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Breaking (perceived) rules in order to improve care


Don Berwick, M.D., and the other co-authors of a JAMA piece suggest that the providers may well need to break rules to improve patient care and improve the working lives of clinicians.

This flows from the Institute for Healthcare Improvement Leadership Alliance’s hosting a “Breaking the Rules for Better Care Week.” For that matter, many participants have found that what might have seen as rigid rules  weren’t legally required to be rules at all.

Two dozen  provider participants  have identified 342 rules that had little or no clinical value to patients. The IHI then categorized those rules into three groups, summarized by FierceHealthcare below:

  1. “Habits formed by organizational behaviors, which generally have no legal, regulatory or administrative requirements. An example of this would be preventing staff from keeping bottled water at nursing stations.
  2. “Organizational rules that could be changed without impacting regulatory compliance. For instance, some may charge for parking or have restricted visiting hours.
  3. “Rules required by regulations and statutes. The most frequently cited was the “three-day rule” for patients’ access to skilled nursing facilities.

“The majority of rules identified (62%) were of the second type. Sixteen percent fell into the first group, and 22% fit the third.”

“Contrary to initial expectations, although wasteful statutory and regulatory barriers existed, the majority of obstructive and wasteful rules identified by patients and staff were fully within the administrative control of healthcare executives and managers to change,” the JAMA co-authors wrote.

To read the JAMA piece, please hit this link.

To read an analysis of the JAMA article by FierceHealthcare, please hit this link.


Safety across the care continuum


Video: Tejal Gandhi, M.D., chief clinical and safety officer at the Institute for Healthcare Improvement, discusses the need to consider safety issues across the entire care continuum. This, of course, becomes increasingly important as more and more care moves out of hospitals and into clinics, physician groups and other non-hospital settings and as more nurse practitioners and physician assistants do the work once  done only by doctors.

To see the video, please hit this link.


Crucial role of employers in making ACA work better


In an article in the Harvard Business Review, Robert S. Mecklenburg, M.D., medical director of the Center for Health Care Solutions at Virginia Mason Medical Center, and Lindsay A. Martin, executive director of innovation and an adviser at the Institute for Healthcare Improvement, write that large employers are key to making the Affordable Care Act work up to its potential.

They write:  {L}arge employers can play a powerful role in building on what the ACA and other initiatives have achieved to date and accelerate the positive transformation of the U.S. healthcare system.”

“Through the ACA, many new customers have been able to enter the healthcare  market, but the market remains inefficient. The ACA includes mechanisms for cost reduction that employers can build upon by contributing their purchasing power to create a complementary quality-based market to address the trillion dollars in waste that continues to burden patients, providers, and employers alike.

“Businesses as well as public sector entities can play a lead role in mitigating political hyper-partisanship and special interests by working directly with local healthcare providers to define, secure, and execute to transparent standards. Pragmatism can prevail.”

To read the article, please hit this link.

Integrate military and civilian trauma care, says report


A U.S. soldier undergoes surgery in New Guinea in World War II.

Writers of a report by the National Academies of Sciences, Engineering and Medicine are asking the government to integrate military and civilian trauma care to address our era of mass shootings and other terror attacks.

The  authors write that up to 30,000 Americans die each year of traumatic injuries that they might have survived had they received better emergency care.

“Both the military and civilian sectors have made impressive progress and important innovations in trauma care, but there are serious limitations in the diffusion of those gains from location to location,” Donald Berwick, M.D., president emeritus of the Institute for Healthcare Improvement and chairman of the committee that wrote the report, said in a statement. “Even as the successes have saved many lives, the disparities have cost many lives.”

Dr. Berwick also served as acting director of the Centers for Medicare & Medicaid Services.

The authors proposed that between wars, military hospitals  also operate as civilian trauma centers—to share lessons from the battlefield and to maintain the military trauma teams’  readiness for the next conflict.

To read the Wall Street Journal article on this, please hit this link.


New IHI head talks about his Scottish experience



The “Old Course” at St. Andrews. Mr. Feeley, like many Scots, is an enthusiastic golfer.

Derek Feeley is the new  chief executive of the Institute for Healthcare Improvement. Mr.  Feeley is  from Scotland, where he was head of the national healthcare system before becoming executive vice president of the IHI in 2013.

In this Hospitals & Health Networks interview he talks his experience in Scotland. Among his remarks:

“{The Scottish system is}a single-payer system. It’s almost exclusively tax funded. There’s very little competition. The National Health Service is more or less a monopoly provider of health care, but part of my responsibilities in Scotland was extended to the health of the population, as well as to delivering effective health care, and I had to do that within a cash-limited financial allocation…. So what I had to do in leading that healthcare system is what we call the Triple Aim at IHI:”

  • “Improving the patient experience of care (including quality and satisfaction).
  • “Improving the health of populations.
  • “Reducing the per capita cost of healthcare.”

