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Oops! Wrong leg-Sorry

Wrong site surgeries are performed up to 40 times per day, according to an article in the Jun. 29 Orange County Register. Or at least that is the number reported to the Joint Commission.  

On January 1, 2003, the Joint Commission issued National Patient Safety Goal 4 which aimed to, “to eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family.”   

It’s now 2011, so how can wrong site surgeries still be happening?

Recently, we reviewed our universal protocol (time-out) policy at one of our hospitals. We didn’t revise the policy because it was incorrect—we revised it to raise awareness of the policy. Certainly doing the same thing, the same way every time can enhance quality, but it can also become a nonthinking habit. We’re not making widgets; we are caring for people, so we always need to be thinking. Checklists should serve as reminders, not as a mindless task. Physicians and nurses are smart people, so why can’t we get this right 100% of the time? Certainly our patients (and we) think we should.  Is this really that much harder and more complex than it looks?

What are you doing to raise awareness to prevent wrong-site surgeries? How do you keep something that is mundane fresh?  How do you make sure you do the right thing for every patient every time? One of the things we do is revise policies and make a big deal about them again. I’m interested in your thoughts and approaches. Please sure in the comments below.

The sleep doctor question

An article in the July 1, 2011 Los Angeles Times, titled “Limiting resident physicians’ work hours to save lives” again raises the question of whether resident fatigue affects patient care. I assume there is no coincidence that the article appeared the day that the newly minted physicians began training. The article, co-authored by Lucian Leape, MD, chair of the Lucian Leape Institute and adjunct professor of health policy at Harvard School of Public Health and Helen Haskell, founder of Mothers Against Medical Error, cites studies that go back at least 40 years demonstrating that fatigued residents make more mistakes than well-rested residents.

New rules limit first year residents to shifts no longer than 16 hours, and more senior residents to 28-hour shifts. When I was in training, my surgical brethren and I thought that if you were only on call every other night, you missed half of the interesting cases. I wonder whether today’s residents are as “tough” as we were back in the day. Should slave labor be reintroduced? Or are folks like Dr. Leape right?  Back in the day, we assumed our patients were safe and received quality care—were we right?  I don’t think so. So is 16 hours right?  Should it be 12?  Should it be less?  Should residency programs add a year to training programs so that residents can get the necessary experience, and still get some sleep?  What do you think?

The New Normal

Most press coverage of the Affordable Care Act (or Obamacare, as it is known to some) has emphasized the expansion of insurance coverage , leaving the impression that overall healthcare costs will increase under this law. An article by Gail Wilensky in the New England Journal of Medicine points out that the act requires costs to decrease. Although almost everyone will have access to care, payments to medical providers will be reduced by the extent necessary to achieve savings. Unlike the Sustainable Growth Rate initiative, Medicare costs will not be allowed to grow at all, and the cuts will be borne by all providers, not just doctors.  This confirms my earlier impression that value-based purchasing is basically a shell game. 

Uncle Sam is now dealing three-card monte. There will be no winners in this game, but some will lose less than others. Hospitals may lose up to 10% of Medicare revenue by the time the Affordable Care Act is fully implemented.  In Philadelphia, where I now live, only one of the 16 hospitals had an operating profit margin greater than 10% last year. None of the 27 hospitals in Connecticut achieved a 10% margin in 2009.  Hospitals are not entirely dependent on Medicare, but private insurers are not likely to make up the losses from Medicare. In fact, many insurance providers are developing their own pay-for-performance systems. 

Where is this going? One could envision that multiple rounds of payment cuts could force most of the hospitals in America out of business. This will not occur, as public demand will cause modifications once access to care is significantly reduced, but at least some hospitals will close. 

Everyone reading this must understand that healthcare in America will be less lucrative than in the past.  Some physicians and hospitals may benefit at others’ expense.  Hospitalists need to prepare for very difficult negotiations with hospitals and expect to come away with less money for a given level of effort.  It is time to abandon the notion that one is entitled to a certain level of income by virtue of holding a medical license or a particular set of skills.  Your work is worth what the market will pay for it.  I am old enough to remember when a visit with a doctor cost only two dollars, and patients paid out of their own pockets.  We are not returning to those days, but the era of unlimited taxation to support the medical-industrial complex is over.  Get ready for the new normal.

