Hospital Quality: A Different View

Paul Farmer (of Partners in Health fame) has an easy-to-apply formula for DSC00749quickly assessing the quality of hospitals or clinics anywhere in the world. He says that given the resources of the country, he looks at the quality of the hospital/clinic bathrooms and the gardens surrounding it. Based on just those two items, he claims he can accurately assess overall hospital/clinic quality—and afterwards correlate it with more ‘objective’ measures of quality and safety. Try out his quality assessment at your own hospital/clinic work-site, and maybe as a New Year’s resolution try to influence improvements.

My office at work is in the world’s largest university building: the Warren G. Magnuson Health Sciences Building at the University of Washington. The building has close to 6,000, 000 square feet of space and is composed of over twenty wings whose hallways are connected, but in a haphazard, disorienting way. The building is an Escher-esque sort of place, with faceless people wandering the hallways and strange concrete staircases going everywhere and nowhere. Ten thousand or so people work (or are hospital patients) in this building. At any given time at least half of the people are lost. I am usually one of them. The building includes a hospital and four health science schools—medicine, nursing, public health and dentistry. The fifth health science school—social work—was lucky and is far across campus in its own (very small) building.

The Health Sciences Building is sandwiched between three busy streets and one busy ship canal. Many of its courtyards are completely covered in concrete, with only a few stalwart and scraggly rhododendrons popping up in places. The bathrooms are tiled and painted a sickly yellow-beige that reminds me of public high school gym locker rooms.

My office is in the ugliest wing of the world’s largest university building. My office has a fault line running through it. There is a 6-inch wide grey rubber seam that bisects my office in two—it runs up one wall, across the ceiling, down the other wall, and across the floor. This rubber seam is the building’s earthquake shock absorbers. I often wonder what it would be like to stand on the fault line during an earthquake. Would I be safer there than ducking under my fake-wood desk? My office also has a door that goes nowhere. Supposedly it allows access to various pipes and electrical wires in the concrete-encased outer phalanges of the building. This door is perpetually locked and I have hung a silk scarf over it to make it seem less weird. I tell students it’s where old faculty members go to die. I often want to crawl in there and take a nap.

The particular part of the Health Sciences building I work in, the T-wing, was built in the late 1960’s and is a prime example of Brutalism. It is also a prime example of why Brutalism is not an architectural style suited either for Seattle weather or for being attached to a hospital. Outside and inside it appears to be made of crumbling, damp and moldy concrete. In one staircase I use there are arm-sized stalactites forming on the ceiling and liquid is perpetually dripping from their pointed ends into a black and green puddle in one corner of a stair landing. It has a bizarre beauty. Over Winter Break the stalactites were removed and the ceiling painted over. I find that I miss them.

University of Washington Medical Center does fairly well on most quality measures included in Medicare’s Hospital Compare. Under ‘patient satisfaction survey’ they include an item on cleanliness of bathrooms. (Gardens aren’t included). If you haven’t used this website before, I encourage you to do a search of hospitals in your area. They have recently added a section on hospital readmission rates.

Hospital Dirty Laundry Exposed

Laundry (Photo credit: Bilal Kamoon)

Julie Creswell and Reed Abelson of the NYT are writing a series of fascinating articles exposing hospital giant HCA (Hospital Corporation of America), now the largest for-profit hospital chain in the US. Their NYT article today “A Giant Hospital Chain is Blazing a Profit Trail” finally explains to me the story behind the strange digital billboards I saw in June when I was visiting my father in Richmond, Virginia. They seemed to be everywhere along major roads, flashing obnoxious red-lighted wait times for the emergency rooms at two HCA hospitals–one being CJW, which the NYT article calls out as being one of the worst hospitals in the US in terms of bedsores (bedsores being a fairly good indicator of poor nursing care).

Last week (8-6-12, “Hospital Chain Inquiry Cited Unnecessary Cardiac Work) they wrote about a whistleblower, C.T. Tomlinson, a traveling nurse, who in 2010 worked as a cardiac nurse at the Lawnwood Regional Medical Center in Florida. Tomlinson was present in the cardiac catheterization lab when an HCA cardiologist inserted a stent into a patient who did not need it. Tomlinson reported the incident to his nursing supervisor who supposedly told him to forget about it. So he wrote a letter to the chief ethics officer of HCA’s hospitals in Florida who investigated his complaints and found them to be substantiated. Soon after Tomlinson wrote the letter of complaint, his contract to work as a nurse with HCA was terminated. It is not clear from the article whether or not he has filed a lawsuit for wrongful termination under Whistleblower protection. The HCA chief ethics officer’s investigation found that about half of all the cardiac catheterizations at Lawnwood Regional Medical Center were unnecessary, but did not alert the patients involved. It is unclear how many patients may have been harmed by the unnecessary cardiac work they had done. HCA also did not alert Medicare, state Medicaid or private insurers who were charged for the expensive procedures.


