Measuring care at the end-of-life

To the growing list of hospital report cards, add ConsumerReports, which today released its hospital ratings, based on research into end-of-life care from the Dartmouth Medical School.

ConsumerReports has rated hospitals as relatively more aggressive or more conservative in providing care for elderly persons during the last two years of their lives, a time when patients typically have multiple hospital admissions.

This report card suggests that more aggressive care is not always better, according to today's report in The Post-Standard. Dr. David Goodman, a co-author of the Dartmouth Atlas of Health Care, is quoted in today's New York Times:

The general principle is that greater intensity of care is not better, and at the high end can actually be harmful.

ConsumerReports measures how aggressive hospitals are when treating congestive heart failure, lung disease, cancer, dementia, heart disease, kidney failure, circulatory disease, diabetes and liver disease.

At 37% Community General is ranked as being more conservative than the other Syracuse hospitals in the care of elderly patients during their final years of life.

The charts in this morning's Post-Standard are not available on-line, so I created the accompanying graph from the newspaper data to show the relative differences among Syracuse hospitals. Higher percentages mean "more aggressive care in the final two years of life for persons over age 65."

If you'd like to see the ratings of the Syracuse area hospitals, go directly to this link: ConsumerReports.

For comparison purposes, I checked the ConsumerReports site to see how the Mayo Clinic's hospitals were rated. There are two Mayo hospitals in Rochester, MN, and here are their scores:

- Rochester Methodist Hospital, 42%

- St. Mary's Hospital, 28%

This Memorial Day

Memorial Day reportedly has its roots in 1863, when the Civil War was being fought.

Women in Columbus, Mississippi, decorated with flowers the graves of Confederate war solders, then showed the same respect to the nearby graves of Union soldiers.

In 1866, following the War, a drugstore owner in Waterloo, NY, closed his store on May 30 as a sign of respect for the war dead, and the tradition of Decoration Day ( later Memorial Day) began. Waterloo is about 50 miles west of Syracuse.

By 1882 Memorial Day was observed for the first time as a national day of remembrance for those who died in the nation’s wars.

Today we pay our respects to all who have died representing our nation.

Our low infection rate

It was great to see Community General Hospital's hard work on reducing infections reported in this morning's Post Standard.

The news story was based on data released today in the New York State Hospital Report Card by the Niagara Health Quality Coalition.

The report included a graph (not available in the newspaper's on-line version), comparing infection rates for intravenous lines and catheters among area hospitals, based on 2006 data. The graph showed the infection rates as percentages.

I think it's difficult to appreciate such differences when small numbers are displayed in a percentage format. How significant is the gap between the highest infection rate (0.686%) and the lowest rate (0.090%)? To me, it's not immediately apparent.

So I changed the newspaper's display to show infection rates for every thousand patients who were discharged from local hospitals (see the graph, above). This makes the difference readily understandable. Specifically, the highest infection rate was 6.86 infections per 1,000. The lowest, 0.90 infections per 1,000.

The difference between the highest and the lowest infection rates was 5.96 patients among every one thousand patients treated at the hospitals.

I'm proud of what Community General Hospital has accomplished in keeping our infection rate below the state average (2.21 per 1,000) and below the rates of other local hospitals.

Congratulations to the doctors, nurses, clinical and support staff for their conscientious efforts in controlling infections! And a special hats off to Mitchell Brodey, MD, infectious disease specialist, and to Sue Chamberlain, RN and her infection control staff.

Congratulations, Ed and Marian

Congratulations to Drs. Marian and Ed Schoenheit, who were honored last evening at the Memory Makers gala of the Alzheimer’s Association of Central New York. The Schoenheits have been active in the Association for ten years, following Ed’s diagnosis with Alzheimer’s disease.

Marian Schoenheit, EdD, is a Board member of Community General Hospital, and Ed Schoenheit, MD, is a past president of its medical staff.

Prior to her retirement, Marian served as Associate Dean of Professional Studies at SUNY Oswego, Director of Elementary Education for the Liverpool Central School District, and as a principal in the West Genesee Central School District. She is a past Board member of the Onondaga County Public Libraries and United Way of Central New York, Board Chair of Skaneateles Savings Bank and past President of the local Pres-Ex Forum and United Cerebral Palsy Association.

Ed, an internist, practiced at Community until the mid 1980's, when he retired from medicine to study law. He is a graduate of Harvard Medical School and Syracuse University College of Law. Ed is a past medical director of Oswego Hospital and A. L. Lee Memorial Hospital in Fulton, NY, and he is a member of Syracuse’s Century Club and a past member of the Syracuse Home Association.

What the brief bio's don't say is what smart and humble and able people they are. It is a privilege to know the Schoenheits. Congratulations to a wonderful couple...wonderful citizens of our community.

One never forgets a kindness

About 25 years ago, George Wortley took my ten-year old son’s hands and placed them on the podium that stands in the well of the House of Representatives.

