Nothing satisfies a writer like getting a story back from a reader that confirms that at least one other person understood your point. I find that sometimes the person who is commenting adds a story that makes my original thought even more effective. I received such a comment recently from an “Interested Reader” who is a healthcare professional working in a midwestern healthcare system. He was responding to the June 29th edition of “Healthcare Musings.”
Gene,
Thank you for this letter. The passage “We are focused on teamwork within units, but I fear that we are not effectively focused on the teamwork involved in processes of care that involve participants from multiple services or teams.” really rung true to me.
My mother had a minor care coordination breakdown after a recent hospital stay. The neurologist prescribed Coumadin. The pharmacist administered the first dose and ordered my mom to get blood drawn daily. The primary care provider knew of the order. But after the first blood draw, we realized the question of ‘who is supposed to read the test results?’ never got answered. After a dozen phone calls, the neurologist’s office, originally confident their job was done, had to sheepishly admit they hadn’t thought of that. And in the end, the primary care provider’s office (correctly, in my judgment) took over.
To me, this highlights the complexity. Handoffs are tricky business. Even when it seems like we’ve checked all the boxes, we find critical pieces of information missing.
My mom was a strong advocate for herself and she had excellent community support. A person without her resources might have given up on the medication adjustment. And the scary part to me is that the care providers might never have found out if that had happened.
What I liked most about his comment is that he took a generalization that I had offered and put meat on the point with a story that underlined its significance. It should be a horror to us all to realize that almost twenty years after To Err Is Human and Crossing the Quality Chasm pointed out the lack of quality in our systems of care, we still have a huge problem. Our systems of care are still not safe and still lack true quality, if quality is defined in the context of outcomes. By now, we all should know that the care we provide ought to be:
- Safe
- Effective
- Efficient
- Personalized
- Timely
- Equitable
Sadly, recent data suggests that over the last 20 years we have lost ground on the objective of providing such care, even as we have verified the truth of the concept that quality is primarily a systems issue. In May 2016 Johns Hopkins Medicine published data to suggest that there were 250,000 deaths annually from errors making medical errors the third leading cause of death in America. When to Err is Human was published at the turn of the century, it estimated that there were 98,000 deaths annually, or the equivalent to a jumbo jet crashing daily. The point of that analogy always seemed to me to be that the public would be outraged and something would happen in Congress if we lost a plane full of people every day, but we hardly notice the deaths from medical errors because they often go undocumented in the course of care. The deaths from medical errors are spread across the nation and its more than 5000 hospitals and almost a million physicians.
Perhaps the 98,000 deaths in 1999 vary from the 250,000 deaths now because the counting methodology is different. I really don’t think responding to that concern is a useful endeavor. It is just the sort of discussion designed to deflect our attention away from the core issues. The story that my “Interested Reader” tells about the disorganized care that his mother received in a system demonstrates a need for improvement whether it is emblematic of care that causes 98,000 deaths or 250,000 deaths a year. The Reader and his mother are relieved that through their own efforts they were able to clarify who was responsible for managing her anticoagulation. The reader makes the most salient point when he writes:
My mom was a strong advocate for herself and she had excellent community support. A person without her resources might have given up on the medication adjustment. And the scary part to me is that the care providers might never have found out if that had happened.
I am sure that some of the 98,000 or 250,000 deaths are due to errors in management of anticoagulation in patients who are not as resourceful as they were. Even more disturbing is the possibility that some deaths occur because of a lack of clarity about who was responsible for the management of the anticoagulation. The point that I was making in the piece that the Reader responded to was that the challenge of continuous improvement is even greater when the process of care involves multiple “services.” In this instance it was neurology and primary care. It could have been orthopedics, cardiology, mental health and primary care, or perhaps pediatrics, obstetrics and primary care. There are many processes of care that involve multiple hospital or outpatient “service lines.” Do they communicate well? Do they make effective handoffs of responsibility? In reality many of the “defects in care” that lead to the lapses in quality that then lead to the events that result in deaths from medical errors occur at the interface of “service lines.” Lean and other mechanisms of continuous improvement can facilitate managing processes of care between service lines.
