MedEd

Is Medicare’s “No Pay for Errors” Plan a Good Idea?

In this month’s issue of the Joint Commission Journal of Quality and Patient Safety, I (with UCSF’s Adams Dudley and the American Hospital Association's Nancy Foster) tackle this provocative question. The answer may surprise you: yes (probably). The devil will be in the details.I hope you’ll have a chance to read the full article (the Joint Commission Journal has made it freely available to readers of AHRQ Patient Safety Network, so you can get it here). But the bottom line is this: in our judgment, a policy of withholding payment for adverse events is reasonable when the following criteria are satisfied:Evidence demonstrates that the adverse events in question can largely be prevented by widespread adoption of achievable practices.The events can be measured accurately, in a way that is auditable.The events resulted in clinically significant patient harm.It is possible, through chart review, to differentiate adverse events that began in the hospital…

More Consequences of IT: The Disappearance of Radiology Rounds

When I was a med student, the Beating Heart of the Hospital of the University of Pennsylvania (HUP) was not the CEO’s suite, the neurosurgeon’s OR, or the Dean’s lair. It was the seat of one Wallace Miller, Sr., in the decidedly unglamorous Chest Reading Room.Do you even know where the chest reading room of your radiology department is?Everybody – and I mean everybody, from the lowliest student to the seniorest clinician – brought their films to “The Wal” to figure out what was going on. For students like me, the trip to Mecca was both fun and terrifying. “What’s this opacity?” he asked me once, the memory seared in my medulla oblongata. “A… a pneumonia?” I stammered. “Mooiaaa” retorted the Oracle, turning his head away in mock disgust. I loved it.One night last week, my ward team got 8 new admissions. After sprinting through the H&Ps and doing a…

How Clinical IT is Transforming Hospital Care – For Better and Worse

My friend Mark Smith, who runs the California HealthCare Foundation, once wryly observed, “Have you ever noticed that the doctors who talk about how much fun primary care is only practice it one afternoon a week?” I may have become the hospitalist version of Mark’s Ivory Tower internists, but I’ll take my chances.I just finished a two-week stint on the wards. I loved it, but I only do clinical ward attending a couple of months per year – I realize that those of you who see patients all the time may not be quite as jazzed. Nevertheless, one of the advantages of doing clinical medicine sporadically is that it leaves me well positioned to notice changes in clinical care, for the same reason that people who see your kids every six months are struck by their growth spurts.Today, some thoughts on information technology and its impact on day-to-day hospital care.…

Did I Violate Federal Regulations Today? (I Hope So)

The patient safety and quality movements are precious and fragile. Just as IOM reports I and II spawned these modern, life-saving revolutions, the Federal shutdown of the Hopkins/Michigan checklist program may help extinguish them. After all, Tipping Points can tip both ways. I laid out the issues in this prior post. Those of you who know me know that I am anything but a rabble-rouser – I have the affliction of seeing both sides of every issue. But, as someone who cares about the lives of patients, this one gets me PISSED. Apparently, many of you feel the same way – particular thanks to Paul Levy, Charlie Baker, Maggie Mahar, Jim Sabin, AHA Prez Rich Umbdenstock, and of course Atul Gawande. After many of you wrote, blogged, and otherwise bellowed, “I’m Mad As Hell And I’m Not Gonna Take This Anymore,” the Office for Health Research Protection issued an Orwellian…

Bureaucracy Run Amok: Can Checklists Kill?

As you may know, I’ve argued that that the quality and safety of healthcare have traditionally been underregulated. But regulators are like patients with Parkinson’s: it’s hard to get them unglued, but once they’re moving, it’s hard to stop them. Welcome to Exhibit A. Last month, I described Atul Gawande’s thrilling New Yorker article recounting the seminal work by Peter Pronovost and his Johns Hopkins colleagues in Michigan. By implementing checklists to prompt people to follow safety procedures (like using barrier precautions during catheter insertions), they were able to slash the infection rate in over 100 Michigan ICUs. The results were tremendous savings – of over 1500 lives and $200 million. The original Pronovost study was published a year ago in the New England Journal of Medicine – AHRQ Patient Safety Network, the federal government’s patient safety portal, deemed it an “instant classic,” a status granted only 1-2 articles each…
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