compensated for the work he or she does? Maybe so. The Medscape survey indicated that 70% of pulmonologists reported that they felt fairly compensated. The only specialists who reported feeing more fairly compensated were emergency medicine physicians at 74%. Interestingly, some of the specialists who were least likely to feel that they were fairly compensated were also the specialists who had the highest incomes. Only 50% of plastic surgeons and 51% of orthopedic surgeons felt fairly compensated.

So why are pulmonologists so happy and willing to go into medicine again? No one knows for sure but I have my own opinions.

  1. Variation in practice location. It is said that variety is the spice of life and few other specialists practice in such a variety of locations. On any given week, a pulmonologist will see patients in the outpatient clinic, the intensive care unit, the bronchoscopy suite, a hospital nursing unit, or a long-term acute care hospital. It is hard to get bored when you have contact with so many other doctors, nurses, and respiratory therapists.
  2. Pulmonologists have a built-in mid-life crises solution. Very few physicians do a pure pulmonary or pure critical care medicine fellowship. Instead, most do a combined pulmonary-critical care fellowship. It takes about 14 years of college/medical school/residency/fellowship to finally become an attending pulmonary & critical care physician so most start their career about age 32 and then retire around age 66. Straight out of fellowship, most newly minted pulmonary/critical care physicians do mostly critical care. This is because in the ICU, the first day on the job, you have a full set of patients whereas it takes a few years to build up an outpatient pulmonary referral base. At the other end of one’s career, when a pulmonary/critical care physician gets closer to retirement, he or she has built up a nice outpatient practice and is tired of the emotional and physical demands of the ICU. For most, the pulmonary and the critical care curves cross at age 45; younger than that and they do mostly critical care, older than that and they do mostly pulmonary. So right when many professionals are getting tired of their job in their mid-40’s, the critical care physician is metamorphosing into a pulmonologist and gets to have a different job for the second half of his or her career. When I started my career, I identified mainly as a critical care physician. Now, I identify mainly as a pulmonologist. It was surprising to me that whereas 88% of pulmonologists would choose medicine again, only 75% of critical care physicians said they would choose medicine again as a career. This may relate more to age than career choice since self-identified pulmonologists are older than self-identified critical care physicians.
  3. They do procedures… in moderation. In the past month, I have done (or supervised fellows doing) central lines, arterial lines, chest tubes, bronchoscopies, thoracenteses, ventilator management, endotracheal intubations, pulmonary exercise tests, and PFT interpretations. But procedures are only a minor part of the pulmonologist’s workday. Nevertheless, that mix of both procedures and E/M (evaluation and management) services gives variety to the workday and keeps one from being stuck in a career rut.
  4. We are entering a golden era of pulmonary medicine. Pulmonary is about 20 years behind oncology and 30 years behind cardiology with regards to scientific breakthroughs. We as a society have invested enormous public and corporate research money into finding cures for cancer and cardiovascular disease in the past several decades and it has really paid off. Pulmonary diseases such as idiopathic pulmonary fibrosis, cystic fibrosis, and asthma are just now getting the major research breakthroughs that oncology and cardiology have already experienced and many of the previously untreatable pulmonary diseases are becoming not only treatable but sometimes even curable. That makes for it being a very exciting time to be a pulmonologist.

This is all just speculation of course. But it is comforting to know that the majority of doctors in all specialties would do it all over again if they could. Pulmonologists just want to do it all over again a little more.

April 28, 2019

Categories
Inpatient Practice

If Your Hospital Length Of Stay Is Too Long, Look At Your Observation Rate

Hospitals are under enormous pressure to reduce length of stay. Since the hospital is paid by the diagnosis and not by the number of days a patient spends in the hospital, the shorter the length of stay, the higher the financial margin. In addition, if the hospital is frequently full to capacity, it is far cheaper to reduce length of stay than to build additional hospital rooms and hire additional nurses. In a previous post, I listed ways that the hospital can decrease its length of stay (or length of stay index which is the length of stay adjusted for the severity of the patients’ medical conditions). One often overlooked contribution to an excessively long length of stay is an excessive number of patients in observation status.

Observation status is for patients who are anticipated to require less than “2 midnights” in the hospital. It was designed for those patients who present to the emergency department with uncertain symptoms and the doctors just need a day or so to determine if the symptoms are something serious or something that could have been treated as an outpatient. However, observation status has evolved into something altogether different. Now, insurance companies and Medicare increasingly look at observation status as patients with illnesses that you can fix in the hospital in less than 2 days. In other words, patients that absolutely need to be in the hospital but that can turn around quickly and be discharged in < 3 days.

The top 3 diagnoses of patients in observation status are chest pain, abdominal pain, and syncope. However, I have had insurance companies deny patients who are admitted to the ICU in respiratory failure requiring intubation and mechanical ventilation if the doctors were able to treat that patient and get them off of the ventilator in < 1 day and out of the hospital in 3 days.

The number of patients in observation status is increasing: in 2011, Medicare spent $690 million on observation status care but by 2016, that number had grown to $3.1 billion. CMS likes observation status because it saves Medicare money – patients are treated as outpatients, therefore they have to pay a 20% co-pay for the hospital stay and they have to pay for their pharmacy charges, thus saving Medicare from having to pay these charges. However, the net effect of this is to transfer much of the costs to the patients and to the hospitals. Therefore, hospitals can lose money on observation status patients, particularly those in the hospital for medical (as opposed to surgical) conditions.

Palmetto (a Medicare administration contractor) uses the following definition for determining observation time:

“Observation time begins at the clock time documented in the patient’s medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating observation care in accordance with a physician’s order. Hospitals should round to the nearest hour. “

This is generally interpreted as the time the patient is placed in a bed in the emergency department. On the other hand, inpatient length of stay begins at the time that an admission order is written and this time can be considerably later than when the patient was first placed in an emergency department bed. Therefore, when thinking about observation versus regular admission:

  1. Observation: the clock starts when a patient is placed in an emergency room bed
  2. Inpatient admission: the clock starts when an admission order is written

The percentage of hospitalized patients in observation status has been steadily increasing over the past decade, to the point that now, many hospitals will have > 30% of hospitalized patients in observation status. But too high of a percentage of observation patients can adversely affect your inpatient length of stay index (as well as the hospital’s financial margin).