Will forcing docs to work full-time take pressure off the shortage?

Dr. Karen Sibert’s recent New York Times Op-Ed has been raising some eyebrows in the medical community. In her article, Dr. Sibert contends that physicians (particularly female physicians) should practice full-time to help meet increasing shortages. Dr. Carolyn Anderson, a contributing writer for the Huffington Post, recently published a response to the article, arguing that obligating physicians to work full-time is a “band aid solution” to meeting shortages and only results in burnt-out doctors.

Evidence from the Physician Retention Survey we conduct annually with American Medical Group Association shows that providing flexible work options for doctors is key to keeping them employed through all stages of the career cycle. Part-time options are a viable solution for keeping more physicians in practice, while providing them the chance to lead well-balanced lives. 

What do you think? Would requiring physicians to work full-time help meet shortages while still providing quality care?

ACO fuzzy math?

The details surrounding the proposed rules for creating an accountable care organization (ACO) continue to become more complicated—specifically the cost associated with establishing and sustaining an ACO.  The Centers for Medicare & Medicaid Services (CMS) originally estimated a cost of $1.8 million in its proposed rule for start-up and one year of ongoing operations.  Now, according to the American Hospital Association (AHA) study released in mid-May, the start-up investmentmay not be accurately represented by the number that CMS released.  The study found that the cost associated with the elements necessary to manage the care of a population is much higher.  The study revealed start-upcosts of $5.3 million to $12.0 million based on size of the hospital or health system.  That’s a far cry from $1.8 million.

According to the AHA, CMS falls well short on their estimation.  It doesn’t necessarily surprise me that CMS would underestimate the costs of establishing and running a successful ACO.  After all, they don’t operate a business.  However, these numbers are extremely far apart, and it seems to me that this is something that may reflect how little is truly certain or reliable about the costs associated with ACOs.  To me, it seems prudent to re-evaluate the ACO cost models before putting the regulations in place.  So what do you think? Whose estimation should we trust more? Should we believe the true number is somewhere in the middle? Or do we need to sharpen the pencils again to determine the real costs of launching an ACO?

Report quality and ethical issues internally first

If a medical staff member feels obligated to report inappropriate care or conduct, he or she should take certain steps to reduce his or her liability risk. The first step is to report issues internally to a medical staff leader, says Tim Adelman, Esq., partner at Adelman, Sheff & Smith, LLC, in Annapolis, MD.

Although the reporting physician may not be protected under whistleblower laws during this initial step (some states’ whistleblower laws require healthcare professionals to report to an outside organization to gain protection), reporting issues internally helps physiicans maintain professional relationships.

“You risk putting yourself in a bad psition if you report your colleagues or the hospital you work at without giving them a fair chance to address the issue,” says Adelman. If the reporting party doesn’t give the facility or colleagues a chance to correct the behavior, he or she may find it uncomfortable to work there in the future.

Adelman also suggests that physicians take a step back to ensure that they are reporting the facility or individual(s) for the right reasons. Are they eporting because they engaged in disruptive behavior and want to defend their actions? Are they seeking revenge? Physicians should reconsider reporting for any reason other than a legitimate concern.

“I would never discourage [physicians] from reporting, but what I would encourage them to look at is what they are trying to accomplish and what they want to have happen in the future,” says Adelman.

If a physician does report a colleague or the facility at which he or she works to an outside board because efforts to address the issues internally have failed, the physician should be sure to have adequate documentation of the questionable or offending behavior. The reporting party should also be sure that the act of reporting won’t come as a surprise to the individuals involved. “Any time that it is perceived as sneaky or out to get someone, it is going to really taint your reputation and credbility.”

To learn more about physician reporting, check out the June issue of Credentialing & Peer Review Legal Insider (subscription required).

Managing ED call during maternity and paternity leave

A hospital I recently visited has been struggling over ED call, an experience many hospitals share. A gastroenterologist had gone out early for maternity leave due to pregnancy complications, triggering a debate over whether the remaining gastroenterologists would pick up her previously scheduled call slots or simply leave them uncovered.  One of the remaining gastroenterologists had made arrangements before her maternity leave several years previously to do extra call to “pay back” her colleagues for the call she would not take during her maternity leave. This gastroenterologist happened to be responsible for making up the call schedule and had assumed that the physician who is currently on maternity leave would do the same. However, no one discussed this with her. In fact, she had no intention of paying back any call missed during her maternity leave, and the medical staff had not adopted a policy on the matter. The result:  conflict, incriminations, and the risk of uncovered call slots.