Bedside Nursing

British nurse in nurses' station.
British nurse in nurses’ station. (Photo credit: Wikipedia)

Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.

Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.

Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.

Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.

Then there is the fact that hospital-based jobs for nurses are rapidly disappearing as hospital administrators reduce their nursing staff, and as more hospitals merge or close altogether. Some experts claim that one-third of all hospitals in the US will close by 2020 (see David Houle and Jonathan Fleece’s post on KevinMD. 3-15-12)

Bedside nursing is probably a term that needs to be, well, put to sleep.


Hospital and Doctor Compare: Patient Beware

Patient Recognition Month Poster
Patient Recognition Month Poster (Photo credit: Army Medicine)

Nurse and NYT’s Well Blog contributor Theresa Brown has a NYT Op-ed piece today entitled “Hospitals Aren’t Hotels,” in which she states “…the growing focus on measuring ‘patient satisfaction’ as a way to judge the quality of a hospital’s care is worrisomely off the mark.” She points to the patient satisfaction section of The Centers for Medicare and Medicaid’s Hospital Compare website, where consumers can look up individual hospital quality of care information. Based on Medicare patient data and hospital reporting mechanisms, Hospital Compare includes process and outcome of medical care measures, use of medical imaging, patient safety measures, Medicare payment/volume, as well as a 10-item survey of patient’s hospital experiences.

It is instructive to note that patient satisfaction is only one of six categories of quality of care data on Hospital Compare from which consumers can make more informed medical care decisions. Obviously it is only useful for planned procedures and hospitalizations, since patients having a heart attack aren’t likely to stop and look up Hospital Compare data on their iPads. I used Hospital Compare several years ago when my sister asked my advice as to Seattle-area hospital choices for her planned abdominal hernia repair. At the time, Swedish Hospital had the highest volumes and best patient outcomes (including patient safety) for this surgical procedure, so my sister then picked a surgeon from their list. She had a decent hospital experience. Today for grins I pretended I needed to have laparoscopic gallbladder removal (I don’t) and ‘shopped’ for Seattle-area hospitals based on this specific procedure. Of the three geographically closest hospitals—Group Health Central, Northwest, and University of Washington Medical Center (UWMC), Group Health came out the clear winner overall for quality of care measures that are most meaningful to me: patient safety (UWMC is worse than national average for hospital acquired conditions such as infections and things besides vital organs left in after surgery—and for the ominous sounding “accidental cuts and tears from medical treatment”), having medications explained to me before they are given, nurses and doctors who communicate with patients well, and the area around patient rooms being quiet at night.

It can be and is argued that patient satisfaction with care is not a valid measure of outcome of medical care. I know from teaching that I can make my students happy and get high ‘student satisfaction’ with teaching scores, and still not have done my job of actually teaching them anything of importance. In her NYT Op-ed piece today, Ms. Brown uses an example of an elderly cancer patient who was told by the hospital oncologist that he was basically too old to qualify for treatment and was sent home. He may have not scored that hospital very high on his Medicare hospital survey, since he didn’t get what he wanted. Ms. Brown links to a recent study by Joshua Fenton at UC Davis showing that higher patient satisfaction scores with individual doctors was linked with greater use of hospital services (higher medical cost) and increased mortality. To me that’s a no-brainer and points to the danger of overuse of health care—more health care is not better health care, and health care can be dangerous to your health.

US doctors have been fighting consumer ratings of individual doctors. (see Ron Lieber’s “The Web is awash in reviews, but not for doctors. Here’s why.” NYT, 3-9-12) The developer of the online site created now includes ratings of close to 1.4 million physicians in the US and Canada. The founder of gets at least one lawsuit threat a week from physicians who don’t like what’s been posted about them. A physician reputation management service, Medical Justice, set up a system whereby physicians had patients sign a “no web posting opinions of the doctor” agreement in exchange for enhanced patient privacy protections. That’s almost like a restaurant owner asking you to sign an agreement not to post a review on Yelp in exchange for not putting flies in your soup. The Medical Justice system collapsed after a complaint was filed with the Federal Trade Commission.