“You are standing,” he said, “in the exact spot where every President since Woodrow Wilson has stood to address Congress.” He then proceeded to name each President in sequence, concluding with Ronald Reagan who was then in office.

Mr. Wortley was the Congressman representing the Syracuse area from 1981 to 1989. In the early 80’s my older son and I visited him one day while we were in Washington, DC during the spring school break. Without an appointment we stopped at his office at noontime. When I introduced Mr. Wortley to my son, he eagerly said, “Let’s me show you the House,” then led us across the street for a cook’s tour of the House of Representatives.

Mr. Wortley handed my son his electronic voting card and asked him to swipe it, just as he did for Congressional votes. He showed him a table used by the Whips that still had bullet marks from a terrorist attack on the House in 1954. He took us to a room off the floor where Members of Congress used to smoke cigars and stay abreast of breaking news from teletype machines. He escorted my son to the Capitol rotunda and demonstrated how clearly one can hear a mere whisper.

I knew Mr. Wortley before his election to the House of Representatives. As a Syracuse businessman, he worked with me on projects for Community General Hospital and for my previous employers. I had not been politically active, nor was I a campaign contributor. I was just a constituent to whom he showed kindness when my son and I stopped to say, “Hello.” Mr. Wortley's enthusiasm for the Congress and for US history was contagious.

Mr. Wortley was kind to my younger son, as well. He provided a reference letter to the adoption agency when my wife and I were in the process of adopting our younger son, who is foreign-born. Later, after our son arrived in the US, Mr. Wortley sent him a touching personal letter of welcome.

I haven’t seen Mr. Wortley in many years. Since he left the Congress, he has worked in Washington, DC, and he lives in Florida. He recently co-chaired a fund drive for the lone sailor project in Fort Lauderdale (see the photo).

I keep tabs on Mr. Wortley through his brother, Ed Wortley, whom just about everyone at Community knows as the employee pharmacist. Ed tells me that George keeps tabs on Community too, occasionally reading my blog postings.

The kindness and enthusiasm of George Wortley came to mind when Ed and I visited for a few minutes on our way out of work yesterday. It prompted me to share these fond memories of our former Congressman.

One never forgets a kindness – it lasts forever.

Thank you, employees!

Turnabout is fair play

Every few months, it seems, there’s a story about the quality of care at one or more local hospitals, based on the report of one or another watchdog organization.

Two recent Post-Standard stories come to mind. One story was about death rates associated with open-heart surgery, and it was based on statistics from the New York State Department of Health. Another story concerned the federal government’s new reporting on hospital patient satisfaction, about which I commented.

Who are these quality watchdogs? Besides the state and federal government, some are non-profit organizations, such as Leapfrog or the Niagara Coalition for Quality Care. They may be for-profit companies, such as HealthGrades (which licenses its endorsements to hospitals and sells its data directly to the public). Health insurance companies also purport to report on the quality of physicians and hospitals.

How good are the reports from these watchdog groups? That is the question that the Healthcare Association of New York State (HANYS) has started to answer.

Last year the HANYS’ Quality Institute (in which I participated) reported that

…hospital quality “report cards”… have not yet fully lived up to their promise of informing consumers and helping providers improve care. Problems with the accuracy, clarity, timeliness, and comparability of quality measures persist….Hospital quality reports contain useful information, but the reports are different in the way they examine quality data, and are at times contradictory.

Now, believing that turnabout is fair play, HANYS has published its own ratings of the watchdogs' report cards. HANYS scores the watchdogs based on specific criteria. For example, does the organization disclose the methodology it uses? Is its methodology able to be verified by third parties? Does the organization use statistical methods to adjust for significant differences in illness severity for patients at different hospitals?

Based on its criteria, HANYS ranks eight publicly available hospital report cards from A to D with A as the best rating.

The Centers for Medicaid and Medicare Services , A
The New York State Department of Health, A
The Joint Commission, B
The Leapfrog Group, C
The Niagara Health Quality Coalition on Hospital Quality, C
HealthGrades, D
Solucient, D
U.S. News and World Report, D

HANYS calls its report-card-on-report-cards “a first step toward providing consistent and understandable comparative information about hospital quality.”

Public reporting of hospital data for comparison purposes is a good idea. I support it. But it’s a confusing picture out there, as I have discussed elsewhere,[1] and HANYS has made an important contribution to help consumers better understand exactly what is involved in the public reports they may read about or consult.

[1] See my previous postings: Of quality and board oversight, Hospital mortality rates, and Mortality & hospital report cards.

Green acres

On Earth Day, April 22, twenty-five Community General Hospital employees showed their appreciation of our 42-acres of the planet.

Earth Day is about preserving and protecting the environment, and the Community people did just that. They used part of a beautiful spring afternoon to clean our campus of debris from the past year.

With temperatures near 80 degrees, the team filled some 30 large trash bags with junk. Everything from an air conditioning compressor to old car tires were found, collected and properly disposed of. (Yes, there are obvious questions: who dumps such stuff on our campus and why?)

To spark enthusiasm, there were two medallions hidden on the grounds, entitling the finders to “food-and-a-flick.”

