Saturday, January 30, 2010

'Best practices' . . . not always best

Dr. Jerome Groopman, whom I have mentioned before, has a fascinating article in the current New York Review of Books about the government's role in setting and requiring "best practices" in health care.

"Best practices" is in quotes because, as Dr. Groopman points out, such standards may not always be "best."

The government requires hospitals to adhere to its standards, and it reports on how well hospitals comply with them. Increasingly, Medicare, Medicaid, and non-government payers penalize hospitals with reduced or recouped payments for failing to comply with expert-defined best practices.

Yet, as Dr. Groopman writes: "[D]octors and other experts acting for the government and making use of research on comparative effectiveness. . . have repeatedly identified 'best practices,' only to have them shown to be ineffective or deleterious."

He ticks off a number of examples of "best practices" gone wrong, including:

- Medicare's tightly controlled blood sugar levels for intensive care patients "resulted in a higher likelihood of death."

- Medicare's recommendations for hip and knee replacements had "no effect" on complications.

- Federally-approved measures for congestive heart failure patients had "no major impact."

- Medicare's requirement for the speedy administration of antibiotics for pneumonia patients in emergency departments made things "worse."

Dr. Groopman even discusses a "best practice" that he helped develop that turned out to be in error. He also talks about common errors a researcher can make leading to a bogus "best practice."

This is not to say that research-based "best practices" are wrong. Adherence to such standards has improved hospital care, and I note Community General's success in such areas a low infection rates and low ventilator-acquired pneumonia.

It turns out, however, there is a difference between standards that are applicable in the same way for all patients (such as infection control practices) and standards as applied to an individual, given the complexity of the patient's illness (such a blood sugar management).

"[O]nce we depart from. . . mechanical procedures and impose a single 'best practice' on a complex malady," according to Dr. Groopman, "our treatment is too often inadequate."

Sunday, January 24, 2010

Dr. Joe Smith & the Center for Orthopedics

There were many poignant moments at Thursday's ribbon cutting for the new Center for Orthopedics as dignitaries recognized the work of Dr. Joseph Smith, a retired member of the medical staff who was severely injured in an accident in 2008.

Dr. Smith served as chairman of the orthopedics department at Community General Hospital for many years. He helped lay the foundation for the service that was recognized last week for its high quality.
That's Dr. Smith in the operating room photo, taken about 2004. He is second from the left.

Praise for Dr. Smith began with Board chair Steve Infanti, who was at the podium to receive awards recognizing the quality of Community's orthopedics program.

The first award was presented by Dr. Marybeth McCall, regional chief medical officer for Excellus BlueCross BlueShield. Excellus' BlueDistinction designation recognizes the quality of Community's spine surgery, as well as its hip and knee replacement surgery.

Allison Leavey of HealthGrades presented Steve with the overall orthopedics excellence award, earned by Community for the fourth straight year. Ms. Leavey also acknowledged HealthGrades' honors for Community's spine surgery, hip and knee replacements, and hip fracture repair.

In accepting the awards, Steve paid tribute to Dr. Smith for the quality of orthopedics, as well as for the growth of the orthopedics service.

Dr. Rick Zogby, chair of orthopedics, in the photo at left, followed Steve with his own spontaneous and heartfelt tribute to his colleague and friend, Dr. Smith.

This was echoed by another speaker, State Senator John DeFrancisco, in the photo below, who told the audience of his lifelong friendship with Dr. Smith. The Senator and the doctor were students together at Christian Brothers Academy years ago.

Following the ribbon cutting by Chief Nursing Officer Christine Stryker, orthopedic nurse manager Wendy Osgood, and area dignitaries, guests and colleagues toured the 25,000 square-foot Center for Orthopedics, which features 36 private rooms and a spacious gym overlooking downtown Syracuse and Onondaga Lake.

The Center features many improvements, among them:

- A silent nurse call system to reduce noise for patients.

- Decentralized nursing stations so professional staff is close to patients.

- Ergonomic flooring for the nurses who spend so much time on their feet.

