Friday, September 28, 2007

Our survey by the Joint Commission

Yesterday the Joint Commission re-accredited Community General Hospital for a full three-year term.

The preliminary award of accreditation was announced at the summation conference for senior management, following a three-day unannounced site visit that involved four surveyors. The re-accreditation is subject to review and finalization by the Joint Commission over the next week.

The review was detailed, and the surveyors identified a number of areas for CGH to make improvements – some of these are requirements for improvement (RFIs) for which we have 45 days to make changes that are acceptable to the Joint Commission. Other changes, called supplemental recommendations, are intended to improve CGH performance even further.

CGH received nine RFIs. Improvements are required in the provision of care, namely better documentation involving pain management and conscious sedation. We need to do better in two national patient safety goals: better medication labeling in the operating room and better measurement of the time frames involving critical test value reporting. Other RFIs involve a change in the Medical Staff’s policy on awarding temporary privileges to physicians in emergency situations and improvement in the signing of verbal orders by physicians. The remaining requirements involve the routine testing of the emergency generator and repairs and safety improvements in the physical plant.

We take the Joint Commission’s RFIs seriously, as we do the supplemental recommendations. We have already begun to make the changes needed.

The surveyors followed a “tracer” methodology. They identified patients at random, reviewed their charts, and traced the progress of their care. They interviewed the patients, spoke with their caregivers, and examined documentation and policies specific to the individual patient and the caregivers. The surveyors visited many areas of the hospital, including off-site departments. Noteworthy were comments they made about CGH employees: “bright,” “very knowledgeable,” “willing to listen,” and “not afraid to explain.” They also challenged us to be more consistent in our processes with comments such as “mandatory,” “not acceptable,” and “inconsistent” to describe areas where we need to improve.

I sincerely appreciate the attention and respect afforded the surveyors by the CGH family, but most of all I thank employees and managers for the preparation, competence, and professionalism they bring to patient care every day.

The surveyors noted with interest our preparations for computerized physician order entry (CPOE), which will be rolled out at CGH next year. They said the introduction of CPOE, electronic medical records and other information technology in the coming years should help improve our processes, further lower the risk of error, and avoid some of the documentation issues that were encountered.

I thank members of the Board of Directors and Medical Staff who participated in the Joint Commission leadership conference: Steve Infanti and Chet Amond, current and past Board chairs; as well as Drs. David Halleran, Thomas Hartzheim, Andrew Merritt, and Howard Weinstein, representing Medical Staff leadership. I appreciate the assistance of Mary Kinneman, interim Chief Nursing Officer, who helped the Nursing Division and the management team improve standards compliance and survey readiness. Dr. Fred Goldberg, new in his role as Chief Medical Officer, was helpful in this survey. Thanks also to Brendan McGrath, interim Vice President – Operations.

I especially acknowledge the staff of the Quality Department, which helps the entire hospital monitor and maintain compliance with our policies and with the Joint Commission standards, particularly Sally Ramsden, Director of Quality and Education, and Wendy Tarby, Director of Performance Improvement.

Last month CGH was honored as one of the Thomson Top 100 Performance Improvement Leaders among the nation’s hospitals. This demonstrated our progress in recent years in reducing mortality, improving patient safety, improving length of stay performance, as well as other measures. Maintaining Joint Commission accreditation is further evidence that Community General Hospital provides quality and safe care for our patients – and that we are committed to making ongoing improvements.

Thank you all, and congratulations.

Saturday, September 22, 2007

The firmament

Earlier this year the Medical Staff, with the help of the Auxiliary, began a recognition award for doctors who bring to their medical practices particularly human qualities. They demonstrate sensitivity, thoughtfulness, appreciation and respect – STAR is the acronym.

What do the medical STARs do? They play chess with nursing home residents. They treat others as equals. They have a rapport with their nursing colleagues.

Last March the STAR honor went to Joseph T. Barry, MD, a chess player who, if he loses a game, buys pizza for the residents. I wrote about Dr. Barry’s honor recently. An internist specializing in geriatric medicine, Dr. Barry is in private practice with Preventive Medicine Associates, PLLC, Camillus, NY. He is also the medical director of Community General Hospital’s sixth floor skilled nursing facility and the Iroquois Nursing Home, located in Jamesville, NY.

Dr. Barry “sets aside time to play chess with multiple residents” at Community General where his “genuine humor and lighthearted challenge to residents has created a splash of excitement.”[1] Dr. Barry is also “a man of the people” who is “always approachable” and who “totally immerses himself in medical problems from the patient’s perspective.”

