Manage My Practice

In 2001, the Institute of Medicine (IOM) published Crossing the Quality Chasm: A New Health System for the 21st Century, which outlined fundamental changes that must be made in order to improve healthcare in the United States.  Here is a quote from the book:

“The U.S. health care delivery system does not provide consistent, high-quality medical care to all people.  Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge–yet there is strong evidence that this frequently is not the case.  Health care harms patients too frequently and routinely fails to deliver its potential benefits.  Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.”

Although the concepts in the books have been widely implemented in the inpatient setting (100,000 Lives Campaign and now 5 Million Lives Campaign), not as much has been done in the outpatient setting, predominantly because inpatient safety has been (rightfully) highlighted by needless deaths and injury (The Josie King Story, The Dennis Quaid Story.)  These same concepts must be applied in the outpatient setting to achieve improved patient care and patient satisfaction.  Ultimately, patients will demand to know what medical practices are doing to provide safe, effective, patient-centered, timely, efficient and equitable care.  This is a great book to read (you can read it online) and think about in preparation for the changes coming with healthcare reform, “Payment for Performance” (P4P) and electronic medical records promulgation.

Aim #1: Care should be SAFE: Patients should not be harmed by the care that is intended to help them. Current estimates from the Agency for Healthcare Research and Quality place medical errors as the eighth leading cause of death in this country. About 7,000 — people per year are estimated to die from medication errors alone — about 16 percent more deaths than the number attributable to work-related injuries.

Aim #2: Care should be EFFECTIVE: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit. Estimates are that about half of all physicians rely on clinical experience rather than evidence to make decisions. But should they? Experts say that physicians in most practices do not see enough patients with the same conditions over long enough time to draw scientifically valid conclusions about their treatment.

Aim #3: Care should be PATIENT-CENTERED, respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. One study of physician-patient interactions showed that physicians listen to patients’ concerns for an average of 18 seconds before interrupting. Medical schools are beginning to place greater emphasis on the development of good patient-interaction skills.

Aim #4: Care should be TIMELY: reducing waits and sometimes harmful delays for both those who receive care and those who give care. Many hospital Emergency Departments (EDs) are symptomatic of a system that cannot reliably give timely care. One recent survey revealed the average wait at “crowded” EDs was one hour. One third of U.S. EDs report they must periodically divert ambulances to other facilities.

Aim #5: Care should be EFFICIENT: avoiding waste, including waste of equipment, supplies, ideas and energy. Some experts estimate that most physicians are productive only 50% of their time, in part because the system works against them. Working smarter, not harder, can reduce non-clinical work and increase “face time” with patients.

Aim #6: Care should be EQUITABLE: care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. There is a growing number of studies showing disparities in care and treatment for some population groups. The implications can be dramatic: for example, the life expectancy of a black child is seven years shorter than that of a white child in Baltimore, Maryland, USA.

You can download a PowerPoint program from the Institute for Healthcare Improvement (IHI) that cover the concepts in the book for free here.  Registration is required, but it is free and gives you access to lots of tools and resources.

You can also read the book for free online by clicking on the “READ” icon below.  No registration is required.

What books, websites, blogs, organizations or people would you add to the list of resources to prepare us for the changes of the future?

Not on facebook yet?

CMS is.

There’s nothing I can say but close your door for 16 minutes and 59 seconds and watch this.

mhealth is short for “Mobile Health” and is medical and public health practice supported by mobile devices, like MP3 players and smartphones. Here’s a link for more info on smartphones, medical applications and other fun stuff from Epocrates.

The last conference I went to might be the last conference I ever go to.  I do like some parts of conferences, but not all, or even most. Medical manager conferences do not seem to have changed since I first started going to them in the late 80′s.  Big sessions with big names. Little sessions with little names. The Exhibit Hall. Parties. Get-togethers. Late nights and early mornings.

I usually expect to accomplish two things during the conference.