Insurance companies and health plans collect consumer ratings and medical outcomes data for individual doctors and other providers, but they don’t make these data available to consumers. With the Affordable Care Act/health care reform, starting January 1, 2013, Medicare will be required to provide consumers more information on doctors as well as on hospitals. (As of this writing, they have a “Physician Compare” site, but it only allows searches to find physicians who accept Medicare.) I disagree with Theresa Brown on this issue. I think that patient satisfaction as one aspect of judging the quality of hospital or other medical care is essential for improving our health care system. It is an essential component of patient-centered care.

No More Free (drug) Lunches or Pens

As part of the Affordable Care Act (ACA) health care reform, drug companies will soon be required to report payments and free lunches/dinners/cruises/vacations/gifts to physicians or payments to teaching hospitals. It includes any free ‘educational’ service for physicians or teaching hospitals. This is section 6002 of the ACA and is known as the Physician Payment Sunshine Act (sunshine, as in shedding light on or transparency). As part of the mandatory reporting, individual physicians and hospitals will be named, along with what items of monetary value they received and by which companies. This information will be publically available and easily searchable. Companies will be assessed hefty fines of up to $1 million for failing to report the information. This Sunshine Act was supposed to have already been implemented, but has been delayed while government officials at the Centers for Medicaid and Medicare sift through public comment and iron out final details.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!

Follow the Money

All nurses should be required to take college-level micro/macro economics. Trying to teach nursing students the basics of health policy is almost impossible if they are not comfortable with economic terms and concepts.

I was reminded of this recently, when in a fit of fall office cleaning, I finally gave away my copy of Samuelson’s economics textbook. It was stuffed full of class notes, health economic diagrams and highlighted paragraphs. Two quarters of economics were required for my public health degree, and both were taught by a passionate German economist who waved dollar bills around his head for effect. I begrudgingly signed up for his course, found it—and him—fascinating, and it has been the single most useful class I’ve ever taken in any of my health care programs. That and a water and sanitation class: the basics of health care.

Economics of health care finds its way into my mailbox. My home mail these days mainly consists of utility bills and glossy medical newsletters by local hospitals. The cover of the latest one (photographed here) is oh so Seattle, showing two smiling but scary looking roller derby women. I’ve met one of the women (off rink thankfully) and she is quite nice in person. Inside the hospital newsletter/magazine is a two page article about the women’s roller derby team, the various sports injuries team members have endured, their team orthopedist and the orthopedic surgical ‘cures’ performed at the hospital. I get similar hospital newsletters from two other local hospitals I’ve been a patient at. All three highlight the hospital cash cows of cardiac surgery, cancer care, and orthopedic surgery (none of which I’ve been there for).  I’ve been successful getting off the mailing lists of most all major catalog/merchandise companies, but have not been able to stop getting these hospital newsletter/magazines. It is oh so NOT Seattle, being decidedly un-green and tree/salmon-killing.

I know that I am bombarded with these hospital newsletters because: 1) I have decent health insurance, 2) I’m getting towards the age when cardiac/cancer/ortho surgeries may be needed, 3) I might be crazy enough and able to afford to make a monetary donation to a certain hospital unit/program, and 4) perhaps because I am a health care provider and can recommend certain hospitals to my friends and relatives.

Most experts on hospital advertising agree that the main purpose of such advertising is brand recognition—and that hospital advertising increases (as do the costs obviously) as competition increases for insured/affluent/paying customer-patients. If you ask hospital PR people (I have), they will say their newsletters are an important patient education/health literacy effort—a public service of sorts. But when you analyze the content of articles and print ads, this claim doesn’t hold up. Most are not written or reviewed by clinically-knowledgeable people, they play up emotional content (her heart was fixed and she can now play with puppies and kittens and grandchildren!), and they exaggerate benefits/leave out adverse effects of surgeries and other treatments. Hardly real health education. Most industrialized countries ban or severely restrict health care advertising.

A fascinating underlying reason for hospital/physician advertising (as I learned from Paul Levy’s blog post on this topic), is that it strokes the egos of physicians and senior executives of hospitals. The doctor egos need stroking because they make money for the hospitals and doctors are free agents and can move to a different/higher paying hospital. Funny how there aren’t too many hospital ads or newsletter articles highlighting nurses.

