Here are some quotations that highlight just how wrong predictions can be when it comes to Surgery and Healthcare.
Click the link below the photo to take a look at the full entry for some all-time highlights!
These predictions are the sort that are so spectacularly wrong that they live on in the lore of the hospital and sometimes even blow up on the people who made them.They serve as reminders, routinely, of just how off things can be when it comes to predicting trends in Surgery and Healthcare. They warn us about how far off we can be even when we’re sure about what’s coming next.So, here’s a lesson in uncertainty when it comes to the future. Think about these next time you want to make a prediction in public!
It’s that time again! 2017 is nearing a close, and this is the time of year that The Surgical Lab offers a digest of some of our most viewed (and controversial) posts. Take a look at the Amazon entry for the 2017 digest, including posts like Healthcare Is A Decade Behind Other Industries and other key posts from the year!
Guys, listen: on my recent daily read through of articles on healthcare quality, I ran across one that made me want to share.
It all started with a quote that “Cost is the number one threat to quality in the United States…”
Before I jump in and comment on the quote, just a few things. First, the person who gave the quote is really very excellent and quite intelligent. Second, sometimes what we say in the context of an interview doesn’t exactly come across correctly once the article is written out and distributed out there for all of us to see.
For instance, I’ve done interviews for USA Today and several other publications…all with excellent reporters attached to each article. No matter how good they are, sometimes they select something for the final article that doesn’t really make sense out of the context of the interview.
Maybe some of that is what happened to Peggy O’Kane with her quote I describe above. (Click the link at the bottom of the entry for the full article including her quote.)
Now, allowing for that: the idea that cost is the number one threat to quality in the United States is, to my mind, a cart-before-horse type statement.
It’s way off the mark. Here’s why:
- Even low level quality improvement projects in healthcare routinely recover $300,000+ from the Cost of Poor Quality (COPQ).
- US healthcare spends around 14% of its GDP to achieve a median life expectancy that is usually ranked worse than 20th in the world.
If these facts weren’t enough, here’s just a sample off the top of my head that highlights how much cost is incurred by a healthcare lab owing to poor quality:
Each answer option in Ms. Dawson’s question is a well-known truism in quality improvement circles. (She asks which one best highlights long term cost savings to be had via investment in quality.) But look at choice D–that demonstrates how costs for the lab are increased by Cost of Poor Quality (or COPQ). Reducing that COPQ would allow for improved profits to the hospital. A poor level of quality is a great deal of the REASON for higher costs…and that level can be improved.
That’s the whole point here: given the performance of our system overall (and, by the way, our health system can do some awesome things) it is exactly backwards to claim that cost is a threat to quality. In fact, it’s the other way around.
For all you healthcare colleagues out there, let me say it this way: you wouldn’t say a patient’s abdominal pain is a threat to their perforated gastric ulcer. So don’t blame the symptom that is high healthcare costs on the real issue: healthcare system quality. It’s just plain backwards.
Cost is the number 1 threat to quality in the United States,” said Peggy O’Kane, founder and President of the National Committee for Quality Assurance. “It hurts the ability of doctors to do a good job. We have a lot of high deductibles that stand in the way of getting the kind of primary care and chronic disease management care that people need.
Ahhh Healthcare…few things are straightforward with you aren’t they? For those of you following along, take this as one more example of the special nuances of applying classic quality concepts in healthcare: value added time.
In other fields, value added time (VAT) has a relatively straightforward application. It’s often defined as time spent in a system that contributes value for which the customer will pay.
But oh, Healthcare…you wily creature: who is the customer we are talking about here? Who gives the Voice Of the Customer (VOC) that we use to reconcile the process? Let me share how I’ve applied the concept of VAT to healthcare processes before…
First, we have to remove ourselves from all the buzz and worry about what perhaps should be in Healthcare and focus on what is: the third party payer of some kind (government, insurance company, someone else…) is the person who reimburses for services provided. Sometimes patients pay for their own care.
Bottom line: in general, these third party payers decide whether (and how) to reimburse for services rendered based on the note written by the “provider” (whether that be the physician, the advanced practitioner, or someone else).
…and that’s where the VAT finds its application.
Amazingly, if you haven’t seen it before, the VAT in many systems is only about 1% of the time spent in the system (!) Only 1% of the time we spend doing something is actually contributing value. In healthcare, what is that VAT?
One way to look at it is that the VAT in providing care to a patient is the time spent writing the note.
Now, of course, what we write in the note has to be things we did or thought about. So if we write we took out an appendix, well, we actually need to have done just that. Writing down things we didn’t do is inaccurate and may even hurt the patient. It’s also probably illegal.
But placing the note at the center of the universe for VAT does some important things. Consider some important questions that come up routinely:
- If the note is so important for VAT, shouldn’t we make it easier to create the note by improving the user design of Electronic Health Records?
- If the note is so important for VAT, shouldn’t we embed coders and billers more directly in our systems that create them….even at night and on weekends?
- If the note is so important for VAT, shouldn’t we encourage collaboration between coding staff and the providers creating the note?