- A physical therapy gym to help patients recover faster and more comfortably.

- Wi-fi Internet access for all patients.

- Tempur-Pedic mattresses on beds that can help prevent falls and even weigh patients.

- PVC-free wall covering and vinyl-free flooring.

- LED down lights and other features to conserve power.

- Plumbing that reduces water consumption.

The Center for Orthopedics was funded by $7.6 million from a grant awarded under New York State's Healthcare Efficiency and Affordability Law (HEAL). The HEAL grant was given to Community for its compliance with the decisions of the Commission on Healthcare Facilities for the 21st Century ("Berger Commission").

My thanks, especially to Ken Redmore, Community's Director of Facilities and Construction, who managed the project from start to finish, through design, bidding, build-out, including all state approvals and coordination. He brought the project to completion on time and within budget.

There were many colleagues and friends at the opening ceremonies, and I appreciated the presence, among them, of Dr. Paul Kronenberg, president and CEO of Crouse Hospital -- Community General's prospective merger partner.

As lovely as the new Center is, we all know that facilities alone do not assure excellence. Only people do that. Community's orthopedics service relies upon its excellent people: from the orthopedic surgeons, to the operating room and nursing staff, as supported by physical therapists, other ancillary staff, and the entire support team.

It is great to see our staff recognized and our patients the beneficiaries of an excellent facility. They begin to use the new Center this week.

Sunday, January 17, 2010

Our fraying social contract

During his two years as medical staff president, Dr. Dave Halleran used the word “collegiality” in most meetings. "Collegiality,” in his lexicon, reflects a social contract between hospitals and their medical staffs. In recent years, that social contract has been in need of mending.

“Collegiality” refers to that combination of obligation and respect that exists among doctors within their medical groups, within their specialties, and among the departments at the hospitals where they have privileges. That combination is meant to serve patients well, supporting the availability of care as well as care that reflects experience, judgment and skill.

Today it is not uncommon for one or more hospitals in a given community to have gaps in specialty on-call schedules at their emergency rooms. There are not enough available (or willing) physicians to complete the roster. Nor is it unheard of for one specialist to assert it is really another specialist’s duty to respond to a patient’s specific need in this or that hospital at this or that time of the day. On-line educational credits have replaced in-hospital educational meetings for many physicians, and hospital department meetings are both less frequent and less well attended than they were, even ten years ago.

These are examples of a fraying social contract.

The acute care hospital used to be a more essential part of – indeed, the center of – a physician’s professional life. The hospital provided the 24-hour staff and services, the high-tech equipment, and the array of specialists a doctor needed to care for her patients. Today many physicians focus so much of their time in outpatient settings they may never come to the hospital, or rarely so.


Because the things for which patients used to be hospitalized can often be accomplished in the office or in an outpatient setting. Government-driven payment models have tended to reward outpatient and procedure-based care, more so than hospital care. Reductions in payments have encouraged doctors to form larger medical groups, and these groups have developed both the patient base and the capital base to provide outpatient services that were once a big part of the hospital world.

All this means that private doctors are less able – and less willing – to come to hospitals in the middle of the night to take care of an emergency patient they may have never met before. This may be a point of annoyance among medical specialists who may not know each other or, even if they do, whose collegiality may be tested since they haven't seen much of one another for some period of time.

At the medical staff meeting last week, Dr. Halleran, a colon-rectal surgeon, stepped down as staff president and handed the gavel to Dr. Richard Lockwood, a specialist in internal medicine. In his farewell remarks, Dr. Halleran recalled a time “when doctors used to talk about patient care with each other. Today our discussions,” he lamented, “seem to be more about insurance payments or government rules.”

During the meeting, Dr. Halleran paid tribute to his father, once an internist in midtown Manhattan, whom he affectionately called “a real doctor.” He explained that his father “had office hours five and one-half days a week, went to the hospital seven days a week, and still managed to visit patients regularly in their homes.”