Daniel L. Dombroski, MD, who received the STAR award in June, is a general surgeon who “treats everyone as his equal and has the ability to make the patients and staff members feel like they matter.” To him “the patient’s feelings and needs are just as important as their medical condition.”

Dr. Dombroski maintains a private practice in Physicians Office Building – North on the CGH campus. He participates in the hospital’s Wound Care Management Center, and he was honored by LeMoyne College in 2001with its Distinguished Alumni Award.

The September STAR honor went to James Watts, MD, an internist with “a wonderful bedside manner,” who has “a great rapport with nurses and other staff.” Dr. Watts is “always willing to go out of his way to help” and is considered by the staff on Three West to be “a breath of fresh air during a stressful day.”

Dr. Watts is in private practice with the FamilyCare Medical Group PC, which has more than 20 locations throughout the Syracuse area. Dr. Watts’ office is in Physicians Office Building – North. He is Co-chairman of the Medical Records Committee.

Being kind and respectful is not merely good citizenship. These are the attributes of individuals who build positive relationships with other members of the caring team. This can aid communications at all levels. Better communications help reduce risks for patients – and reduced risks mean better patient safety. Being a pleasant person is good medicine too.

If you want to acknowledge another STAR within our medical staff, pick up a nomination form in the Medical Affairs office (first floor, west wing) and in other locations throughout the hospital. You can also find a copy on the hospital’s intranet – go to CGHNet, find “Forms” in the drop-down menu and click on “Physician STAR Award.”

[1] All quotes are from the nominating forms submitted about the physicians by members of the CGH family.

Saturday, September 15, 2007

Hospital mortality rates

A wry pathologist once explained to me the reason for post mortem examinations. “Patients die,” he said, “for one of two reasons – patient failure or doctor failure. We ought to know which.”

Today we understand that many factors contribute to hospital outcomes. It is not just what a doctor orders or what a doctor does. Hospital outcomes are affected by the doctor working with the entire caring team, as well as by the effectiveness of hospital processes and support systems. Hospitals are complex places.

Last June the federal government's Hospital Compare website began reporting risk-adjusted 30-day mortality data for hospital heart patients.[1] The government’s report shows that 98.5% and 99.5% of all hospitals treating heart attacks and heart failure, respectively, had mortality rates that were consistent with the national rates.[2] Community General and the other Syracuse hospitals were all within the mortality rate mainstream of the nation’s hospitals.

The government’s website does not show hospital-specific mortality rates, and this lack of detail has been criticized by some. USA Today said that, by not listing hospital-specific death rates, the government’s web page “leaves 98% of the hospitals in the USA statistically indistinguishable from one another.” The newspaper also quoted a source at the Robert Wood Johnson Foundation as saying, “I would want to know if my hospital has higher death rates than the hospital across town.”

But others worry that mortality rates, even after statistical risk-adjustment, do not capture underlying differences that may be affected by patients’ own decision-making, particularly the end-of-life decisions made by the sickest patients. The authors of a recent article in the Journal of the American Medical Association (JAMA) suggest that the public reporting of hospital mortality rates might actually encourage the “overly aggressive treatment” of patients in their final weeks of life at the expense of effective pain control.

Several years ago, an insurance company published misleading mortality data about the pneumonia patients cared for at Community General Hospital. As reported, the pneumonia patients’ mortality was significantly higher at CGH than at other area hospitals. After investigation, we determined that the company did not take into account patients’ advance directives.[3] An examination of the records of the patients found that that 90% of the pneumonia patients who died had a DNR order.[4] In other words, most of the pneumonia deaths occurred among patients who had decided they did not want extraordinary measures used to prolong their lives. Of the non-DNR pneumonia patients cared for at CGH, the death rate was less than one percent. I discussed this situation in 2005.

Interestingly, JAMA reports that the federal government will likely add the mortality rates of pneumonia patients to its website in the future. According to the commentary in JAMA:
“Mortality is a good quality measure for individuals with acute illness who are not supposed to die…However, mortality is a poor quality measure for the majority of patients with multiple chronic diseases who are near the end of their life, and may be engaged in…decisions that result in an earlier (or less delayed) death.”
Hospital report cards are good things, and they will improve over time. As patients and families learn to use these report cards, they will become more informed about differences among hospitals – as well as about limitations of the report cards themselves.

[1] Risk-adjustment is a complex statistical process that takes into account differences in the complexity of patient conditions and differences in hospital service programs so that the mortality rates are, in fact, comparable among hospitals.
[2] The data reflect patients discharged from hospitals from October 2005 through September 2006.
[3] Advance directives are the written instructions patients give to doctors and hospitals that specify the care the patients want to receive (or don’t want to deceive) in the event they cannot make future medical decisions for themselves.
[4] DNR (“do not resuscitate”) is one form of advance directive.