The application of VAT in healthcare, in this way, has some interesting consequences for how we improve the value in our systems.
In healthcare there are some special issues in application of this definition. For example, who is the payer in the situation? When we say value-added time as anything for which the customer will pay, who is the customer? We usually use a third party payer’s perspective as the answer for “who is the customer” because they are usually the ones actually paying for the services and systems. Rather than talk about who should be paying for services in American healthcare we, instead, focus on who does. In this respect we treat the third party payer, the source of funds, as the actual entity paying for use of services. This also has some interesting consequences. The third party payer, in fact, bases their payment on physician, surgeon or healthcare provider notation. In fact what they actually are paying for is the tangible product they see which is the note. Again, the note the physician, advanced practitioner, or healthcare provider supplies is what the third party payer reimburses. In fact, they also use that as a rational to decline payment. Consider how, if we gave a service but didn’t write it down, we would not be reimbursed.
Once again, we see the current state of US healthcare at the forefront in the news. What’s the current state? Read on…
In a nutshell, we have the world’s most expensive healthcare and only middle-of-the-pack outcomes on key metrics. Yes, you can argue about why or lament just how sick our patients are…but, bottom line, we’re a long way off.
Take a look at the excerpt and the opinion piece below to learn more about the current state of US healthcare and what lurks behind the public discourse on the health of our US healthcare system.
Nonetheless, a real debate over healthcare would begin with an accurate diagnosis of our ailing system. We have the world’s most expensive healthcare, and despite the superior quality of American providers, science and technology — our life expectancy and infant mortality rates are the middle of the pack among developed nations. The cost, quality and patient experience of care varies widely among doctors and hospitals. Despite billions of dollars of investments in information technology, medical records still don’t follow patients across providers, and we lack the real-time data insights that fuel quality improvement in other industries. Finally, our healthcare system emphasizes treating people when they are sick — not keeping them well.
Come on now, you had to know about this problem with healthcare quality reporting. No? Well don’t take my word for it. I’ve previously written about the lack of standards when it comes to defining value in healthcare and how we really can’t blame patients for misunderstanding healthcare value.
And now, this: a recent JAMA online first that talks all about how we don’t have standards when it comes to healthcare quality reporting. Oh boy don’t we!
Once upon a time, I worked for an organization that claimed it had no catheter associated urinary tract infections or central line infections in the ICU for more than two years!
Was this organization incredibly adept at quality improvement initiatives? No, not really. Had it closed its ICU to patients? (That may be the only way to truly prevent those nosocomial infections.) Nope, sure hadn’t.
Several issues were at play, including a stubborn refusal to diagnose those infections even when they were obviously present and contributing to patient morbidity and mortality. Can we blame them? I’m not sure…there are plenty of pressures to avoid “never” diagnoses from CMS.
I’m not saying that makes it ok to ignore these diagnoses, but it does make it more understandable. Hospitals didn’t create these incentive games, after all.
In any event, a lack of definitions and reporting standards regarding quality endpoints doesn’t help! Take a look and click the link below to review the latest JAMA take on just how many issues we have with standardization of quality issues. One more reason our field is a decade behind others in terms of quality improvement.
Although hospitals and physicians are perceived as trusted entities, these organizations have an incentive to present themselves in a positive light. This conflict of interest should be less pronounced when outside entities, such as the Centers for Medicare & Medicaid Services (CMS) or the Leapfrog Group, report to the public about health care quality.Evidence suggests that some organizations may be providing potentially misleading information to the public. For instance, one hospital stated on its website, “Come to us, we have no infections,” without stating which types of infections were included, how this performance outcome was measured, or how long the hospital had gone without an infection.5 Even though there has not been a systematic study of the accuracy of the quality data reported by hospitals and physicians on their own websites, concerns are likely to increase with the number and types of measures now being reported (eg, patient experience, costs), some of which may be more meaningful to patients.The potential for misinformation is understandable given the absence of standards to guide the reporting efforts of hospitals and physicians.
…and can you really blame them? I mean, after all, it’s REALLY tough right now for those of us in Medicine to measure “value”. I wrote about the issue here and it’s a huge problem. (Some examples of all the definitions of “value in healthcare” are shared here.)
Take a look at the excerpt below, and click the link, for recent survey info that indicates patients don’t fully get that concept of what low value care looks like.
Previously, I described a novel tool to measure healthcare value here…but let me tell you: whether you like that potential measure or not, right now there’s no commonly accepted way to measure what value looks like in healthcare.
Can you blame patients for not understanding what “low value” care looks like if we, in the healthcare game, can’t get together on how exactly to measure value? Nope, probably not.
The researchers found that two-thirds of those surveyed “had some sense of what low-value care might entail, though many were uncertain about the specifics.” Additionally:Many who offered a description of low-value care saw it in terms of only testing, not treatment.About 5% “anticipated that excessive medical care might harm patients.”About 1% made a link between low-value care and medical costs – either their own or the nation’s.Pages
(Click the Soundcloud app above to hear David read this article.)
By: David Kashmer (@DavidKashmer, LinkedIn here.)