Dr. Halleran served as a medical staff president before. About a decade ago, he performed that service for another medical staff where he is a member in good standing, at St. Joseph’s Hospital Health Center. That means Dr. Halleran has demonstrated his medical staff “good citizenship” twice.

You don’t get elected staff president two times and at two different hospitals, unless you are someone special.

Dr. Halleran is.

Two facts about a STAR doctor

At Dr. Halleran’s final meeting as medical staff president, Dr. Fred Goldberg, chief medical officer, recognized him with the STAR award for demonstrating the qualities of “Sensitivity, Thoughtfulness, Appreciation, and Respect”

A number of people nominated Dr. Halleran for the honor, and here is some of what they said:

▪ “It is not uncommon for Dr. Halleran to discuss sensitive issues with nurses and ask their input regarding patient care.”

▪ He “[w]ill support and intervene with difficult situations and patients.”

▪ “He is respectful to us as staff and always trying to make this a better place for all of us.”

▪ “He reminds me of the country doctor going door to door making house calls. More importantly, I believe he reminds all of us of what it means to truly ‘care’ for patients and each other. We are so fortunate to have him here at Community General Hospital and in our lives.”

Congratulations, Dr. Halleran. It has been a privilege to work with you in your leadership role.

Here are two facts about Dr. Halleran that may not be widely known:

▪ In October 2008 he was named one of the best doctors in Central New York by CNY Magazine.

On December 8 1980, Dr. Halleran was a surgical resident at Roosevelt Hospital in mid-town Manhattan, when the police brought in a victim of four gunshots. As he cared for the patient, someone looked through the patient's wallet for identification. The driver's license read: John Lennon.

Saturday, January 9, 2010

Collaborations in season

This week the Greater Syracuse Chamber of Commerce (I am on its board of directors) and the Metropolitan Development Association (Community General Hospital is an MDA member) announced their merger “to build the most effective organization to promote business in Central New York.”

The Chamber and the MDA have worked on the merger for some months, following authorization by their boards to study and plan the process. The combined organization will be the largest economic development entity in Upstate New York.

A lot of credit for this goes to Darlene Kerr, Chamber president, and to Robert Simpson, MDA president. Months ago they put aside parochial interests to launch the affiliation discussions. Merger planning was by an 11-member committee under the leadership of former Syracuse University Chancellor Kenneth Shaw, MDA board chair, and Mary Ann Tyszko, president of SRC Tec, Inc., who chairs the Chamber board.

This initiative of the Chamber and MDA is a model of civic-minded, community planning.

llaborations, it seems, are in season.

As the Chamber board reviewed the merger plan last week, I looked across the table at fellow Chamber board member Dr. Paul Kronenberg, president of Crouse Hospital. Crouse Hospital, of course, is the prospective merger partner of Community General Hospital, as we announced last fall.

As of year-end, Dr. Kronenberg and I were able to report
that the hospital boards had approved a memorandum of understanding that permits us to hire legal counsel, along with experts in hospital merger planning. We have started the planning process that will put flesh on the bones of our merger concept. Crouse and Community have jointly hired Nixon Peabody LLC as transaction counsel and Alvarez and Marsal as feasibility consultants. I sent a memo about this to members of the CGH family.

With the announcement by the Chamber and MDA, the Post-Standard is already discussing the potential for consolidating economic development programs operated by the City of Syracuse and the County of Onondaga.

More than a decade ago, I chaired a consolidation committee for the Private Industry Council that resulted in the formation of CNY Works, an organization that combines and coordinates services to train and assist job seekers that were once operated separately by city and county governments. Many of us hoped that CNY Works would point the way to other combinations of government functions in the interests of efficiency and effectiveness. . . but such combinations have been painfully slow to develop.

The Chamber and the MDA are coming together. Crouse and Community are planning a merger. Is it too much to hope these examples might help inspire new interest in consolidating the functions of local governments?

A note about the blog

I am sorry about my blog activity (or lack thereof) these last several weeks. There have been technical problems, and I have been distracted by my holiday schedule and occupied by work on merger planning. Stay tuned. . .