Dr John M

cardiac electrophysiologist, cyclist, learner

An important quality measure in hospitals

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My hospital has just weathered an impressive upswing in patient volume. The house was full for weeks. The experience highlights an important aspect about quality care–an obvious one that doesn’t always make headlines.

What I notice when the hospital gets full is that patients are sent to units that they don’t normally go to. For instance, at my hospital, like yours probably as well, there are numerous different types of heart units. We have units that see general cardiology problems, some that focus on post-cardiac surgery and one that gets patients after cardiac procedures or heart rhythm issues. An especially nifty thing about my hospital is that leadership finds a way to keep staff together on one unit. Familiar faces treating familiar diseases leads to a specialized team approach to care.

Here is a good example: the unit that most of my patients head to after ablation procedures is also the one that sees arrhythmia patients started on rhythm-control drugs. Without knowing, the staff have all become AF experts. They have heard my philosophy of treating AF and understand well the dangers of over-treating AF. They get the importance of the QT interval. This ‘inside’ knowledge gathered over time allows them to impart specific educational stuff–not generic pamphlet stuff–to their patients. It’s the same on other units: different teams have different areas of expertise. You get the picture.

This degree of specialization is really important. For better or worse, Medicine has grown highly specialized. Though old-fashioned things like compassion, listening and respect traverse all disciplines, familiarity with a group of diseases makes a huge difference. Patient education is key. No, I don’t have a study to quote here, only common sense and years of experience.

My hospital has done a great job retaining skilled and compassionate staff and then keeping them together on teams. These sorts of basics, playground knowledge if you will, which are hard to place on a spreadsheet, are the ones that really matter. (Why do you think acute MI care has improved so dramatically?) Quality healthcare isn’t just about clicks and lists; it’s about people with skills and knowledge, matched with appropriate patients and working in a rewarding environment.

It’s good where I am. I like being part of the teams. Good medicine is clearly a team sport.

Just sayin something positive.

JMM

Difficult days to be an inpatient: Joint Commission Day or July 1?

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There was just something about the voice that peaked my interest. Normally, announcements in a hospital are muted, measured and perhaps even staid. But this one was not any of these.

The voice over the intercom robustly and frankly welcomed the staff of the Joint Commission.

Reflexively, I thought: “how nice of us to warmly welcome the inspectors.” But one breath later, I laughed out loud. Brilliant. Wrap the “they are here” message with a warm southern welcome. Huge Grin!

Now folks, you know that writing about the day that TJC visits your hospital would be akin to riding a narrow, treacherous, “high-consequence” single-track.

A mountain-biker faced with danger has two choices:

A.) Grab the gusto, focus the mind and let it rip. Commit.

B.) The more sensible–albeit blander–way of navigating such danger is to get off and walk. Live to fight another day.

So what’s a medical blogger to do when it’s time to recap the sensations of a TJC visit?  Ride the trail or get off and walk?

Hmm..

I would never write about how a normally calm, well-trained, well-meaning, all-human staff works less well when watched by people in suits. Serious people that hold the ability to–with a swath of a pen–assault something that caregivers hold precious: the self-esteem that comes from caring. Stop.

I won’t write about how it inflames my heart to see dedicated people get criticized by someone who has…Stopping here. Lots of Danger!

I would never say that a colleague described being fearful during a complicated procedure that was being observed by TJC. The worry was that the staff would do all the “right” things, but forget…Stopping again.

I would never even think that a nurse could not do two things simultaneously. Of course they can type in every box on five computer tabs AND tend to the patient. Hello. Everyone knows that we medical people can text click and care safely. And hospitals aren’t struggling, healthcare costs not skyrocketing because we have to hire one nurse to log computer notes while the other does nursing. That we have 5 people in the room for AF ablation in the US and two in Hamburg has nothing to do with why it costs 80,000$ here and 8000$ there.