There are some clinical situations when it is very clear that a patient should be in observation status. For example, a patient who comes in with new chest pain and you are not sure if it is angina or just a strained chest muscle and so you put the patient in observation status for the night so you can do a stress test in the morning – if the stress test is negative, the patient remains in observation status and goes home and if the stress tests is positive, the patient is converted to inpatient status to get the heart worked up further. However, frequently it is not clear on the surface whether the patient should be in observation status or be an inpatient. So, hospitals frequently uses proprietary decision-making support tools such as the Milliman criteria. Additionally, hospitals will often employ “physician advisors” to help in the decision about whether or not a given patient should be in observation status, particularly when the admitting physician disagrees with the decision support tool recommendation.

Putting a patient in observation status is safe and does not expose the hospital to a risk of audit by Medicare. However, an excessively conservative approach to observation status could result in many patients who would have a low inpatient length of stay being classified as observation status and thus inflating the inpatient length of stay.

Therefore, to keep the inpatient length of stay down, the hospital must use observation status correctly. In other words, over use of observation status will result in an increase in the inpatient length of stay. If the hospital’s length of stay is high, then check the percentage of patients who are in observation status and determine if some of those observation patients could be more correctly classified as inpatients.

March 12, 2019

Categories
Inpatient Practice

Readmission Reduction And Increased Mortality: The Law Of Unintended Consequences Cannot Be Broken

On Christmas Day, an article was published in JAMA that confirmed what many of us had suspected for a long time. When hospitals are penalized for high 30-day readmission rates, patients are more likely to die.

The background is that 30-day readmission rates in U.S. hospitals are disturbingly common and very expensive. In a 2009 article in the New England Journal of Medicine, Jencks and colleagues found that overall, 21% of patients admitted to American hospitals are readmitted within 30 days of being discharged. The total cost of these readmissions was estimated to be $17.4 billion. Ten years ago, this sent reverberations of horrification through the health financing community where it was immediately assumed that hospitals were gaming the system by discharging their patients too early and with insufficient outpatient transitional care. So, in 2010, CMS announced the Hospital Readmission Reduction Program that imposed financial penalties on hospitals that had higher than expected 30-day readmission rates for patients with heart failure, myocardial infarction, and pneumonia beginning in 2012. In subsequent years, COPD, coronary bypass surgery, and joint replacements were added. The result of this program was that hospitals developed many programs to keep patients from “bouncing back” to the hospital.

Many of these programs were (and still are) noble and effective, such as ensuring that there is good communication with the outpatient primary care physician, ensuring that discharge medication reconciliation occurs, and ensuring that there is adequate home healthcare pre-arranged before discharge. However, there was an unintended consequence of the program: creating “the wall”.

In the 1978 satirical novel, The House of God by Samuel Shem, an innocent new medical intern named Roy Basch learns strategies to survive his intern year from a senior resident named The Fat Man. In the book, one of the most respected physicians in the hospital was “The Wall”. This was a physician in the emergency room who refused to admit a patient (“Meet ’em and street ’em”). With the advent of the Hospital Readmission Reduction Program, all of a sudden, “being a wall” was seen as being very admirable. Not just the physicians in the ER but also the primary care physicians, transition clinics, and home health nurses who tried to do everything possible to keep patients from going back to the hospital. In other words, we created a culture of “a readmission is a sign of weakness”.

The recent JAMA article looked at 8.3 million hospital admissions for heart failure, myocardial infarction, and pneumonia before and after the Hospital Readmission Reduction Program was instituted. The result: after the program was begun, the outpatient mortality of heart failure and pneumonia increased significantly. However, there was no difference in the inpatient mortality for those patients who did get readmitted. The insinuation is that by keeping patients from coming back to the hospital who really needed to be in the hospital, patients were more likely to die.

There are dozens of reasons that patients get readmitted to the hospital within 30 days of discharge and some of them are truly preventable. But the overwhelmingly most common reason for readmission is that the patients are just sick. And when we create barriers for admitting patients who truly need inpatient care, patients get sicker and die. In this sense, the Hospital Readmission Reduction Program has been very effective: it has kept patients from coming back into the hospital, it is just that many of those patients really needed to be in the hospital.

So, where does this all leave us? Our hospitals do need to be good stewards of our country’s healthcare finances so we do need to put programs in place that promote continued recovery after patients are discharged. But by non-selectively penalizing our hospitals for readmitting patients who are not recovering, we are inadvertently promoting poor overall health outcomes. CMS policy makers are going to have to take a hard look at the Hospital Readmission Reduction Program to determine if the collateral damage that has resulted justifies continuing the program in its current form. But those of us who care for patients and who operate our country’s hospitals also have to take a hard look at our own practices to be sure that we consistently do the right thing for each patient, even when that thing may result in financial penalties by readmitting them when they need our services.

January 13, 2019

Categories
Inpatient Practice Outpatient Practice

Influenza Always Gets The Last Word

I am on this earth because of influenza. This is the 100th year anniversary of the influenza epidemic of 1918 that infected 1/3 of the word’s population and killed 1 out of every 10 people infected. One of those people was my grandmother’s first husband. She was a nurse at a hospital in Durham, North Carolina and after her husband’s death, she met a physician fresh out of medical school, my grandfather. So, if the influenza epidemic had not have occurred, she and my grandfather would never have married and I never would have been born.

All told in 1918, 675,000 Americans died of influenza; that works out to 1 out of every 150 citizens. It was particularly lethal for young persons with the result that the U.S. life expectancy dropped from 49 years to 37 years for men and from 54 years to 42 years for women. The influenza strain that swept the world in 1918 was H1N1, the same strain that caused the 2009 pandemic of influenza that also seemed to preferentially kill young adults.

In 2009, 12,000 people in the United States and a half million people worldwide died of influenza. The problem in 2009 was that the strain of H1N1 that emerged was one that had not circulated in humans for decades – about 1/3 of people over age 65 years had antibodies to it from past infection but few young adults had ever been exposed to H1N1 and thus few young people had any immunity at all. Most years, 80% of influenza deaths are in people over age 65 but in 2009, 80% of deaths were in people under age 65. The H1N1 pandemic was therefore notable not for the total number of deaths (which was actually rather low) but for the fact that most of the deaths occurred in young adults. Even in non-pandemic years, influenza kills thousands of Americans. For example, last year, the CDC estimates that 80,000 Americans died of influenza and its complications, the most deaths in 4 decades.