One is to pick up some little pearl of wisdom from a random conversation that goes like this:

THEM: Blah blah blah blah.
ME: Hey, what did you just say?
THEM: Blah blah blah blah.
ME: You do that? At your practice? And it works?
THEM: Blah.
ME: How do you do that?
THEM: Blah blah blah blah yadda yadda yadda.
ME: I’ve gotta try it – thanks so much! Hey can I get your card and call you if I get stuck?
THEM: Blah yadda yadda.
ME: Yeah, great to meet you too!

The second is the brain time I get during a totally boring session when I can think without interruption about a problem I’m trying to solve.  I can reflect, scribble notes and no one cares. The phone is not ringing, there’s not a line at my door, there’s not a to-do list to do in my to-do book.  One thing I can never get enough of is time to think.  Work is full, almost every minute, with noise and interruptions and lots of people needing something.  What I need, what we all need, is more time to think.  If you never have time to think, or plan, or process, there is no managing going on.

Here is what my dream conference would look like:

1. Speakers on big screens – What is the value of having a big name speaker come personally to a conference?  Have them speak virtually.  Save a lot of money for us and save a lot of time for them.  Come to think of it, what do the big names actually contribute to the conference?  I’m not sure.
2. Infomercials – Why not have the exhibitors do infomercials at breaks in the programs? Anyone can make a video explaining their product. The videos could be available on the conference YouTube Channel for anyone who misses the infomercials and wants to flip through them.
3. No exhibit hall – I’ve heard so many vendors say they won’t have the budget soon to attend conferences.  How do vendors raise the money to attend conferences, give out goodies and door prizes and sponsor parties? By raising their product price, of course.  When I hear people say “We couldn’t have a conference without the exhibit hall,” I think “I bet we could have a better conference without the exhibit hall.”  No exhibit hall means a lot more time to meet with people I really want to see. No exhibit hall means I don’t have to carry home a bunch of literature I don’t want. No exhibit hall means I don’t have to feel guilty about finding the fastest way from the front of the hall to the coffee stand/food/bar.
4. Breakouts on demand – I’d like to go to smaller breakout sessions when I want to fit them into my schedule.  If I get into a great discussion with someone, I don’t want to drop it to run to a session, I want to go with the flow.  Breakouts could be constantly running on screens in dedicated rooms, or I could get them on my laptop whenever I was ready for them.
5. The Unconference - there are several versions of the Unconference, but the version I’ve been exposed to is one where a huge block of time at a conference was completely unprogrammed.  It was the second day of a two-day conference and all throughout the first day, attendees wrote things they wanted to talk about on Post-it notes and stuck them on a big blank wall.  The conference organizers were responsible for combining like ideas, assigning a time and a room and finding a facilitator for the topic.  I came to a conference with a need and my need was met!  Conferences, especially large ones, by necessity must choose topics and book speakers far in advance.  With as fluid as healthcare now is, conferences need to match the fluidity of healthcare to be pertinent.
6. Networking, networking, networking – What can’t I get ANY other place? A conversation with my peers.  People with different experiences, different perspectives and different ideas.  That’s the best thing I can bring home from a conference.

What does your dream conference look like?

HEALTHCARE BILL IMPACT ON INDIVIDUALS AND RAGE

A number of people asked me about the impact of health reform on them as individuals.  Here is a great story from the Atlanta Journal-Constitution that takes specific examples of individuals and families and speculates on how the new bill(s) will impact them.

For 2010, the changes are minimal:

• Dependent children may be covered by their parents’ health insurance policies until age 26.
• A high-risk insurance pool will open for people with pre-existing conditions who have been uninsured for six months.
• In 2011 Medicare will pay for an annual checkup, and deductibles and co-payments for many preventive services and screenings will be eliminated. The Medicare prescription drug doughnut hole will gradually narrow every year until it is eliminated in 2020. People in the  “doughnut hole” could receive a $250 rebate this year.