All models are wrong, but some are useful.
Remember when you first heard of the Swiss-Cheese model of medical error? It sounds so good, right? When a bunch of items line up, we get a defect. It’s satisfying. We all share some knowledge of Swiss Cheese–it’s a common image.
That’s what makes it so attractive–and, of course, the Swiss Cheese model is a much better mental model than what came before, which was some more loose concept of a bunch of items that made an error or, worse yet, a profound emphasis on how someone screwed up and how that produced a bad outcome.
Models supplant each other over time. Sun goes around the Earth (geocentric) model was supplanted by the sun at the center (heliocentric) model–thank you Kepler and Copernicus!
Now, we can do better with our model of medical error and defect, because medical errors really don’t follow a Swiss Cheese model. So let’s get a better one and develop our shared model together.
In fact, medical errors are more like Frogger. Now that we have more Millenials in the workplace than ever (who seem to be much more comfortable as digital natives than I am as a Gen Xer), we can use a more refined idea of medical error that will resonate with the group who staff our hospitals. Here’s how medical errors are more like Frogger than Swiss Cheese:
(1) In Swiss Cheese, the holes stay still. That’s not how it is with medical errors. In fact, each layer of a system that a patient passes through has a probability of having an issue. Some layers are lower, and some are higher. Concepts like Rolled Throughput Yield reflect this and are much more akin to how things actually work than the illusion that we have fixed holes…thinking of holes gives the illusion that, if only we could only identify and plug those holes, life would be perfect!
In Frogger, there are gaps in each line of cars that pass by. We need to get the frog to pass through each line safely and oh, by the way, the holes are moving and sometimes not in the same place. That kind of probabilistic thinking is much more akin to medical errors: each line of traffic has an associated chance of squishing us before we get to the other side. The trick is, of course, we can influence and modify the frequency and size of the holes…well, sometimes anyway. Can’t do that with Swiss Cheese for sure and, with Frogger, we can select Fast or Slower modes. (In real life, we have a lot more options. Sometimes I even label the lines of traffic as the 6M‘s.)
(2) In the Swiss Cheese Model, we imagine a block of cheese sort of sitting there. There’s no inherent urgency in cheese (unless you’re severely lactose intolerant or have a milk allergy I guess). It’s sort of a static model that doesn’t do much to indicate safety.
But ahhh, Frogger, well there’s a model that makes it obvious. If you don’t maneuver the frog carefully that’s it–you’re a goner. Of course, we have the advantage of engineering our systems to control the flow of traffic and both the size and presence of gaps. We basically have a cheat code. And, whether your cheat code is Lean, Lean Six Sigma, Six Sigma, Baldrige Excellence Framework, ISO, Lean Startup, or some combination…you have the ultimate ability unlike almost any Frogger player to change the game to your patient’s advantage. Of course, unlike Frogger, your patient only gets one chance to make it through unscathed–that’s very different than the video game world and, although another patient will be coming through the system soon, we’ll never get another chance to help the current patient have a perfect experience.
All of that is highlighted by Frogger and is not made obvious by a piece of cheese.
(3) In Frogger, the Frog starts anywhere. Meaning, not only does the traffic move but the Frog starts anywhere along the bottom of the screen. In Frogger we can control that position, but in real life the patients enter the system with certain positions we can not control easily and, for the purposes of their hospital course anyway, are unable to be changed. It may be their 80 pack year history of smoking, their morbid obesity, or their advanced age. However, the Frogger model recognizes the importance of initial position (which unlike real life we can control more easily) while the Swiss Cheese model doesn’t seem to make clear where we start. Luckily, in real life, I’ve had the great experience of helping systems “cheat” by modifying the initial position…you may not be able to change initial patient comorbid conditions but you can sometimes set them up with a better initial position for the system you’re trying to improve.
Like you, I hear about the Swiss Cheese model a lot. And, don’t get me wrong, it’s much better than what came before. Now, however, in order to recognize the importance of probability, motion, initial position, devising a safe path through traffic, and a host of other considerations, let’s opt for a model that recognizes uncertainty, probability, and safety. With more Millenials than ever in the workplace (even though Frogger predates them!) we have digital natives with whom game imagery is much more prone to resonate than a static piece of cheese.
Use Frogger next time you explain medical error because it embodies how to avoid medical errors MUCH better than cheese.
Dr. David Kashmer, a trauma and acute care surgeon, is a Fellow of the American College of Surgeons and is a nationally known healthcare expert. He serves as a member of the Board of Reviewers for the Malcolm Baldrige National Quality Award. In addition to his Medical Doctor degree from MCP Hahnemann University, now Drexel University College of Medicine, he holds an MBA degree from George Washington University. He also earned a Lean Six Sigma Master Black Belt Certification from Villanova University. Kashmer contributes to TheHill.com, Insights.TheSurgicalLab.com, and The Healthcare Quality Blog.com where the focus is on quality improvement and value in surgery and healthcare.
To learn more about the application of quality improvement tools like Lean Six Sigma in healthcare and Dr. David Kashmer, visit http://TheHealthcareQualityBlog.com