Atrius Health and many other “integrated systems of care” established programs and processes of anticoagulation management more than a decade ago. As these programs evolved, complications from anticoagulation therapy became rare in these systems. It is disappointing to realize that programs of anticoagulation management are not available to every patient because every patient is not the client of an integrated care system that can manage care across departmental and practice boundaries.
We do not talk enough about the reality that our care is still not designed to be patient centric. As a result of our lack of “systemness” the care that we offer is often unsafe, inefficient, less effective, not timely, expensive, and as a result of those flaws, even inequitable at times even when patients are covered by expensive plans and are willing to spend significant amounts of their own resources. God help the patient who is not vigilant, trusts the system, lacks resources, and does not have an advocate to speak for them when they are ill. The data suggests that many of them actually die, and their deaths are frequently not detected as defects in care.
My mother was a “victim” of less than quality care on more than one occasion before she was lucky enough to spend the last seven months of her life of almost 94 years in an excellent hospice program. The picture with this post shows how she looked after a syncopal episode that she suffered when she was discharged on a calcium channel blocker that her EMR clearly recorded had previously caused syncope. What is worse is that the drug was started after a three week hospitalization including over two weeks in an ICU following complications from a cardiac cath at age 92 that represented inappropriate “overuse” of care. She was pressured to have a cath for atypical symptoms most consistent with GI distress and perhaps related to a urinary tract infection that became urosepsis during the procedure. It was such an “emergency” that the on-call cardiologist at the Atlanta hospital did not call me, her son, a cardiologist, to tell me that he thought she needed to be cathed. He got consent for the cath from my father, who was over 90. Dad became quite upset when the cardiologist frightening him with the urgency of her situation. The cardiologist finally called me after the cath when he wanted to know if I thought she should would want to be intubated because she was hypotensive!
We do not talk enough about the errors of overuse of medical procedures, the misuse of procedures, and the failures to take advantage of information that has already been documented. Perhaps more significantly we do not seem concerned when people do not have access to the care they need. Then there are those who do have access, but do not get the care they need because of a failure of critical thinking. There are errors of doing too much, and errors of not doing what is indicated, and errors that lead to bad outcomes as the result of poor critical thinking that results in missing the opportunity to improve a patient’s clinical status.
Poor handoffs within processes of care like the one the mother of the Interested Reader endured and overcame because of her family’s vigilance are more and more likely as care becomes more complex and fragmented. There are so many opportunities for failure that perhaps 250,000 annual deaths is an under call.
What we are not accurately measuring adequately to my knowledge, beyond human suffering, is the economic waste that is the byproduct of overuse, underuse, and misuse of care in complex systems that are not well engineered for efficiency. Low quality care is expensive. Again, I will use my mother’s experience as the example. Her unnecessary cath was followed by a long ICU stay because of complications. She spent almost a month in the hospital. The event probably cost Medicare and Blue Cross at least $250,000 for an unnecessary lengthy hospitalization instead of a more appropriate stay of a day, or so or even a same day discharge home on an antibiotic with appropriate outpatient follow up. That was the totally avoidable waste of hundreds of thousands of dollars not to mention a near death experience that was attributable to poor quality, poor safety, and fuzzy thinking. She never got back to the level of function she had before the unnecessary cath. When the cardiologist called me to say that she was in the ICU after an emergency cath followed by rapid AF, sepsis, and hypotension, he tried to be reassuring by saying, “At least we know her coronaries are open.” There is some information that is not worth the risk or the cost.
I fear that most Americans are not aware that the care they count on is the product of unreliable reliable systems that are often stressed and in further decline. We are all vulnerable, no matter how educated or wealthy we might be. Bad systems do not discriminate. When our focus becomes distracted by financial concerns, or there is a lack of coordination between “service lines” because of self interest within a service or a lack of a management process that coordinates care, or if our systems are populated by clinicians who do not have the time to communicate effectively, or critically think about the presentation before them, bad things can happen to anyone.
We have known what we should do for at least twenty years. Why do we delay the transformations in practice that improve quality? Why do we cling to the old ways that still injure so many people? Why is the fact that we injure so many people, including many who are our own vulnerable elderly parents, not a problem that we all own? We need to tell a lot more stories. Perhaps if we tell enough stories we will find one that opens our eyes to the fundamental importance of care that is really patient centered, safe, equitable, efficient, effective, and timely.