I have to say that I’ve been dumbfounded by the fury raised over the passage of the new healthcare legislation.  I realize that the bills separate people into winners (uninsured, providers with uncompensated charity care, patients with pre-existing conditions, Medicare patients, providers who see Medicaid patients, families with adult children, etc.) and losers (companies who have to pony up more money for their retired employees, insurance companies, illegal immigrants, high wage earners, etc.), but this story placed the fury into a different perspective for me.  It’s a good read.

CONCIERGE PRACTICES

What does healthcare reform mean for the physician practice?  Many are predicting the rise of concierge practices (also called boutique medicine, retainer practices, VIP medicine and cash practices) as physicians find they cannot survive if their patient population is predominantly Medicare, Medicaid and uninsured patients. Concierge practices fall into two categories:

• The first operates on an insurance+ model, which means that the practice accepts and files the insurance for the patient, but also requires an additional out-of-pocket fee of anywhere from $1500 to $1800 per year to be a patient of the practice.  The fee is to cover services that Medicare and commercial insurance do not, such as physicals, phone consultations, wellness counseling and patient education.
• The second operates on a strictly cash basis and the practice does not accept or file any insurance for the patient.  The patient pays a flat fee per year for care (usually in the $5,000 to $15,000 range) and all primary care is provided for that amount.  The patient still needs to carry insurance for prescriptions, hospital services and sub-specialist services.  Imagine being a manager in this type of practice – no pre-authorizations, no insurance department, no eligibility checking, no refunds…

Concierge medicine has not been around that long, but it is growing in popularity by leaps and bounds. The first acknowledged concierge practice was formed in 1996 in the Pacific Northwest.  In 2002, CMS (Centers for Medicare and Medicaid) published a memo stating that physicians may enter into retainer agreements with their patients as long as these agreements do not violate any Medicare requirements.  In 2003, the Department of Health and Human Services ruled that concierge medical practices are not illegal. Today, there are approximately 5,000 physicians using the concierge model in the United States today.

MEDICARE CUTS, MEDICARE CLAIMS AND DON BERWICK

Shortly after all the shouting and voting on healthcare reform was over, Congress recessed for two weeks leaving the controversy over the 21.5% cuts required by the SGR formula still unsettled.  CMS has advised the MACs to again hold claims for services provided from April 1 to April 10 to give Congress a chance to get back to work and back to voting for an additional delay (or not) for the cuts.  If the cuts are allowed to stand, many physicians will start making their own cuts by minimizing the number of Medicare and Medicaid patients they will see.

Amidst this craziness, a voice of sanity is heard and it is Donald Berwick, MD, current President of the Institute for Healthcare Improvement (IHI) and probable Obama pick for the head of CMS. If you don’t know Don Berwick or the IHI, click here to read an interview with him about the IHI’s “100,000 Lives Campaign” or watch the video below of him speaking about the dimensions of quality.  Good stuff!

As I write this Sunday night I am listening to the US House of Representatives’ discussion/posturing prior to a ‘yes” or “no” vote for the Senate’s healthcare reform bill H. R. 3590.  I don’t usually listen to CNN Live, but I want to remember this moment as I think it is the beginning of significant change in healthcare.

I’m not sure what this change will be, but many things that have been status quo for healthcare during my career might change almost beyond recognition by the time I retire. This, I think, is a good thing.  I don’t think the current system is bad, but I sure think it could be better.  As with any change, there will be good things, bad things, and unintended good and bad things.  It should be fascinating.

Discussion has now timed out and the representatives are voting;  216 votes are needed to pass.  The vote has just been announced (10:45 p.m.) and it is 219 Yeas to 210 Nays and the bill is passed!  The next step is for it to be signed into law by President Obama, which might happen tonight or tomorrow.

