Author Archive for wmills

William F. Mills, M.D., MMM, CPE, FAAFP, CMSL, is currently the senior vice president of quality and professional affairs for the Upper Allegheny Health System located in western NY. Mills is a graduate of Hahnemann University School of Medicine and completed his family practice residency at the West Jersey Health System. He is certified by the American Board of Family Medicine, and a fellow in the American Academy of Family Physicians. Mills is currently a clinical assistant professor at the School of Medicine, State University of New York at Buffalo. He is also certified in addiction medicine through the American Society of Addiction Medicine, and currently serves as a medical review officer. Prior to transitioning to full-time administrative medicine, Mills spent more than 20 years as a practicing family physician, and more than 10 years as the medical director of a residential drug and alcohol treatment facility. He also holds a Master of Medical Management degree from the Marshall School of Business, University of Southern California and is a Certified Physician Executive from the Certifying Commission in Medical Management.

Readmission reduction – one more time

Two recent articles in The Journal of the American Medical Association (Jan. 23/30 issue) address the issue of readmissions to hospitals within 30 days of discharge. This is a huge issue as “pay for value” initiatives will be dinging hospitals financially, not to mention the public flogging hospitals will receive with these publicly reportable measures. To be fair, CMS is aware that 20% of patients discharged are readmitted within 30 days, and that is an incredible amount of money that the healthcare system is paying. One of the flaws, as pointed out in the articles, is that readmissions aren’t necessarily the “fault” of the hospital. Hey, but it is easy to punish the hospital; the regulators have been doing that for quite some time.

One of the articles demonstrates that the vast majority of readmissions are for reasons unrelated to the prior hospital stays. Duh! Isn’t this what physicians have been saying for years? Healthcare providers have long known there is a long list of factors contributing to readmissions, including but not limited to: lack of follow up care, patient non-compliance, access to care, cost of medications, cultural and social factors, information transmission, patient understanding of instructions, transitions of care, and, by the way – people who are hospitalized tend to have bodies that are not working at an optimal level.

So what should we do? Isn’t this what healthcare reform and patient-centered medical homes are trying to fix? It sure is! But are there things we can do now? The article does list nine strategies for physicians to try to decrease readmissions by improving the level of care. For that, I commend them. This is their list, but I bet you could add more.

Keep organized information on patients’ medical issues, health goals, functional and psychological status, and behavioral and social issues.
Consider patients’ acute, intermediate and long-term care goals.
Be explicit with patients about social, economic, cultural and other factors that may impede their care.
Use reader-friendly tools such as checklists and “red flag” lists to help patients and caregivers with self-management tasks.
Use motivational interviewing and teach-to-goal methods to support self-care.
Use pharmacy, patient and hospital discharge lists to ensure a fully reconciled and accurate medication list after discharge.
Reinforce medication changes made in the hospital with patients, as appropriate.
Use “pill cards” to help patients track drug changes.
Allocate time to address care coordination tasks, using templates and checklists for specific tasks.

March 01, 2013 | wmills | Comments 0

Nurse to patient ratios: The key to Quality! Really?

A recent article in the Washington Post titled “D.C. Council chairman to propose bill boosting nursing staffs at hospitals” brings up again the issue of nurse-to-patient ratios. D.C. Council Chairman Phil Mendelson is quoted as saying “I think this bill is today’s version of the eight-hour day — something that we will see business resist but, on the other hand, makes good sense and leads to quality care.”

Wouldn’t it be nice if nurse-to-patient ratios were the key to quality care? The proposed bill includes some ratios, such as intensive care unit patients should have one nurse to every two patients. That sounds good, but some patients require one-on-one nursing due to their complexity, so is the mandate that those patients can’t have one-on-one nursing? Might there be patients in the intensive care units for whom one to three is appropriate? In my experience that answer is absolutely yes!

As far back as when I was in medical school, and that’s a long time ago, when nurses (or physicians) were busy, there was always an outcry for more help. But when things were not as busy, you rarely heard “We have too much help.” The difference is that most folks of my generation went into healthcare to help people. So if more people needed help, we stayed late, came in early, vented our frustrations to each other (not to the media) and just did our jobs. Certainly some places have unsafe ratios and that needs to be addressed – but not with legislation.

Who is in the best position to determine how to care for patients: health care providers or legislators? Should we in healthcare not be the ones to fix this? I for one don’t want to be the person who can’t be admitted to the hospital when sick because I would cause the nurse to have one too many patients. Quality is multi-factorial, and I object when non-clinicians use the word quality as a hot button to stir up the public. I wholeheartedly agree that staffing should be safe, but as with many things in life, there is not a bright line here, but a gray zone. Thoughts?

February 13, 2013 | wmills | Comments 0

Healthcare workers and flu vaccination

At last count, 47 states were having “flu emergencies,” with a marked increase of reported influenza cases compared to recent years. So it’s time for me to share one of my pet peeves again: influenza immunizations for healthcare workers.