As of December 22, 2018, the epidemiology of this influenza season (red line in this graph from the CDC) is falling in-between that of the 2016-2017 season and the 2017-2018 season. Most of the influenza being seen this year is once again the influenza A H1N1 strain with a smattering of H3N2 and influenza B. The flu claimed its first celebrity of the season this week when 26-year-old Fox News commentator, Bre Payton, died the day after developing influenza.

Yet still there are people who fear influenza vaccinations and refuse to get a simple and inexpensive flu shot that can save their lives. Here are some of the reasons for not getting a flu shot that I hear from my own patients:

  1. “I always get the flu every time I get a flu shot.” It is impossible to get the flu from a flu shot as there is no live virus in the vaccine. You are no more likely to get the flu from a flu shot as you are to get pregnant from taking a birth control pill. Yet nevertheless, more than half of parents believe that their child can contract the flu from a vaccine.
  2. “I don’t need a flu shot because I never get the flu.” This is like saying that you don’t need to wear a seatbelt because you’ve never been in a car accident. These people probably have had the flu but just didn’t realize it and attributed their symptoms to a cold or other illness. No human in innately immune from influenza. If you inhale a bunch of influenza viruses, then you are going to get the flu.
  3. “I don’t want a flu shot because it causes autism.” Yes, and the earth is flat, unicorns are real, and the tooth fairy plays poker with Elvis and the Easter bunny every Saturday night. Conspiracy theorists love this one. 20 years ago, in 1998, Andrew Wakefield published a paper in the journal, The Lancet, suggesting that the measles, mumps, and rubella vaccine was linked to childhood developmental disturbances. It turned out that Wakefield was funded by attorneys who were suing the vaccine manufacturer for allegedly causing autism. Wakefield was later found guilty of fraud, he lost his license to practice medicine, and the journal retracted his article. But the myth lived on and in 2005, journalist David Kirby published the book Evidence of Harm – Mercury in Vaccines and the Autism Epidemic: A Medical Controversy that alleged that thimerosal in vaccines causes autism. That same year, class action attorney Robert F. Kennedy, Jr. wrote an article in the Huffington Post making the same allegation (presumably setting himself up to win the mother of all class action lawsuits). Celebrities bought into this, most notably actor Charlie Sheen and former Playboy playmate, Jenny McCarthy, who have become the voices of anti-vaccine activism. Most influenza vaccines do not contain any thimerosal (the preservative that contains mercury). Even those that do contain thimerosal have the same amount of mercury as is in about 4 oz of canned tuna HOWEVER, thimerosal is broken down in our bodies as ethylmercury whereas fish contains methylmercury – ethylmercury is relatively harmless compared to methylmercury. The science is very strong: vaccines do not cause autism.
  4. “I don’t need a flu shot because last year I got one and still got the flu.” Yes, it is true that influenza vaccines are not 100% effective in preventing the flu. However, by creating protective antibodies against influenza, your body will be able to fight it off better so that even if you get the flu, it will be a milder case and you will be less likely to die. A study this year by the CDC found that patients who were admitted to the hospital with influenza and had gotten a flu shot spent four fewer days in the hospital, were 37% less likely to be admitted to the ICU, and were 2-5 times less likely to die compared to those patients who had not received a flu shot.
  5. “If I go outside in the cold and wet air, I’ll get the flu whether or not I get a flu shot.” Influenza is not an environmental microorganism, it lives in people and is transmitted by people. You cannot get the flu (or a common cold) by going outside when the temperature is low or when it is raining. In fact, if you spent all of your time outdoors in flu season, you’d be less likely to get influenza than if you are inside a building in close contact with other people who have the flu.
  6. “I always wait until December to get my flu shot so that it will kick in when the flu seasons hits.” Although it is true that antibody levels will peak several weeks after getting an influenza vaccine, a person cannot predict when they are going to be exposed to the virus in any given year. Getting a flu shot on Monday will not do much good if you are exposed to influenza on Wednesday. A person is better off getting the vaccine as early as possible in the flu season, ideally before the end of October. That being said, it is not too late to get vaccinated, even in January or February, as influenza usually continues to circulate in the United States until March or April each year.
  7. “I don’t want to get a flu shot because I might be pregnant.” If I only had one dose of the flu vaccine in my office, I would save it for a pregnant woman. There is no risk to vaccinating pregnant women and in fact, in the H1N1 pandemic of 2009, pregnant women were among those who were most likely to die when infected with the virus.
  8. “I don’t want a flu shot because I might get Guillian-Barré syndrome.” Every year, 3,000 – 6,000 Americans get Guillian-Barré syndrome (GBS) but every year, 10,000,000 – 50,000,000 Americans get influenza. The vast majority of GBS is not related at all to influenza. However, in 1976, the swine flu vaccine did have an increase risk of GBS with the result that one out of every 10,000 people vaccinated developed GBS. Since that time, the increase in GBS has been about 1 case for every 1 million influenza vaccines. The mortality rate of GBS is 2.8% and the mortality rate of influenza is about 0.16%. If you do the math, there are about 150 influenza vaccine-related cases of GBS in the U.S. each year with about 4 of these patients dying. Therefore, you are about 10,000 times more likely to die of influenza if you are not vaccinated than you are to die of GBS if you are vaccinated. As a general rule, I am not a gambler but I’l take the 10,000:1 odds any day.
  9. “I can’t take the flu shot because I’m allergic to eggs.” Because many influenza vaccines are grown in eggs, these vaccines can contain a tiny amount of egg protein. Nevertheless, the CDC recommends that people with egg allergies should still get influenza vaccinations. Patients with anaphylaxis from eggs should be observed in a medical setting after getting a flu shot. However, studies of over 500 patients with anaphylaxis from eggs and who received influenza vaccines found that none of these people developed a serious reaction from the vaccine. People who can eat cooked eggs are very unlikely to have any reaction to influenza vaccines. For those people who are still afraid of the influenza vaccine because of fears of egg allergy, there is a recombinant influenza vaccine (Flublok) that does not contain any egg protein.
  10. “Flu shots are too expensive.” Most insurance plans cover influenza vaccination and if a person without insurance goes to the local pharmacy, that person will pay about $40 to get it out of pocket. On the other hand, we spend about $10 billion per year in the United States on direct costs of flu-related illness and have another $16 billion per year in lost earnings from flu-related illness. That works out to each case of influenza costing about $530. So, instead of looking at the flu shot as costing you $40 each year, look at it as saving you $490 each year.