Now the representatives are voting on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ which contains fixes to H.R. 3590 that have been negotiated between the two chambers.  The bill has just passed (11:37 p.m.) with 220 Yeas and 211 Nays!  4872 will now go to the Senate for a vote which some are predicting will pass as early as Tuesday.

President Obama spoke from the White House after the votes and said “Tonight we answered the call of history.”  The passage of these bills has been compared to the passage of Medicare in 1965 and the passage of Social Security in 1935.

Here are details of both bills.

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Details on H.R. 3590 ‘‘Patient Protection and Affordable Care Act’’

Cost: $940 billion over ten years.

Deficit: Would reduce the deficit by $143 billion over the first ten years.   Would reduce the deficit by $1.2 trillion dollars in the second ten years.

Coverage: Would expand coverage to 32 million Americans who are currently uninsured.

Health Insurance Exchanges:

• The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 percent and 400 percent of poverty level.
• Separate exchanges would be created for small businesses to purchase coverage — effective 2014.
• Funding available to states to establish exchanges within one year of enactment and until January 1, 2015.

Subsidies: Individuals and families who make between 100 percent – 400 percent of the Federal Poverty Level (FPL) and want to purchase their own health insurance on an exchange are eligible for subsidies. They cannot be eligible for Medicare, Medicaid and cannot be covered by an employer. Eligible buyers receive premium credits and there is a cap for how much they have to contribute to their premiums on a sliding scale.  Federal Poverty Level for family of four is $22,050.

Paying for the Plan:

• Medicare Payroll tax on investment income — Starting in 2012, the Medicare Payroll Tax will be expanded to include unearned income. That will be a 3.8 percent tax on investment income for families making more than $250,000 per year ($200,000 for individuals).
• Excise Tax — Beginning in 2018, insurance companies will pay a 40 percent excise tax on so-called “Cadillac” high-end insurance plans worth over $27,500 for families ($10,200 for individuals). Dental and vision plans are exempt and will not be counted in the total cost of a family’s plan.
• Tanning Tax — 10 percent excise tax on indoor tanning services.

Medicare:

• Closes the Medicare prescription drug “donut hole” by 2020. Seniors who hit the donut hole by 2010 will receive a $250 rebate.
• Beginning in 2011, seniors in the gap will receive a 50 percent discount on brand name drugs. The bill also includes $500 billion in Medicare cuts over the next decade.

Medicaid: Expands Medicaid to include 133 percent of federal poverty level which is $29,327 for a family of four.

• Requires states to expand Medicaid to include childless adults starting in 2014.
• Federal Government pays 100 percent of costs for covering newly eligible individuals through 2016.
• Illegal immigrants are not eligible for Medicaid.

Insurance Reforms:

• Six months after enactment, insurance companies can no longer deny children coverage based on a preexisting condition.
• Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
• Insurance companies must allow children to stay on their parent’s insurance plans through age 26.

Abortion:

• The bill segregates private insurance premium funds from taxpayer funds. Individuals would have to pay for abortion coverage by making two separate payments, private funds would have to be kept in a separate account from federal and taxpayer funds.
• No health care plan would be required to offer abortion coverage. States could pass legislation choosing to opt out of offering abortion coverage through the exchange.

**Separately, anti-abortion Democrats worked out language with the White House on an executive order that would state that no federal funds can be used to pay for abortions except in the case of rape, incest or health of the mother. (Read more here)

Individual Mandate: In 2014, everyone must purchase health insurance or face a $695 annual fine. There are some exceptions for low-income people.

Employer Mandate: Technically, there is no employer mandate. Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines applied to entire number of employees minus some allowances.

Immigration: Illegal immigrants will not be allowed to buy health insurance in the exchanges — even if they pay completely with their own money.

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Details on H.R. 4872 – “The Health Care and Education Affordability Reconciliation Act of 2010″ (fixes to 3590)

COST: $940 billion over 10 years, according to the Congressional Budget Office.