The final reason that health care economics is on my mind is the excellent article in today’s Seattle Times by health reporter Carol Ostrom: ER Building Boom is Wrong Prescription, Experts Say.” In this article she discusses the economic and regulatory issues behind our Seattle-area resort-spa-emergency department craziness—a problem not unique to our region. If you want to understand health care, take or review Economics 101.

Temporary Nurses and Patient Safety

1966 Nurses Strike - San Fransisco Where It Al...
Image by nursing pins via Flickr

California is the only state that mandates minimum nurse to patient hospital staffing ratios. So when hospital nurses go on strike in California, the hospitals postpone elective surgeries in order to reduce patient numbers, and hire temporary nurses to maintain the mandated nurse staffing levels. The recent patient death from a medication error by a temporary nurse at Alta Bates Summit Medical Center in Oakland during a nurses’ strike, has drawn attention to temporary nurses and patient safety.

Late last month more than 23,000 nurses at Sutter, Kaiser, and Children’s Hospital Oakland had a one-day planned strike protesting proposed cuts in employee benefits and patient services. Sutter hospitals locked out the nurses for four days after the strike, saying they had to sign five to eight day contracts with the firms who brought in the temporary nurses. During the lockout a temporary nurse reportedly administered a nutritional supplement through a central line (into the bloodstream) instead of through an abdominal feeding tube. Hospital spokespersons have called it a highly unusual medication error, but quickly added it didn’t have anything to do with the lockout or the use of temporary nurses. Nurses’ union officials have said the patient death wouldn’t have happened if they hadn’t been locked out after the strike. They have filed a complaint with the National Labor Relations Board over the lock out. And they have stated that it reveals that the use of temporary nurses endangers patient safety.

So what is the evidence in terms of temporary nurse staffing and patient safety and quality of care? An oft-cited study by Linda Aiken published in 2007 in the Journal of Nursing Administration, did not find that hospital patient safety was negatively affected by use of temporary nurses. However, her study used survey/self-reported data, and only included Pennsylvania hospitals. A recent large national study found that emergency department medication errors associated with temporary staff were more frequent and more likely to be life-threatening than those by permanent staff (Pham, et al, Journal of Healthcare Quality, July/August 2011). The authors point out that the use of temporary nurses (and other hospital staff) is on the rise due to work-force shortages and perceived cost savings to hospitals.

The Hospital/ Monday October 11th, 2010

Surviving the hospital: Yesterday I brought my Dad home from the hospital. He insisted on opening doors for me and for others as we found our way to the parking garage. He was disappointed he didn’t have surgery. In the 2.5 days he was an inpatient at the teaching hospital he was seen by a total of four doctors, two nurse practitioners and one physician’s assistant all at different times and mostly asking us what the other providers had said (not quizzing us–they really didn’t know). It was confusing for my Dad who kept getting his hopes up that they could do cardiac surgery and fix him up. I was his health care agent and tried to be his advocate. It was exhausting to help him wade through it all. I realized just how messy these “breakpoint conversations” are for everyone and how our health care system really is not set up to help facilitate them. For instance, in a hospital there really is very little in the way of real patient privacy. My Dad had a shared room with a cloth curtain between the beds, which were three feet apart. Without really wanting this information, I now know all of the roommate’s medical conditions and major family situations. He knows ours. I was uncomfortable having the difficult patient/family/provider conversations we were having knowing that Dad’s roomate and his wife were listening. I know it changed what I felt like I could say and ask. At the climax of the main conversation with Dad’s cardiologist (when he was telling Dad his heart was like the engine in an old car–unreliable except to run around town perhaps), the roomate’s colostomy bag exploded and his breathing/forced air machine started beeping loudly. Somehow the conversation continued even though no one could breathe or hear anything. I understand that exploding colostomy bags happen and things hit the fan and you can’t control situations, but this was on a ‘regular’ medical floor and not in intensive care. Surely clever engineers/designers can come up with solutions to the space and privacy issues in hospital rooms, even if they have to be shared rooms. My Dad was ambulatory and the doctor could have taken us to a private consult room somewhere for this sort of conversation and I am sure that would have made it easier for everyone. I was going to suggest it at the time but realized there were no such rooms. I pushed for home nursing care for my Dad and that starts tomorrow–it can segue into hospice/supportive care when the time comes. I had to ask for patient education materials before we were discharged and there really is no clear plan for follow-up with anyone. The home health nurse comes tomorrow and I am hoping that he or she can help pull things together better than they have been so far.