Saturday, September 8, 2007

To the nursing shortage, add doctors

Most people are familiar with the nursing shortage. But there’s another health care story that deserves our attention – the growing shortage of doctors.

Retiring doctors often are unable to find replacements for themselves, especially when they are in solo practice. Sobering facts: 28% of New York’s doctors are in solo practice, and 34% of the state’s doctors are over age 55[1], meaning their retirement is in the foreseeable future.

Why do retiring doctors have a hard time finding younger physicians to replace them?

For one thing, finding a replacement doctor costs money (advertising, travel, and recruitment firm, not to mention the new doctor’s salary). Many practices operate on tight margins, and money spent on recruitment has to come directly out of the budget for staff salaries, including the doctor’s own.

New doctors often come into practice burdened with high debt from their medical schooling. They need a decent income quickly, and they cannot afford to wait, gradually building their patient base over several years as in the “good old days.”

Another concern, physicians need coverage. New physicians need to join a coverage group immediately – that is, a set of doctors who agree to cover the new doctor’s patients on a scheduled basis after office hours and on weekends. Every physician needs such coverage, and those who fail to get it cannot practice indefinitely with self-coverage. No one can work (or be on call) 24 hours a day, seven days a week.

Some parts of the country – those with booming economies or year-round pleasant weather – have advantages when recruiting doctors, just as they do when recruiting engineers or other professionals. Although Central New York's rolling hills, clear lakes, and four seasons are beautiful, its slow-growth economy does not add to its charm.

“At a time when the aging baby boomer population finds itself in need of more medical services,” reported the New York Times recently, “fewer young doctors want to work in many of the distressed cities and towns throughout New York State.”

Add to these complications, a doctor supply problem. In a recent Post-Standard op-ed article, Dr. David Smith, President of SUNY Upstate Medical University, wrote that “too many of the doctors now in training are not choosing the most needed specialties. Primary care physicians, general surgeons, and obstetricians are in high demand.”

And, according to the Wall Street Journal,

[p]rimary-care doctors, including internists, family physicians, and pediatricians are in short supply across the country. Their numbers dropped 6% relative to the general population from 2001 to 2005….The proportion of third-year internal medicine residents choosing to practice primary care fell to 20% in 2005, from 54% in 1998.
Why are fewer doctors going into primary care? Money. The median income of primary care doctors is about 45% below that of specialists, according to the Journal. Remember, doctors have to pay off those medical school loans, which can amount to hundreds of thousands of dollars.

Last year's report by the Center for Health Workforce Studies shows the supply of primary care doctors in Central New York at 64.4 per 100,000 population. That compares with 76.0 per 100,000, the median ratio among all regions of the state. The report also shows that CNY’s physician supply lags other regions in such specialties as pediatricians, neurologists, infectious disease, psychiatry, and others. Although CNY has 2.7 endocrinologists per 100,000 population (which is slightly better than the 2.2 median for all state regions), a recent story reported that several endocrinologists are leaving Syracuse.

If the nursing shortage is a major problem, the doctor shortage is not far behind.

[1] Armstrong DP and Forte GJ. Annual New York Physician Workforce Profile, 2006 Edition. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. December 2006.

Another 'not guilty' in New Orleans

The owners of a New Orleans nursing home, who were on trial for the negligent homicide of 35 nursing home residents in the aftermath of Hurricane Katrina, were found not guilty Friday (September 7) after a mere four hours of jury deliberation.

According to a report in the New York Times:
[The] theory of the hurricane’s destruction — that it resulted mostly from government ineptitude and inaction — is fervently adhered to by many in New Orleans, and apparently in the state’s interior as well, as evidenced by Friday’s swift verdict.
I wrote about this case on August 9.

Saturday, September 1, 2007

Labor Day

Labor Day has been celebrated since the 1880s. The first Labor Day parade was held by the Knights of Labor in New York City, and Congress made Labor Day a national holiday in 1894.

This Labor Day, September 3, Community General Hospital will be caring for patients. Many members of the CGH family will honor this holiday, as they do each year, by working.

Ours is not easy work. It is always exacting work. And what we do benefits society in the most fundamental ways: helping maintain and improve a patient’s function, bringing into the world new human life, easing another’s pain, caring for patients with dignity in their last hours or days.

Thank you, members of the CGH family, whose labor helps others every day... including Labor Day.