HOW MANY COVERED: 32 million uninsured. Major coverage expansion begins in 2014. When fully phased in, 95 percent of eligible Americans would have coverage, compared with 83 percent today.

INSURANCE MANDATE: Almost everyone is required to be insured or else pay a fine. There is an exemption for low-income people. Mandate takes effect in 2014.

INSURANCE MARKET REFORMS: Major consumer safeguards take effect in 2014. Insurers prohibited from denying coverage to people with medical problems or charging them more. Higher premiums for women would be banned. Starting this year, insurers would be forbidden from placing lifetime dollar limits on policies, and from denying coverage to children because of pre-existing medical problems. Parents would be able to keep older kids on their policies up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear.

MEDICAID: Expands the federal-state Medicaid insurance program for the poor to cover people with incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014. The federal government would pay 100 percent of the tab for covering newly eligible individuals through 2016. A special deal that would have given Nebraska 100 percent federal financing for newly eligible Medicaid recipients in perpetuity is eliminated. A different, one-time deal negotiated by Democratic Sen. Mary Landrieu for her state, Louisiana, worth as much as $300 million, remains.

TAXES: Dramatically scales back a Senate-passed tax on high-cost insurance plans that was opposed by House Democrats and labor unions. The tax would be delayed until 2018, and the thresholds at which it is imposed would be $10,200 for individuals and $27,500 for families. To make up for the lost revenue, the bill applies an increased Medicare payroll tax to investment income as well as wages for individuals making more than $200,000, or married couples above $250,000. The tax on investment income would be 3.8 percent.

PRESCRIPTION DRUGS: Gradually closes the “doughnut hole” coverage gap in the Medicare prescription drug benefit that seniors fall into once they have spent $2,830. Seniors who hit the gap this year will receive a $250 rebate. Beginning in 2011, seniors in the gap receive a discount on brand name drugs, initially 50 percent off. When the gap is completely eliminated in 2020, seniors will still be responsible for 25 percent of the cost of their medications until Medicare’s catastrophic coverage kicks in.

EMPLOYER RESPONSIBILITY: As in the Senate bill, businesses are not required to offer coverage. Instead, employers are hit with a fee if the government subsidizes their workers’ coverage. The $2,000-per-employee fee would be assessed on the company’s entire workforce, minus an allowance. Companies with 50 or fewer workers are exempt from the requirement. Part-time workers are included in the calculations, counting two part-timers as one full-time worker.

SUBSIDIES: The proposal provides more generous tax credits for purchasing insurance than the original Senate bill did. The aid is available on a sliding scale for households making up to four times the federal poverty level, $88,200 for a family of four. Premiums for a family of four making $44,000 would be capped at around 6 percent of income.

HOW YOU CHOOSE YOUR HEALTH INSURANCE: Small businesses, the self-employed and the uninsured could pick a plan offered through new state-based purchasing pools called exchanges, opening for business in 2014. The exchanges would offer the same kind of purchasing power that employees of big companies benefit from. People working for medium-to-large firms would not see major changes. But if they lose their jobs or strike out on their own, they may be eligible for subsidized coverage through the exchange.

GOVERNMENT-RUN PLAN: No government-run insurance plan. People purchasing coverage through the new insurance exchanges would have the option of signing up for national plans overseen by the federal office that manages the health plans available to members of Congress. Those plans would be private, but one would have to be nonprofit.

ABORTION: The proposal keeps the abortion provision in the Senate bill. Abortion opponents disagree on whether restrictions on taxpayer funding go far enough. The bill tries to maintain a strict separation between taxpayer dollars and private premiums that would pay for abortion coverage. No health plan would be required to cover abortion. In plans that do cover abortion, policyholders would have to pay for it separately, and that money would have to be kept in a separate account from taxpayer money. States could ban abortion coverage in plans offered through the exchange. Exceptions would be made for cases of rape, incest and danger to the life of the mother.