At the time of writing this blog post, influenza is already widespread in many states. In the next few weeks, my hospital’s nursing units and ICU will be full of patients with influenza-related illness, and some of them will die. Those patients who survive the ICU are always the first ones to ask for a flu shot the next year. But for those who die, like Bre Payton, influenza always gets the last word.

December 29, 2018

Categories
Inpatient Practice

Hospital Workplace Violence

Healthcare workers are more tolerant of violence by patients than almost any other occupations would tolerate violence by customers or clients. In fact, according to OSHA, healthcare workers are more than 4 times more likely to experience workplace violence resulting in days off work than private industry. Patients are the source of workplace injuries (80%), followed by patient family members/friends (12%), students (3%), and co-workers (3%).

However, it is estimated that only 50% – 70% of assaults are reported to managers. A 2014 survey of 3,765 nurses found that 21% had been physically assaulted in the preceding 12-months and more than 50% reported being verbally abused in that time period. A 2011 survey of 7,169 emergency department nurses found that 12% of the nurses had experienced physical violence in the preceding 7 days and 59% had reported verbal abuse during those 7 days. Another 2014 study of 762 nurses found that 92% of emergency department nurses had experienced verbal or physical violence in the preceding year with the most common physical incidence being grabbed (56%), scratched (47%), kicked (41%), pinched (40%), shoved (29%), spat on (34%), slapped (18%), punched (17%), hit by a thrown object (16%), urinated on (13%), or bitten (10%).  A 2002 survey of 72,349 healthcare workers at 142 Veterans Administration hospitals found that 13% had been assaulted in the preceding year. Within healthcare, some jobs are at greater risk than other, for example, psychiatric aides are the most likely to sustain violent injury and are 10-times more likely than the next group, nursing assistants who in turn are 4-times more likely than registered nurses.

So why do we tolerate violence that would not be tolerated in any other industry? There are several reasons:

  1. A sense that it is “just part of the job”.
  2. An unwillingness of healthcare workers to stigmatize their patients when the violence may be a reflection of their underlying disease.
  3. An ethical duty to continue to provide care to a patient, even if the patient’s behavior is poses risk of harm to the healthcare worker.

The most common violent injury sustained by health care workers is being hit, kicked, beaten, or shoved. The next most common injury is from unintentional harm when moving the patient.

Health care violence is also very costly. The direct cost at one hospital system for 30 nurses who required treatment for workplace violence over the course of a year was $94,156 ($78,924 for treatment costs and $15,232 for lost wages). But those direct costs are only the tip of the iceberg of total costs. The indirect costs of caregiver fatigue, burnout, and stress can be enormous as these factors have been associated with increased medical errors, lower patient satisfaction, and higher health care worker turnover. As an example, it costs about $65,000 to replace an RN when separation, lost productivity before a replacement is hired, recruitment, hiring, orientation, and training are all considered.

All told, the American Hospital Association analyzed the financial statements of estimates that community and workplace violence costs U.S. hospitals $2.7 billion per year. If only in-facility violence is considered, the cost is about $1.5 billion ($278 million per hospital). When these costs are broken down, they are 31.6% for security staff and infrastructure, 6.5% for staff training, 3.6% for procedure development, 8.7% for staff turnover, 3.4% for disability, 2.0% for absenteeism, and 1.6% for staff medical care.

A workplace violence prevention program can be effective. The key components are:

  1. Hospital management commitment and worker participation
  2. Worksite analysis and hazard identification
  3. Hazard prevention and control
  4. Safety and health training
  5. Record keeping and program evaluation

More specific interventions to the physical environment that can reduce workplace violence can include:

  1. Security alarms placed in strategic hospital locations
  2. Keypad/badge reader access to patient care areas
  3. Improved lighting
  4. Security cameras
  5. Regular patrols by security personnel
  6. Metal detectors at strategic locations (for example, emergency department entrances)
  7. Panic buttons (including mobile panic buttons)
  8. Prohibition of firearms within the hospital (except by law enforcement officers)
  9. Permit nurses and other healthcare workers to choose whether to display just their first name (rather than first and last names) on their ID badges

Staff training is also important and all staff should be trained in de-escalation techniques so that these techniques can be employed proactively when patients begin using threatening language or show signs of agitation. The Crisis Prevention Institute recommends the following 10 de-escalation tips:

  1. Be empathetic and non-judgmental
  2. Respect personal space
  3. Use non-threatening non-verbal body language
  4. Avoid overreacting
  5. Focus on feelings and encourage patients to talk about those feelings
  6. Ignore challenging questions that can escalate into a power struggle
  7. Set limits with clear, simple, and enforceable limits and consequences
  8. Choose wisely what you insist upon – decide which rules are negotiable and which are not
  9. Allow periods of silence for the patient/visitor to reflect on the situation
  10. Allow time for patients to make decisions

There are a number of organizational factors that can reduce hospital workplace violence. Ensure that staffing is adequate, particularly during meals and visiting hours. Avoid crowded waiting rooms and long waiting times for patients. Community disaster drills are done twice a year in most hospitals. But it is also important to do violence response drills, such as active shooter drills. These can be very effective in creating awareness for alarm locations, security support, escape routes, safe room locations, and emergency communication procedures. Above all, hospital leaders must foster the perception that workplace violence is never OK and that the organization takes workplace violence and its prevention seriously.

When faced with patients or their family/friends who are threatening violence or who are actively violent, healthcare personnel should have a low threshold for calling hospital security or police. Security personnel are generally trained in de-escalation techniques as well as ways to restrain patients without harming them. Most hospitals do not arm security personnel with guns but Tasers are becoming more common to use in those situations where a violent patient or visitor is in danger of harming others or themselves. It is not a crime when a patient who is delirious from sepsis kicks a nurse but when an otherwise alert and oriented patient throws something at that nurse or punches that nurse, it may very well be a crime. Some patients have a history of repeated violence or threats of violence; hospitals cannot always deny those patients emergency care but they can facilitate criminal charges against those patients.