“I had to make sure that the quality of the healthcare experience we were delivering was as high as it could possibly be, and I had to make sure that we were delivering improvements in the health of the population. I had to make sure that we were getting maximum value for every dollar that we were spending.”

“The challenges that leaders are facing in healthcare are pretty similar right across the developed world, actually — economic factors, political change, demographic pressures, the growth of co-morbidities, shifting customer expectations, and the accelerating pace of change. The challenges that leaders are facing are actually very similar across the Developed World. There never has been such a challenging time to be a leader in healthcare, but the good news is, because we are all tackling the same kind of issues, the opportunities for us to collaborate and learn from each other are significant.”

Video: New IHI head talks about the key to population health

In this Hospitals & Health Networks video, Derek Feeley, the incoming head of the Institute for Healthcare Improvement, talks about the key to better population health.




IHI’s chief’s parting word of advice for execs


Maureen Bisognano, the retiring head of the Institute for Healthcare Improvement, has some parting words of advice for hospital executives. They include, reports Hospitals & Health Networks, the need to change how hospital executives:

  • Think about new ways to collaborate with  people they work with now, and find new partners in the field.
  • How they hear  patients’ concerns.
  • How they teach, learn and see.
  • How they care.
  • How they lead.



3 tips on advancing population health



The National Institutes of Health, Bethesda, Md., in Montgomery County. The presence of the NIH and other big healthcare centers in the county have helped make it a healthcare-reform leader.

The Primary Care Coalition in Montgomery County, Md., discusses its lessons as it has pushed to improve population health.

  1. “Every project does not need to focus on all three dimensions of the Triple Aim (but your portfolio of projects does).”
    “Until this year, we tried to include a measure for population health, patient experience, and cost reduction for every project we had. Previously, we thought a Triple Aim portfolio was a collection of projects each of which should achieve all three aims simultaneously. We now understand that our portfolio of projects needs to achieve all three aims. ”
  2. “Be clear on the definition and identification of your population.
    “{A] lesson we learned from Kick-Start the Triple Aim was about the formal structure underlying the Triple Aim. First and foremost is to be clear on how we define and identify our population. For an organization like ours, that can get a little messy. Having complete clarity, however, drives how we operate going forward.”
  3. “Never underestimate the value of learning from patients.
    “The Triple Aim prototyping work we did with IHI {the Institute for Healthcare Improvement} focused on emergency department (ED) utilization and contributed to the success of our efforts to link ED patients to primary care (as described in a study published in Health Affairs in May 2015). During the prototyping, IHI promoted the concept of studying an “n of 1” [with “n” denoting sample size] and pushed us to see how much we could learn from talking to a single patient who went to the ED. We started small and ended up doing a number of interviews.”

ProPublica gives surgery patients more data



ProPublica, an investigative news organization,  posted its Surgeon Scorecard with complication rates for almost 17,000 surgeons on July 13, based  on Medicare billing records.

So here’s more data for patients to go shopping with.

It found that overall complication rates, based on hospital readmissions within 30 days of the surgery and death during the initial stay, were 2-4 percent during the five-year study period.

Medscape reported that “Remarkably, almost 800 surgeons who performed at least 50 procedures had no complications to their name, proof that their colleagues have room for improvement,” ProPublica said.

The procedures in question are knee  and  hip replacement, gallbladder removal, prostate removal, prostate resection and three types of spinal fusion — one involving the neck, and two involving the lower back. ProPublica selected these eight procedures because they are typically performed on healthy patients and “are considered relatively low risk.”

MedScape reported that “The database excludes trauma and other high-risk cases more prone to complications as well as procedures performed on patients admitted from a hospital emergency department or some other healthcare facility.”

Some physicians  worry that the  inability to fully account for individual patient differences in the study could motivate surgeons to turn down complication-prone cases  to avoid  poorer numbers on Surgeon Scorecard.

MedScape reported that Donald Goldmann, M.D., chief medical and scientific officer at the Institute for Healthcare Improvement, said that Surgeon Scorecard doesn’t go far enough in helping patients choose a surgeon.

‘”This is just about readmissions and deaths,’ said Dr. Goldmann, who is also a clinical professor of pediatrics at Harvard Medical School. ‘”That’s interesting, but that’s not going to drive my decision.”

“If I’m having a prostate procedure, I want to know my risk of winding up impotent, or incontinent. If I have a knee replacement, I want to know what my functional status is likely to be a year from now. That’s what matters to the patient.”

How public-health officials, hospitals should team up


“Driven by the increasingly shared vision of managing population health, officials for hospitals and public health departments are working together more closely,” notes Hospitals & Health Networks.

“These two types of health organizations do not have a tradition of working as true partners, but resources are available to aid in the process from such organizations as the Institute of Medicine, the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation.”

This article also takes you to  11 recommendations stemming from 12 successful hospital-public health collaborations.


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