STUDENT LOAN OVERHAUL: Requires the government to originate student loans, closing out a role for banks and other private lenders who charge a fee. The savings – projected to be more than $60 billion over a decade – are plowed into higher Pell Grants for needy college students and increased support for historically black colleges.

MEDICARE: Extends Medicare’s solvency by at least nine years and reduces the rate of its growth by 1.4 percent, while closing the doughnut hole for seniors, meaning there will no longer be a gap in coverage of medication.

With huge growth in 2009, social media is not just a passing trend used by online marketers; it’s a real, effective method of communicating ideas, sharing information and connecting with people across all age and socioeconomic groups. Healthcare, while slower to adopt the social media wave than other industries, is coming to realize the potential social media tools provide to develop connections with patients, potential patients, along with other physicians and healthcare leaders around the world.

What are some of the driving forces behind this explosion in popularity? One reason is that as consumers, we’re no longer trusting of advertising and we don’t want to be marketed to, we want to be engaged, build a relationship, make the company earn our trust and hear our friends or family’s review of their experiences. In fact, studies show that today, only 14% of people trust advertising, whereas 78% of people trust recommendations and referrals. Companies are using social media outlets to build relationships, trust and encourage recommendations and referrals from their engaged consumer base.  As practice, hospital and physician growth are so strongly correlated to patient referral and recommendation volumes, it is only natural healthcare organizations look to social media outlets to continue to foster patient relationships and increase referral volumes.

As of February 2010, where is the healthcare industry in its adoption of this social media explosion? Larger organizations and health systems are utilizing the power to connect, share and engage their patients.  While, on average, smaller private physician groups and individual physician offices are still slightly hesitant and dipping their toes in the social media pool cautiously.  One can understand why healthcare professionals do need to take a more strategic approach to interacting and engaging patients online with potential HIPAA privacy issues and other challenges looming. However, with a carefully crafted social media strategy, many health organizations are realizing the benefits of becoming more accessible in their marketing and reaching out to inform, educate and build trust with patients.  According to Ed Bennett (edbennet.org) hospitals are currently at a 53% adoption rate, with 336 Facebook pages, 430 Twitter Accounts, 254 YouTube Channels and 70 blogs. In total, 557 health systems are reported to be participating in some capacity with social media, with the term “social media” encapsulating many forms and tools, including Facebook, Twitter, YouTube, blogs, LinkedIn, Flickr, and a number of patient forums.

How are healthcare organizations using these tools effectively? Let’s focus on the top three tools currently adopted and being utilized in the healthcare social media sector.

Facebook: Physician practices and health systems alike are using Facebook as a dynamic, community-based website.  It has become a place where physicians and leaders can post timely, organic or professional videos to educate patients and also connect on a more personal level.  As a valuable resource for health information sharing, many organizations are taking the embarrassment out of sensitive subject matter and addressing specific medical problems, questions and issues for patients. Also, introductions to staff members and tours of the facilities are assisting organizations with connecting with their patients outside the four walls of their office and building rapport before patients even arrive for their appointment. Practices are also encouraging patients to participate and engage on their site through discussions and contests.  Private practitioners are more likely to start their social media strategy with just a Facebook Fan Page, while larger health systems and hospitals are embracing other social media tools in combination with Facebook in their initial strategy.

Twitter: Twitter is being adopted quickly by the larger health systems as a way to share information, publicize events like health screenings, fairs and clinics and also connect with other health organizations.  I like to think of it as a public relations channel for these hospital and health systems.  What’s great is that in short, 140 character or less “tweets”, these organizations are sharing a wealth of information to their patients and those patients are finding ways to access this health information and the system like never before.  Overall the smaller, private practitioners are not as quick to adopt Twitter as they are a practice website or even Facebook, but many are starting to realize the benefits of utilizing this community as a way to share their expertise and knowledge, along with driving traffic to their websites.