When people are sick, injured, or dying, the emotions of these people and their friends/family can become untethered, resulting in physical or verbal violence directed toward others. Because healthcare workers are especially vulnerable to this physical or verbal violence, our hospitals must take steps to prevent and respond to workplace violence, perhaps more so than any other workplace environment.

December 14, 2018

Categories
Inpatient Practice Medical Economics

The 2019 Medicare Readmission Penalty

In September, CMS released the financial penalties that hospitals will pay for excessively high percentages of readmissions within 30 days of discharge. This is an annual event when hospitals get to find out how much their reimbursement from Medicare will be cut the next year. CMS focuses on 6 diagnoses when calculating the readmission penalty:

  1. COPD
  2. Coronary artery bypass surgery
  3. Myocardial infarction
  4. Heart failure
  5. Knee and hip replacement surgery
  6. Pneumonia

CMS looks at readmission data from July 2014 through June 2017. The penalties go into effect October 2018 and continue through September 2019. This year, 3,173 hospitals were evaluated and 2,599 (82%) were penalized. Certain classes of hospitals were exempt from evaluation including children’s hospitals, Veterans hospitals, hospitals in the State of Maryland, psychiatric hospitals, and critical access hospitals.

In the past, hospitals that take care of low income patients were penalized more than hospitals that take care of high income patients. For that reason, safety net hospitals and academic hospitals tended to get penalized more highly than other hospitals, in other words, hospitals got penalized for taking care of the poor. CMS overcame some of the limitations of previous years’ penalties by comparing hospitals to other hospitals that have similar patient demographics, rather than comparing all hospitals in the U.S. together. They calculated the number of dual eligible patients (those who have both Medicare and Medicaid) divided by the total number of Medicare patients. Because dual eligible patients are generally lower income than patients with Medicare only, this permitted CMS to compare hospitals that care for similar percentages of low income patients This is an improvement over previous calculations since lower income patients have higher 30-day readmission rates regardless of how good or bad their care was during their initial hospitalization. CMS stratified hospitals into 5 groups based on this calculation. Group 1 had 0-15% dual eligible patients whereas group 5 had 30-100% dual eligible.

The total amount of the penalties for next year is $566,000,000. Hospitals can be penalized a maximum of 3% of their entire Medicare revenues for that fiscal year but nationwide, the average penalty was 0.70%. There are 47 hospitals that incurred the maximum 3% penalty: Texas having the most at 8 hospitals, followed by Louisiana, Missouri, and Kentucky with 4 hospitals each. Here in Central Ohio, our hospitals all did quite well with only minimal penalties:

  1. Dublin Methodist – 0.03%
  2. Ohio State University – 0.06%
  3. Riverside Methodist – 0.17%
  4. Mt. Carmel West – 0.17%
  5. Grant – 0.23%
  6. St. Ann’s – 0.23%
  7. Doctor’s – 0.44%

States that expanded Medicaid have more hospital closures than states that did not expand Medicaid so one might hypothesize that hospitals in Medicaid expansion states would have more financial resources to put into reducing readmissions. So, I spent a few hours with an Excel spreadsheet of the 2019 Medicare penalties for all hospitals in the U.S. and it turns out that there was no difference in the average penalty incurred by hospitals in Medicaid expansion states versus hospitals in non-Medicaid expansion states.

So, overall, next year’s readmission penalties will be more fair than last year’s. But hospitals cannot control everything that a patient does or does not do once they leave the hospital and so the responsibility for fully reducing 30-day readmissions cannot lie solely on the hospitals.

November 24, 2018

Categories
Inpatient Practice

Fireproofing Your Physicians Against Burnout

15,000 physicians responded to the annual Medscape Physician Lifestyle Survey. A component of this survey is in the Medscape National Physician Burnout & Depression Report for 2018. Of these 1,500 physicians, 42% reported being burned out. My own specialty of critical care medicine led the way with 48% reporting burnout. Women were more burned out at 48% than men at 38%. Burnout was most common in the 45 – 54 year old age group – this is the age group that normally is the most productive. The most important contributions to burnout were (1) too many bureaucratic tasks, (2) too many hours at work, (3) lack of respect from administrators/colleagues/staff, (4) electronic medical records, and (5) compensation.

Burnout is expensive. When a physician (or nurse) quits, it costs a lot to replace him or her. There is lost productivity while you are waiting for a replacement. There is the cost of recruitment. And then there is the lost productivity while the replacement physician ramps up in productivity. Overall, it costs about $250,000 to replace a physician ($350,00 – $500,000 if that physician is a critical care physician). Then, if you bring a new physician into an environment that is conducive to burnout, then you are just going to lose another physician in short order.

So, how do you fireproof your physicians against burnout? I’ve attended a lot of presentations on burnout and often, they get mired in a lot of psychological generalities, resulting in me drifting off into daydreams about what I’m going to have for dinner and where I’m going to go on my next vacation. Here are some tangible things that we can do to prevent burnout:

  1. Learn to identify it. Every doctor knows that the best way to cure a cancer is to diagnose it in an early stage. The same goes for burnout. But the only way that a medical director is going to recognize burnout early is to interact with the members of the medical staff on a regular basis. That doesn’t mean sitting in your office firing off emails, it means having face to face conversations with each physician. Doctors usually won’t just say, “Hey, I’m burned out”. Instead, they’ll be rude to patients, get angry with the nurses, get behind on their charting, submit their charges to the billing office later, and stop coming to staff meetings.
  2. Make wellness resources available. At the Ohio State University, we have the STAR program (Stress, Trauma, And Resilience) and we also have an Employee Assistance Program. I make sure that our doctors know about these program – with our Employee Assistance Program, physicians (and staff) can meet with counselors without anyone else knowing and at no cost. Wellness programs like these are common in academic medical centers, large hospitals, and governmental hospitals but they are not always available in smaller hospitals or clinics. But almost every hospital has chaplains and social workers who can be utilized for wellness of not just patients, but also doctors.
  3. Look for excuses to pay compliments. Bad things happen in healthcare all of the time. People get sick. Patients die. Families get angry. Medical errors occur. Doctors get sued. We can’t stop all of these things from happening. As physicians, we are faced with life and death decisions every day and we are the often the ones who are most critical of our own medical judgement. This creates a heavy weight on our souls and that weight has to periodically be counter-balanced with some recognition of the good things that we do. When a surgeon comes to the hospital in the middle of the night to operate on a patient with a bowel perforation, send the surgeon and the anesthesiologist an email thanking them. Or if a cardiologist comes in to do a heart cath on a STEMI patient or a gastroenterologist comes in to do an endoscopy on someone with a GI bleed, then thank them the next day. When it comes to being a medical director, compliments are a more powerful tool than money. Ideally, every physician should leave the hospital each day with a sense of accomplishment.
  4. Be willing to be flexible. Maybe the hospitalist who is a new parent wants to reduce their number of shifts for a few months. Maybe the radiologist who is a single parent wants to read x-rays from home on certain days of the week. Maybe your critical care physician wants to be off duty on Friday nights and Saturday to go to Synagogue or be able to have a quiet place with the pager turned off to do Islamic prayers 5 times a day or to be off on Sunday to attend Mass. We all draw great emotional strength from our families, our religions, and our hobbies. Having flexibility with scheduling in order to preserve the ability of our physicians to draw this strength can build resilience.
  5. Yoga (but only for the millennials). There are two ways to get me to run for the door in a committee meeting or workshop: role-playing and yoga. But then, I’m a baby boomer and baby boomers hate doing yoga (or at least doing it in front of one’s peers). But millennials all seem to love yoga and so it can play a fireproofing role for your doctors under age 50. For those of us over age 50, pizza at committee meetings is more effective.
  6. More is not always better. Hospitals and physician group practices are under enormous pressure to increase productivity by seeing more inpatients/ER patients per shift and by scheduling more outpatients per hour. But being a doctor is not like being a mechanical assembly line robot. It is those interpersonal connections that we make with our patients through conversation that build the doctor-patient relationships that makes us feel good about the work that we are doing and drives us to continue on. When doctors feel they don’t have enough time to do a thorough job of caring each patient or enough time to just talk with their patients, then job satisfaction flies out the window. By keeping patient workloads reasonable, the hospital can save money in the long run by reducing physician turnover.
  7. Beware of night shifts. Critical care physicians who work night shifts are more likely to be burned out. These physicians are especially vulnerable because a lot of the usual wellness support resources close up at 5:00 PM. Hospital leaders need to make the effort to stop by the hospital at night to just check in with the night shift physicians and let them know that their work is valued and appreciated. In many physician groups, as physicians get more senior, they do fewer night shifts. I think this is dangerous because it forces younger physicians to do disproportionately more of the night shifts and creates a culture of the night shifts being perceived as something bad, as something less important, and as something to be avoided. The medical director of our emergency department is my age and does night shifts just like any of the other emergency department physicians and I think that is one of the reasons that he is so effective of a leader of his ER doctors.
  8. Women physicians are different than men physicians. That sentence will probably get me into a lot of trouble but nevertheless, women physicians report being burned out much more than men physicians and this is a fact that we cannot ignore. Women also deal with burnout differently. According to the Medscape National Physician Burnout & Depression Report, The most common strategy to fend off burnout for men is exercise but the most common strategy for women is talking with family and friends. Therefore, offering free gym memberships may be effective to fireproof many of your men physicians whereby promoting schedules that are conducive to social functions and family time may be more effective to fireproof many of your women physicians.
  9. Reduce conflict between physicians and nurses. 23% of physicians reported that reduced conflict with nurses/administrators/physicians would lessen their burnout. By promoting interdisciplinary team-based approaches to quality improvement, hospital governance, and nursing unit management, conflict between nurses and physicians can be reduced. But maybe even more important is for medical directors and nursing directors to lead by example; in other words, the medical directors need to publicly show respect and support for the nursing staff and the nursing directors need to publicly show respect and support for the physicians. Over the decades, I’ve too often seen physicians blame the nurses or vice versa when something goes wrong in the hospital. Medical and nursing leaders must rise above the “blame game” and set an example of interdisciplinary respect.
  10. Ensure that non-physician staff are working at the top of their license. What doctors do uniquely best in the hospital is doctoring. But there are a myriad number of other tasks that go into the care of patients that non-doctors can do. Make sure that there are other hospital staff who can line up home healthcare, fill out home oxygen forms, complete FMLA applications, and schedule outpatient appointments. Thirty-four years ago, as an intern, I had to draw all of the blood cultures, do the EKGs, and even transport patients to radiology to get a chest x-ray after 5:00 PM – it is amazing to me that I didn’t go up in flames of burnout back then. Your physicians should spend most of their workday doing physician work.
  11. Make your electronic medical record work for the doctors rather than make the doctors work for the EMR. Electronic medical records were identified as the 4th biggest contribution to burnout in the Medscape survey. It shouldn’t have to be that way because the EMR is just a tool and the purpose of any tool is to make a given task easier to do, whether that tool is a wrench or a garden shovel. Too often, we design our EMRs around meeting governmental regulations and billing requirements first with the physician experience being second. This should really be the other way around and we need to design our EMR software to be as easy to navigate as possible. Hospitals need to put resources into information technology support in the way of 24-hour telephone help lines, periodic EMR optimization education for physicians, and  staff who can do a lot of the basic data entry into the EMR.
  12. Ensure compensation equality. This doesn’t mean that the family physician should make the same salary as the neurosurgeon. But it does mean that there is a compensation plan that is transparent with respect to the rules that go into salary determination. Almost every human being on the planet thinks that they should get paid more for what they do. But most of the time, getting paid more is not as important as knowing that you are getting paid fairly.
  13. Be optimistic. As physician leaders, if we show optimism for the future, it can be infectious. Every doctor has had a department chair, division director, or medical director who seemed like Eeyore from Winnie the Pooh and the Hundred Acre Wood. When physicians know about all of the good things that are happening or are going to happen at the hospital, it can go a long way toward dousing the flames of burnout.
  14. Promote interaction with other physicians. In past years, physicians drank coffee with each other in the physician lounge, ate together in the physician dining room, sat with each other during grand rounds, and spoke face to face about patients as attending and consultant. Now, coffee is usually drank in the nursing stations while staring into a computer monitor, we watch grand rounds remotely over the internet, and consultants leave their recommendations in the electronic medical record. As a consequence, we have less human to human interactions with our colleagues. By having (good quality) coffee and snacks in the physician lounge, doctors will aggregate there. By putting the surgeon’s workroom in the same location as the anesthesiologists’ break room, you can foster communication. Look for ways to create opportunities for physicians to be together in the hospital.
  15. Changes should not come as surprises. Burned out physicians often feel like they are just “another cog in the wheel”. One thing that fosters this feeling is if the physicians feel like the hospital administration is making all of the decisions for the future without involving the physicians. What physician wants to learn from an article in the local newspaper that the hospital is building a new surgical unit or radiation therapy building? By updating and involving the physicians with future plans for the hospital at every step in the planning process, the physicians will feel more engaged – that engagement is one of the chief defenses against burnout.