And finally friends, you won’t ever see the essay–that I have written more than three times, but never published–on how the Joint Commission disallowed our ability to use the best sedative available. The fact that we had safely (zero breathing-related problems) used propofol for more than a decade and thousands of cases mattered not. Or that non-anesthesiologists now have two choices for sedating patients:

  • use anesthesia and dramatically increases the cost and limit access;
  • or sedate patients with far inferior drugs. Prolonged sedation after the procedure, nausea, retching and QT-prolonging anti-vomiting medicines are all on the come back in cardiac labs across the US–in the name of quality.

No way. The pursuit of quality dose not have unintended consequences.

JMM

Was there a third way to ride that trail?

Starting to go for it, but then seeing the danger; stopping short and dabbing. At least you tried.

Balance in life and medicine is often elusive…

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Today, after a string of hard but professionally gratifying days in the EP lab, a nurse and friend asks me at dinner time while still working in the lab, “Hey, how’s that reading books and writing thing going?”   Funny how a question lingers in the mind.

A discovery is in the midst.  Not huge news to most but as a trained observer, the revelation occurs to me spontaneously while working on powerpoint at 2300 hours.  It is a “two-fer:”   When new at something, like a beginner cyclist, there is this inwardly generated enthusiasm that must be tempered for balance purposes.  Secondly, time in the day limits one’s achievements.  Ablating all day precludes the attaining of peak fitness or peak learning or really little else.  But, I believe that the best in quality are from those with balance -the balance of time to read a journal article, go to meeting or maybe even review the coagulation cascade so as to understand the mechanism of action of a new blood thinner.
Joining a new group with eight other busy doctors of the heart and doing the rhythm work, combined with many of my patients acquired from 15 years, has created a bustle akin to years past.  So either it is one of the thunderstorms in medicine where procedures seem to come forth endlessly or it is a pattern that will require common sense managing in the future.
“Balance” in work, so as to father, husband, write, read and soon when the weather changes ride the bicycle, is so fundamental yet difficult to achieve at least consistently.
So for the moment more work, but soon a meeting with a medical assistant and a procedure scheduler to “adjust” things.  Get balanced and be a better doctor.
JMM

On quality of care as a strategy for success…

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Taking care of heart attacks is about speed, the “door to balloon time” is the primary metric used to determine a hospital’s worthiness.  So congratulations to the Santa Rosa Memorial’s staff for being the fastest in the country, but they should not delude themselves with the notion that high quality care is all that is needed.

For heart attack care, my hospital (Baptist East) is presently, and historically been the fastest in our community.  Providing outstanding care is one strategy for holding a competitive advantage in a capitalistic milieu.  It seems obvious that in the delivery of health care, either by the doctor or hospital, “quality” should be the primary determinant of success -like having the best food and service in the restaurant industry.

However, the health care delivery paradigm is much different than a “regular” business.  The quality of care provided is regrettably way down the priority list of reasons for getting referrals.  How could this be you may ask?   There are many reasons for this injustice, but the latest one, especially here in Louisville, is the buying of doctors by hospitals. The lower reimbursement to individual doctors provides a strong incentive to “associate” or to be owned by a hospital.

Recently, I was speaking with a high quality cancer doctor who is in a high quality practice which deservedly is extremely busy.  With a sweep of a pen and a “pot of gold” promised, a large competing hospital bought huge portions of the primary care doctors and employed a new group of cancer doctors across the street.  So, despite their present high quality and years of good service, this group’s business is diminished greatly.  The referring doctors owned by the competing hospital are “encouraged” to send their patients to their owner’s specialists.  She told me, “the recently bought referring doctors will send their mom to me, but their patients to the other group of cancer doctors, as they are owned by the same corporation.”

This referral bias is one of many frustrating business practices of medicine. Consumers  should know this.   I see this everyday and after 15 years it is still depressing.   Here we have the fastest heart attack care in the area and chest pain patients often go across the street to the two competitors, one is an ER without a hospital and the other is a hospital without angioplasty -for heart attacks, both scenarios delay care immensely.  Why is this?   A consumers (patients) lack of knowing, or believing billboards and ownership of their primary care doctor are the main reasons.

A wish list…

That the quality of care delivered be the primary driver of referrals.

That patients had the means to know the best best quality doctors and hospitals.

If they could know the best care, that they would choose it over a possibly lower priced or more convenient service elsewhere.

JMM