YouTube: Healthcare organizations are using YouTube like their own, private television station that can be shared with millions of viewers across the world.  Again, more popular amongst the larger health organizations, videos of procedures, interviews with clinicians, tours of new facilities and patient testimonials are being posted in a searchable, user-friendly manner to continue to enhance brand awareness, build trust and gain patient loyalty.  This social media tool can be used much like Facebook, easing patient fears and answering tough or embarrassing questions. It can also give patients a visual insight into the facility so they know what to expect before arriving at an appointment or for a procedure.  It can act as an online referral source, highlighting patients that have had outstanding experiences and are recommending that organization to over a billion of their closest friends and family online. YouTube is the second largest search engine and healthcare professionals are quickly utilizing its power to share and connect with patients.

The fact of the matter is that for all industries, including healthcare, social media is both a curse and a blessing. Patients, who are now consumers with choices, can post content and interact freely with their physicians and their hospitals, sharing both outstanding experiences and negative experiences.  Many health professionals are worried about their vulnerability, but social media is real life, online.  As 2010 progresses, you’ll be seeing more and more attention placed on social media by healthcare professionals and by the end of the year, it will be a necessity for organizations to be participating and engaging online, or be left out.

A loved one was recently hospitalized for surgery in a nearby town.  During the experience there were several moments when I had to decide whether or not I would say something to nurses about hand washing and cleanliness. To my great surprise, I was too intimidated to say anything!  The one time I did speak up went something like this:

•    Hey, is that nurse filling my loved one’s water pitcher?
•    She’s trying to make the water not too cold or hot, that’s good.
•    Oh, no, she is letting the water run over her hands and into the pitcher!  Should I say something?
•    She’s probably going to dump out that water and fill it up with water her hands haven’t been in.
•    Nope, she’s turning off the water.  Do I say something?
•    Me: “Hey, that water ran over your hands!”
•    Nurse: “Don’t worry, I wash my hands all the time.”
•    Me: “No, I don’t think we should take that chance.”
•    Nurse: ‘I’m really hurt that you would think I’d do something like that.”

This was a personal seminal moment.  I could not believe that after working with physicians and nurses in healthcare for 25 years that I would be intimidated about saying something about cleanliness.  I was worried about the potential impact that my questioning would have on the care of my loved one.  That made me hesitate about saying something until a situation came up where I could not keep quiet.  I could not suppress my concern based on the possible impact to my loved one.

What about the nurse’s reaction?  It was defensive, and she was telling me in essence “I can’t believe you’d question my decision-making.”  In discussing the situation later with my husband (not the patient), he assured me that I had done the right thing.  He asked me if I saw the waiter in a restaurant washing his hands at my table, would I then let him dip his hands in my soup?

This hospital experience was 99% wonderful. I thought the hospital paid excellent attention to the needs of the patient and the family.  I thought it was clean, the caregivers were very good, and I would recommend the hospital.  But the wall is still up about questioning at this hospital and probably every hospital across the US.  It is a hard call to tell the professionals that they are doing something wrong.  A cleanliness episode can happen so fast that you don’t have time to debate yourself about saying something.

How can we make it okay to question caregivers for the benefit of the patient?


The Medical Home, also called the Patient-Centered Medical Home, and the Personal Medical Home, is a movement to solve the problem of fragmented care (one hand doesn’t know what the other is doing) by having a primary care physician or practitioner act as the center of all care information for the patient.   Fragmented care is dangerous (lack of coordination of care causes mistakes and mistreatments), costly (repetition of diagnostic tests and regimens), and wasteful of healthcare resources.  The Medical Home plan goals are to provide care for all individuals, improve care, and decrease healthcare costs.

“Crossing the Quality Chasm: A New Health System for the 21st Century” was published in 2001 by the Institute of Medicine.  In this landmark book, the patient’s role and responsibility for navigating the healthcare system and acting as the information hub around which the spokes of primary, specialty and tertiary care providers revolve was denounced (more…)