This was our second annual Earth Day celebration to keep the campus green. It is great to see this event becoming part of the Community General tradition.

Here are the names of those who helped (and if you look carefully, you can find most of them in the photo): Jim Aiello, Michelle Berkey, Mike Brown, John Carnowski, Ann Coniski, Kristin Dombroske, Mary Gazarra, Pam Johnson, Kathy Kendrick, Deb Kurtz, Mellissa Martin, Jim O'Brien, Gillian Ottman, Judy Piedmonte, Lynnette Pittinger, Sally Ramsden, Ken Redmore, Linda Rizzo, Joan Russell, Dave Salati, Cecilia Sansone, Nancy Thompson, Tracey Van Dyke, Pauline Warboy, John Zacharek.

My thanks to all who participated in keeping the earth – and Community – beautiful!

Not me

Several people have asked if the Post-Standard made the mistake last week in its story A health report card, about the HCAHPS survey results. The newspaper attributed Tom Quinn’s comments to the marketing director at Cortland Regional Health Center.

The answer is no, the newspaper did not make a mistake. There is another Tom Quinn, and he works in Cortland, NY.

There are many namesakes, and if you Google “Tom Quinn,” you find pages and pages of us. Tom Quinn, the astronomer. Tom Quinn, the fictional case officer in Britain’s MI5. Tom Quinn, author. Criminal defense lawyer. Film actor.

As a 14-year old, I attended a junior seminary in Pennsylvania. One day after class, I discovered that my name was crudely scratched in a corner of a blackboard. I pointed this out to the priest who taught us Latin. “I didn’t do that,” I sheepishly explained. “I know,” he said with a big grin. “It’s been there for years. Today that Tom Quinn is probably in jail.”

More than medicine

For the first time the federal government is reporting how well hospitals satisfy the patients they care for. These are statistics hospitals have looked at internally, but they’ve never been publicly compared before.

Among Syracuse hospitals, the patients at St. Joseph’s Hospital Health Center gave it somewhat higher satisfaction scores. My congratulations to CEO Ted Pasinski & the staff at St. Joe's. Community General Hospital's patient satisfaction is the next best locally, as reported by the federal Centers for Medicare & Medicaid Services (CMS).

Since last year, all hospitals have been required to submit to CMS the results of their patient satisfaction surveys using a standard methodology called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, pronounced “H-caps”). Hospitals that fail to submit such data will have their Medicare payments reduced by two percent – so there is an incentive to comply.

Although the HCAHPS scores were posted only recently, the federal government has been developing its patient satisfaction methodology for years. As a matter of fact, Community was one of 132 hospitals nationwide that helped pilot a version of the HCAHPS survey in 2003.

Last month the HCAHPS scores were posted on the CMS website. In the list below are the patients’ scores for Syracuse hospitals for the first five of ten HCAHPS questions. These data are for patients surveyed during the period October 2006 - June 2007.

Nurses always communicate well
Community - 72%
Crouse - 66%
St. Joseph's - 77%
University - 68%

Doctors always communicate well
Community - 78%
Crouse - 73%
St. Joseph's - 77%
University - 73%

Patients always received help as soon as they wanted
Community - 60%
Crouse - 48%
St. Joseph's - 64%
University - 49%

Pain was always well controlled
Community - 65%
Crouse - 61%
St. Joseph's - 68%
University - 63%

Staff always explained about medicine before giving it to patients
Community - 54%
Crouse - 51%
St. Joseph's - 53%
University - 52%

Notice that the government reports the percentage of responses from patients who said they were “always” satisfied with respect to the specific question.

“Always” is a demanding standard. “Always” means a hospital did not fail to meet the patient’s expectations even a single time during the course of a hospital stay. To give this perspective, would your spouse say that he or she is “always” satisfied with the way you manage the finances, discipline the kids, or maintain the lawn? Would your co-workers or your supervisor report they are “always” satisfied with your performance on the job?

HCAHPS scores do not address the underlying issues of quality care, only its social aspects. But hospital care is a mix of clinical processes and interpersonal communications. Hospital care is "more than medicine." I have written before about the importance of two-way communication and the personal touch. [1]

Patients expect hospital quality to be first rate. They expect us to provide the right care to the right patient on time and as promised. They do not expect errors or omissions. Quality care is baseline. It’s what they need us for. But care that is delivered respectfully and with a personal touch is always recognized, always welcomed, and always appreciated.

That is why we acknowledge members of our staff who are especially kind, helpful, and responsive. Our STAR award honors physicians who demonstrate “sensitivity, thoughtfulness, appreciation and respect,” and our WOW award recognizes employees who make “an extra effort” to assure a patient’s needs have been met, even exceeded.

CMS will update the patient scores on its website each quarter. We as an industry – and we as an individual hospital – have more to do to improve the percentage of patients who say we “always” meet their needs.


[1] See these postings on the “More than Medicine” blog: The importance of listening , Stop me if I say something you don’t understand, and Whatever became of bedside manner