Burnout among physicians has always been there but it is more prevalent now than ever before and we are more aware of it than ever before. Fortunately, there are tangible things that we can do to make our hospital environments less combustible and thus prevent it.

November 16, 2018

Categories
Inpatient Practice

The Cost Of Hospital-Acquired Conditions

This time of the year, all across the country, hospitals are creating scorecards of quality metrics for the upcoming year. But what are the economics of those quality metric choices? It turns out each metric has very different financial implications for the hospital and so there are some metrics that are more cost-effective to achieve than others. Most hospitals focus on hospital-acquired conditions and build their quality goals around reducing these conditions.

Last November, the Agency for Healthcare Research and Quality (AHRQ) published an analysis of the cost of common hospital-acquired conditions. When you study the literature on these costs, you’ll find that there is an enormous range of estimates for each condition in different studies and journal articles. The AHRQ is an agency of the U.S. Department of Health and Human Services and has taken a reasonably thorough and unbiased review of the literature on the cost of these conditions and so their estimates are likely to be at least as accurate as anyone else’s. The findings are summarized in this table, ranked from most expensive to least expensive.

The last cost estimates by the AHRQ was 8 years ago, in 2010 and there has been some fairly substantial changes in the estimates of several of the conditions. Most notably is CAUTI (catheter-associated urinary tract infection) that in 2010 was estimated to incur an additional cost of $1,090 and now is estimated to cost $13,783. Although the cost of most conditions has risen since 2010, the estimated cost of two conditions is now lower than in 2010: the cost of falls is down from $7,888 to $6,694 and the cost of pressure ulcers is down from $18,537 to $14,506.

Improving The Metric Does Not Necessarily Improve The Finances

The first step for a hospital is to accurately track all of these hospital-acquired conditions. The challenge is that for some of these conditions, the “official” definitions by agencies such as the Centers for Disease Control (CDC) are often too broad and can result in defining some patients as having a hospital-acquired condition when the physicians who are actually treating the patients know that their condition is not truly a hospital-acquired condition. For example, failure to document a pre-existing pressure ulcer at the time of hospital admission will count as a hospital-acquired pressure ulcer from a reporting standpoint. Improving the metric by better documenting that pre-existing pressure ulcer does not really save any money.

Thus improving the metric for public reporting purposes will make the Board of Trustees happy and make the public relations department happy but does not necessarily improve the hospital’s financial margin.

Focus On The ICU

The two most expensive hospital-acquired conditions are ventilator-associated pneumonia and CLABSI (central line-associated blood stream infection). Both of these generally occur in the intensive care units. The reasons that these conditions are so expensive is that they significantly increase hospital length of stay (and more specifically/expensively the ICU length of stay), they often result in other complications (such as shock or renal failure), and they cost a lot to treat due to the use of very expensive antibiotics. Simply by reducing 5 cases of these conditions, you can save nearly a quarter of a million dollars a year. Therefore, if the hospital has limited epidemiology resources, it should focus the infection prevention resources on the ICU.

Conditions that often happen in a standard medical/surgical nursing unit, such as falls, CAUTIs, and pressure ulcers, are not as costly. As an example, eliminating 3 urinary tract infections saves less money than eliminating 1 central line infection.

Create A Quality Profit And Loss Statement

Reducing hospital-acquired conditions results in “hidden money”. It is money that adds to the hospital’s end of year profit or margin but usually, you don’t realize where it came from. Moreover, the annual hospital capital budget will not reflect these savings. Therefore, in order to show the true value of reducing hospital-acquired conditions, you need a specialized profit and loss statement.

Lets take a hypothetical hospital that had 30 Clostridium difficile infections in 2016. They decide to purchase ultraviolet light-emitting sterilizing machines with an anticipation of reducing their C diff infections by 40%, or to 18 per year. The total projected savings will be $207,120 per year. They buy 3 UV emitting machines at $100,000 each ($300,000 total initial cost) and then depreciate them over 3 years ($100,000 per year depreciated cost). It takes 1 full-time environmental service worker per day to manage the machines and so to run them 1 shift, 7 days a week, 52 weeks a year, you will need to hire 2 FTE EVS workers at $75,000 (salary + benefits). Therefore the total cost will be $175,000 per year. In the final analysis, you will end up spending $175,000 but you end up saving $32,120 because of the reduction in C diff cases.

By creating a quality metric-specific profit and loss statement, you can identify which conditions are going to be financially most lucrative to improve. This allows you to prioritize those quality metrics for the purposes of hospital quality scorecards.

Recognize That There Is A Limit To What You Can Do

No matter how hard you try, sick patients develop complications and you cannot always avoid them. If a patient has unrecognized homozygous Factor V Leiden and then comes in for an elective hip surgery, then normal deep venous thrombosis prophylaxis measures are probably not going to prevent that patient from getting a DVT. So, there comes a limit when the incidence of a hospital-acquired condition becomes so low that putting incrementally more money into trying to reduce it further is neither practical nor possible.

July 13, 2018

Categories
Academic Medicine Inpatient Practice

Setting Achievable Hospital Quality Goals

All across the country, hospital quality departments set goals for the upcoming year. For academic medical centers, that fiscal year is starts July 1st. And every year, at every hospital, those goals are set a little higher and hospital leaders get frustrated when a year from now, those goals are not met. The tactic that should be used to avoid all of this frustration is setting realistic goals.