This came back into the public arena again earlier this month when ABC News ran a story about eight employees who were fired from an Indiana hospital because they refused this year’s flu shot. A former president of the National Foundation for Infectious Diseases was reportedly quoted as saying “I cannot think of a reason for any health care professional to decline influenza immunization that’s valid.” A bit of a strong statement, but one I wholeheartedly agree with!

I feel that it is unconscionable for healthcare workers to put the at-risk population we care for in jeopardy of acquiring a potentially life threatening illness due to our “right” to refuse immunization. That said, what about religious convictions? What about our right to decide what is “best” for us?

Who is responsible if a significant adverse reaction occurs to a healthcare worker that was “forced” to be immunized? I believe the benefits of yearly influenza immunization far outweigh the risks. Many of our employees who declined the vaccine earlier this year have now decided to get it. I wonder what that means about their initial reasons for refusal. What do you think?

February 05, 2013 | wmills | Comments 1

New York State – the place to get really sick?

Is New York State the best place to be if you become septic? Isn’t this the state that brought a bill to the assembly in 2011 that threatened to make “reckless infection of a patient with a communicable disease by a health care provider” a felony? Now, the governor has mandated that all New York hospitals develop aggressive procedures for identifying sepsis. Didn’t the “Surviving Sepsis Campaign” start in 2002? So – better late than never, New York.

But wait – why is a state governor mandating this? Shouldn’t something like this come from the medical folks and not the government? Could it be that N.Y. hospitals aren’t doing such a great job at diagnosing and managing sepsis? As a physician I am embarrassed that the government needs to tell us that this is an issue. I’m proud to say my hospitals have been following the sepsis guidelines for years, but I guess some hospitals haven’t.

Shouldn’t this evidence-based medicine approach to diagnosing and treating sepsis be a quality factor monitored by physicians, nurses, quality personnel, and medical staff professionals? Should we be waiting for the government to tell us what the right thing to do for our patients is? Should our hospitals’ credentialing and privileging process be more attuned to matters of life and death than to the number of discharge summaries not dictated in a “timely” fashion? What do you think?

January 29, 2013 | wmills | Comments 0

Patient Satisfaction Blog Series for CRC 2012

Easier? It can make my job easier?

You are now experts at improving the three physician-specific questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey:

During this hospital stay, how often did doctors treat you with courtesy and respect?
During this hospital stay, how often did doctors listen carefully to you?
During this hospital stay, how often did doctors explain things in a way you could understand?

I mentioned last week that this would make your job easier. How can that be? The following are some of the benefits that come from having satisfied patients:

Fulfills patient priorities and wants
Improves professional standing
Improves compliance with recommended treatments and follow up
Reduces liability risks and costs
Improves staff retention and satisfaction
Improves physician satisfaction
Reduces unnecessary calls, returns to the ED, and professional aggravation
Improves clinical outcomes and measures

There are other benefits as well. If you think back, you can probably find an example for each of the above from your own journey in the medical profession (as either a patient or provider). Happiness (satisfaction) is contagious!

Hopefully this series has whetted your appetite to do further reading, research, and reflection on improving patient satisfaction. Although “because the government says so” may be adequate motivation for some, the real motivation should come from our desire to provide the best patient care possible. After all, isn’t that what we are all about?

Editor’s note: William Mills, MD, MD, MMM, CPE, FACPE, CMSL, FAAFP, is a featured speaker at the 15^th annual Credentialing Resource Center Symposium, May 10-11. He will be speaking on using patient satisfaction scores to drive improvement as well as how to privilege low- and no-volume practitioners. For more information, click here.

March 02, 2012 | wmills | Comments 0

Patient Satisfaction Blog Series for CRC 2012

Blah, Blah, Blah?

As I mentioned in my last post, there are three physician-specific questions on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey:

During this hospital stay, how often did doctors treat you with courtesy and respect?
During this hospital stay, how often did doctors listen carefully to you?
During this hospital stay, how often did doctors explain things in a way you could understand?

This post will deal with tips to improve your scores on the explanation question. By now, I’m sure you would make Emily Post proud of how polite you are. (For those much younger than I, she was the queen of etiquette.) I also expect you have made some brilliant diagnoses as a result of your improved listening skills. Now it is time to focus on how you explain things to patients and increase those scores at the same time. Your patient shouldn’t feel like Charlie Brown talking to his parents and just hear “blah, blah, blah,” when you are explaining important health related issues.