Read the rest of this article at

Provide hospitalists with adequate billing and coding training

One of the best things that hospitalist program managers can do to ensure adequate training is to work with the billing department to find an individual who is qualified to educate hospitalists about billing.

“More and more practices have a certified coder on staff whose job it is to work with the doctors, train them, and conduct audits of the documentation to give them feedback on what they are doing right and wrong,” says Leslie Flores, MHA, partner at Nelson Flores Hospital Medicine Consultants in La Quinta, CA.

Not all hopsitalist programs have a certified coder available. In that case, the program may need to rely on a noncertified individual in the billing department or a hospitalist who is charged with training newcomers. However, having a hospitalist conduct the training may be dangerous, says Flores. “If that physician has developed bad habits, he may pass them on to new people.”

Another option for hospitalist programs is to hire an external consultant. “It is more expensive, but I think it is worth it,” says Jonathan Lovins, MD, SFHM, hospitalist and assistant clinical professor of medicine at Duke University School of Medicine in Durham, NC. Facilities may be able to find coding auditors and trainers through the Society of Hospital Medicine or the American Association of Certified Coders.

The rule of thumb, says Lovins, is for every hospitalist to receive at least two hours of training on billing and coding when they first start and refresher courses every year. The training should include notes from previous encounters with patients. “If you do it without notes, it is very abstract, and people don’t take away much from it. Bring in real hopsitalist notes.”

Check out the June 2011 issue of Medical Staff Briefing for more information about training hospitalists in billing and coding (subscription required).

Check out our new resource for medical staff leaders

Medical Staff Leadership Essentials: A Guide to Developing Leadership Skills and Recruiting the Next Generation provides valuable insight to help new and veteran medical staff leaders develop, retain, and recruit a legacy of effective future physician leaders. Written by 35-year medical staff veteran R. Dean White, DDS, MS, a medical staff consultant in Granbury, TX, and reviewed by The Greeley Company’s Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, this book is a complete training resource for any medical staff leader who may have been elected (or thrown)  his or her position with little experience. It’s also great for veteran leaders who wish to train incoming leaders. Check out table of contents:

  • Chapter 1: Principles of leadership
  • Chapter 2: Foundational leadership skills that can be learned
  • Chapter 3: Roles and responsibilities of medical staff leaders
  • Chapter 4: Identifying and recruiting medical staff leaders
  • Chapter 5: Educating medical staff leaders
  • Chapter 6: Nominating and selecting medical staff leaders
  • Chapter 7: Succession planning and leadership retention
  • Chapter 8: Understanding the medical staff culture to meet future challenges
  • Chapter 9: Reflections and resources
  • Chapter 10: From the field: Medical staff leaders share their thoughts on what it means to lead

To order, click here.

Authors explore the ethics of physicians participating in capital punishment

The Hastings Center Report this month explores the ethics involved with physicians participating in lethal injection. On one hand, allowing physicians to participate may make deaths swifter and more humane for patients, but on the other hand, killing patients goes against physicians’ code of ethics to “first, do no harm.” In 2010, the American Board of Anesthesiologists decided to revoke the certification of any physician who participated in capital punishment, following the AMA’s lead.

Free-standing emergency departments on the rise

Free-standing emergency departments are on the rise, according to Physician News Digest. The majority of patients currently visit emergency departments for non-urgent and semi-urgent care, and visiting a free-standing emergency department, which is not attached or associated with a hospital, can save them money and reduce wait times in hospital-associated emergency departments. They aren’t the best choice, however, for true emergencies, such as heart attacks, and it’s difficult for patients to know which facilities offer which services, say critics.

ACGME-compliant staffing model reduces costs for hospital

When the ACGME released its new Common Program Requirements, many balked at the estimated cost of implementing and remaining compliant with the new rules. However, the University of California, San Francisco’s (UCSF) Benioff Children’s Hospital found that the right staffing model can reduce hospitalization costs by 11% and shorten lengths of stay by 18%, reports Hospitalist News Digital Network.

“In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams,” the article states.