T. Dewey's Profile
Public reporting of outcomes can be a 2 edged sword. On the one hand, hospitals and physicians can be graded and held accountable for outcomes, and risk adjustment is often used in an attempt to “level the playing field” and not penalize physicians or programs that care for a larger percentage of higher risk patients. However, the system can be gamed and not accurately reflect the quality it supposedly delivers. While training in NY, which was one of the earliest to publicly report physician outcomes with CABG, I witnessed a dramatic increase in ancillary procedures being performed on higher risk patients because it would knock those patients out of a reportable category. This clearly circumvents the spirit if not the intent of outcomes reporting. Additionally, a significant number of patients were denied potentially life saving procedures out of concern that a physicians’ report card may be negatively effected and business lost as a result. Bottom line is that any system that acts as a disincentive to care for patients, even those with many co-morbidities, may not reflect well on the practice of medicine.
This appears to be a classic example of the market adjusting for what patients desire out of healthcare but is at odds with third party payers idea of value. Ad hoc episodes of care delivered efficiently and cost effectively appeal strongly to distinct classes of patients: younger, healthier (those without the burden of major chronic diseases), and those with the ability to pay for the service either out of pocket or through insurance. Unfortunately this paradigm is at odds with the concept of integrated care, and does not provide the longitudinal care many patients require, specifically the elderly or those with severe chronic disease. It also may alter the patient mix at hospitals and ED’s as these will see a disproportionate share of the unfunded or lightly funded patient that may not be able to pay for or access the acute care stand alone facility. Ultimately, the solution may require a merging of acute care stand alone facilities and larger hospital chains with integrated mechanisms to ensure patient navigation, compliance, and referral to specialists within network in order to safeguard patients from falling through the cracks.
Change over time in the operating rooms is a focus of every hospital in that the potential for decreasing the cycle time of one of the most expensive patient care areas directly contributes to the bottom line. Unfortunately multiple variables contribute to delayed turn over times, and some are more readily addressed than others. The best example I have personally witnessed occurs at the Herzzentrum Leipzig where turn over times between cases average 15 to 20 minutes. The core of their model is an ante-room outside the OR, where patients are placed under a general anesthetic, have their monitoring lines placed and are positioned for surgery on an operating room table while the patient in the OR is being closed. At the conclusion of the case, the previously operated patient exits the room through one door, a quick clean of the room is done, and the new patient enters from the ante-room. All that remains is the prep and drape the patient. This model is clearly dependent on having anesthesia capacity and the support staff to service the ante-room, but it is remarkably efficient. The incentives in this model revolve around that teams don’t go home until the final cases are underway, and team metrics are collected and reported in terms of efficiency. Under performing teams are counseled, shown the standard that’s expected and if unable to perform adequately replaced.
Dashboards can be an effective and useful tool if properly developed and distributed. The key components to utilization at our institution revolve around user friendliness and functionality. Clinicians, chronically time compressed, have little patience for dashboards that are difficult to decipher and ponderous to use. Additionally, the data presented should be relevant to the user, accurate, and as near real time as possible. We use multiple dashboards that present the same information but segregated by time frame each giving a different perspective on the same information, and each actionable in different ways. We audit our data semi-annually to determine its accuracy. Having the primary stakeholders intimately involved in the data elements presented also helps to improve engagement as well as understanding of the data presented.