Patients (those are the horizontal people in hospitals) are often not at their intellectual peak while hospitalized. Remember this is our workplace—not theirs—so we need to be a little more diligent when explaining complex, emotionally charged issues. Here are a few pointers that will help you with your ability to explain what’s going on in a way that the patient may understand:

Provide more information than you believe is necessary
Provide the option of having another person in the room to hear the information, take notes, and ask questions
Encourage patients to write down their questions in between visits. This allows them the opportunity to think about the previous interactions and formulate questions that specifically address their fears and concerns
Ask patients if they need any more information

Remember that we often get caught up in our jargon and patients “appear” to understand as they don’t want to disappoint their physician or appear not so bright. Ask follow-up questions that probe their understanding. You may be surprised by how much your patient did not understand once you start asking them these questions.

So go forth and improve the satisfaction of those we serve, while simultaneously improving quality, publicly reported measures and making your job easier. I couldn’t resist. This will make your job easier. Read next week’s post to see how.

February 23, 2012 | wmills | Comments 0

Patient Satisfaction Blog Series for CRC 2012

I’m Sorry, What Did You Say?

As I mentioned in my last post, there are three physician-specific questions on the Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS survey. They are:

During this hospital stay, how often did doctors treat you with courtesy and respect?
During this hospital stay, how often did doctors listen carefully to you?
During this hospital stay, how often did doctors explain things in a way you could understand?

This post will deal with tips to improve your scores on the listening question. Hopefully you have tried to be a little more respectful (as discussed in my last post) and have found it rewarding. So let’s improve your listening skills now.

You have probably figured out this is a perception issue, and you are correct. The following tips have been shown to improve the patient’s perception that you are listening:

Sit down during the conversation portion of the visit
Ask open-ended questions and listen with empathy
Use “reflective” listening (paraphrase, clarify, ask for understanding)
Offer a physical gesture, such as a handshake, a touch on the shoulder, or a pat on the knee
Make eye contact with the patient and family
Pay attention to the patient and not the chart or cell phone

Although these tips improve the perception that you are listening, you actually do need to listen carefully. Remember back to medical school when the wise attending said that the patient will tell you what is wrong with them if you will only listen? My experience is that they were right. How about your experience?

February 16, 2012 | wmills | Comments 0

Patient Satisfaction Blog Series for CRC 2012

Courtesy and Respect? Don’t have to; I’m the Physician!

As I mentioned in my last post, there are three physician-specific questions on the Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS survey:

During this hospital stay, how often did doctors treat you with courtesy and respect?
During this hospital stay, how often did doctors listen carefully to you?
During this hospital stay, how often did doctors explain things in a way you could understand?

This post will deal with tips to improve your scores on the courtesy and respect question. Hopefully you have bought into the concept that improving patient satisfaction improves quality. If you haven’t yet, then try these suggestions and see what happens.

Since approximately 85% of communication is non-verbal, pay particular attention to your body language. We have all been in situations where the body language was so loud, that the spoken words could not be “heard.” Clear your mind prior to beginning the encounter.

Brush up on your polite behaviors such as:

Knocking on the door before entering
Making eye contact with the patient and visitors
Introducing yourself and the members of your team
Addressing the patient by their preferred name

Do not discuss the patient in the third person when they are present. They are not just the “gallbladder in room 203” but actually a person, too.

These are just a few of the proven methods to improve patient satisfaction and your score on this question. Try these out this week; next week I’ll be sharing about listening skills.

February 07, 2012 | wmills | Comments 0

Patient Satisfaction Blog Series for CRC 2012

Pat Sat/HCAHPS/P4P – Huh?

This is the first of a series of five postings that will attempt to make sense of some the above. Patient satisfaction has risen to the top of many a list as the government and other payers are establishing pay for performance (P4P) initiatives. One of the reasons everyone is working on this is there is a clear connection between patient satisfaction and quality. Check out the New England Journal of Medicine for more information on this (2008; 359:1921-1931).

Because patients, payers, and politicians now care about patient satisfaction, the next three posts will provide tips for improving scores on the three physician specific questions on the HCAHPS questionnaire. The last post will tie it all together to show physicians and MSPs how patient satisfaction affects physician performance.

To start, what is HCAHPS? The Hospital Consumer Assessment of Healthcare Providers and Systems is a 27-question survey developed by Centers for Medicare and Medicaid Services with the following goals in mind:

To produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers
To create incentives for hospitals to improve quality of care by making public survey results
To enhance accountability in healthcare by increasing transparency of the quality of hospital care provided in return for public investment (also by making public the survey results)

Although this survey covers a number of areas, my blog posts will cover these three physician-specific questions:

During this hospital stay, how often did physicians treat you with courtesy and respect?
During this hospital stay, how often did physicians listen carefully to you?
During this hospital stay, how often did physicians explain things in a way you could understand?

Until next time, try to get your arms around the fact that improving patient satisfaction will improve quality. For many of us, this fact will be difficult to swallow, but swallowing (internalizing) this will be critical for our success in the future.

January 27, 2012 | wmills | Comments 0