In an academic medical center, there are all sorts of goals that are set for the physicians to achieve:

  1. Quality goals set by the hospital quality department
  2. Productivity goals set by the practice administrators
  3. Educational goals set by the medical school
  4. Efficiency goals set by the hospital finance department
  5. Research goals set by the department chairmen
  6. Citizenship goals set by the medical directors

For the physician with relatively limited time and emotional energy, all of these various goals compete with each other. The hospital finance department gets frustrated when the physician’s efficiency measured by getting all of the hospital discharges completed by mid-morning is affected by the physician doing too much teaching on rounds. The department chairman gets frustrated when the physician’s research output is affected by the physician spending too much time in the hospital trying to meet RVU targets. And the quality department gets frustrated when the physician is spending too much time in citizenship activities such as attending committee meetings and not focusing on spending more time with individual patients in order to improve patient satisfaction scores.

For the physician who is faced with the expectation of achieving a 75th or 90th percentile for all of these various goals, it is overwhelming and not realistically achievable. It is human nature to direct one’s limited time and energy to those goals that are achievable and then effectively ignore those that are not achievable.

As an example, lets say the quality department sets a quality goal that all physicians will do bedside rounds on every patient 3 times a day and the practice administrator sets a productivity goal of 4,000 wRVUs per year. If a physician currently rounds on every patient once a day and had a productivity of 3,500 wRVUs last year, then to both increase the number of daily visits by 2 additional visits with each patient each day AND increase the wRVUs by 500 in the next year, the only way to achieve both goals is for the physician to work more hours every day (the physician has to bill the patient the same amount whether he/she sees that patient 3 times a day or just once a day). From the physician’s standpoint, he/she will have to choose between meeting the quality department’s goal by increasing the number of daily encounters with each patient by 200% or meeting the practice administrator’s productivity goal by increasing the number of patients that the physician sees by 14%. Given these competing demands, most physicians will choose to go after the wRVU goal and ignore the quality goal because the wRVU goal is more achievable.

So, how should we set quality goals?

  1.  Recognize that most physicians cannot be above average in everything. The physician who wins all of the teaching awards get them because he/she is spending a lot of time doing bedside teaching rather than trying to knock the wRVU targets out of the park.
  2. Expect small annual incremental improvements and evelop long-term, aspirational goals. My favorite NFL team, the Cleveland Browns were winless last season at 0-16. Next year, I’m not expecting them to go to the Super Bowl but I’d be happy with 2 wins next season, 5 the following season, and then make the playoffs in 3 years. Setting long-term goals with incremental increases every year over a several year period is more realistic.
  3. Realize that the physicians can’t go it alone. Increasing productivity may require investing in more outpatient exam rooms per doctor, or geographically locating all of a hospitalist’s patients to one nursing station, or staffing up the case management department to facilitate discharge planning. Achieving higher goals requires giving the physicians the tools they need to meet those goals.
  4. Get the right benchmarks. For example, if you are tracking hospital mortality and are at a large tertiary care medical center that has a high percentage of complex, critically ill patients, then using a crude mortality rate will not be useful because your patients are sicker and have a higher expected death rate than those at a smaller community hospital. In this situation, using the mortality index would be a more appropriate way of comparing how well your hospital is doing in patient mortality. The mortality index adjusts the crude mortality rate by the severity of patient illness. For the tertiary care hospital to achieve the same crude mortality rate as a small community hospital or an orthopedic specialty hospital is unrealistic.
  5. The best theoretic result is not always the best achievable result. In an ideal world, there should be zero hospital-acquired central venous catheter infections. However, that is not going to happen, the bacteria always finds a way in the sickest patients and central lines are mainly used in the sickest patients. Therefore, setting a hospital goal of zero central line associated blood stream infections is not realistically achievable and if every year the doctors and nurses feel demoralized because they could not achieve a goal of zero, staff morale will suffer.
  6. Don’t create a storm of goals. There are 300 different merit-based incentive payment system (MIPS) measures. If you hold your physicians responsible for achieving all of these, their heads will be spinning and they will likely just give up. Focus efforts on a limited number of goals that are of highest priority for the hospital. Five or six goals for each physicians is a good target.
  7. Publicize next year’s goals before the start of next year. This seems so common-sense but many hospitals procrastinate on getting goals finalized and then getting those goals publicized to the physicians on time. A hospital that disseminates the annual quality goals 3 months into the year is doomed to failure since by the time the physicians and hospital staff know what their annual goals are, 25% of the year has already gone by. It would be kind of like a head football coach not telling the other coaches and the players what the game plan is until after the first quarter.
  8. Provide timely regular feedback. If one of the hospital’s quality goals is to reduce readmissions for heart failure patients, then report the 30-day readmission rate on a monthly basis, as soon as the data is available. People usually can’t remember what they did differently 6 months ago, let alone a year ago. Regular and timely feedback allows physicians and hospital staff to determine in real time what is working and what is not working and then adjust behavior and practices accordingly.
  9. Achieving a ranking is not achieving a quality goal. I’m probably going to get into trouble for this one because every hospital focuses on the U.S. News and World Report annual ranking of hospitals. Boards of Trustees, CEOs, Deans, and medical directors all define success as “moving up in the ranking”. It is true that in many situations, a higher national ranking by rating groups such as  U.S. News, Leapfrog, etc. do incorporate quality in the determination of ranking. However, the goal of the hospital should be to get the quality right and not just to get the ranking. Medicine is not like NCAA football where the highest ranked team at the end of the season wins. We win when our patients get the best care for their condition possible. The rankings and awards can come later.
  10. But… set goals that are achievable but not too achievable. To be successful in getting NIH research grants, research scientists know that they have to have half of the work already done before they submit a grant so that achieving the goals of the grant (and continuation of funding) is assured. Similarly, it is human nature for hospital leaders to choose goals that they know that they can achieve so that they are assured of looking good at the end of the year. For example, if I, as a medical director, set a quality goal of reducing Clostridium difficile infections by 20% next year and I know that the hospital just purchased an expensive ultraviolet light C diff decontamination system that the literature says reduces C diff rates by 50%, then at the end of the year, my quality goal scorecard is going to look great – it is like benefitting by insider trading.

The hospitals’ ultimate goal is to match the healthcare resources of the hospital to the healthcare needs of the community in a way that maximally benefits the patients. In most situations, a hospital cannot change overnight to perfectly match these needs and the alignment of hospital resources with community healthcare needs is a long-term journey. Setting achievable quality goals is a critical part of this journey.

July 11, 2018