Archive for March 2008

Average Time of Discharge: Why a Hospital is Not a Hilton

Do you get as annoyed as I do about being pressured on your “Time of Discharge?” I just received my monthly report, and we’re in The Doghouse again: our average TOD – 3:28 pm – is hours after “check-out time.” But when did we turn into the Holiday Inn?Let’s start by appreciating where this comes from. Many hospitals, including mine, tend to run full – given the huge fixed costs of operating a modern hospital, being full is probably the only way you can be profitable, just like the airlines. Queuing theory (don’t tell me you’ve forgotten your queuing theory!) tells us that, when you’re full, you should look for fundamental choke points and do your best to relieve them. There are PhDs working for McDonald’s whose lives are dedicated to figuring out how to avoid lines at lunchtime rush hour, and others working in aviation who model the best…

The Great Quality Debate: Berwick’s Plea for Action vs. Evidence-Based Medicine

In this week’s JAMA, Dr. Don Berwick, CEO of the Institute for Healthcare Improvement, argues that evidence-based standards should be relaxed for quality improvement practices. Ironically, a few pages away, a Swiss study finds than an IHI-endorsed MRSA prevention strategy doesn't work.What’s a person or hospital to do?A little background on both issues, beginning with the Berwick piece. Don, as everybody knows, is the world’s leading figure in safety and quality – much of today’s quality movement was generated by the force of his ideas and personality. His Institute for Healthcare Improvement (IHI) has become indispensable to workers in the field, spreading the gospel and providing tons of practical tools, conferences, and other resources that have undoubtedly saved thousands of lives. Personally, I think he is a uniquely brilliant and effective person – one of the truly remarkable people in healthcare.But, beginning with a report on evidence-based patient safety practices…

NPR’s Morning Edition Story on Physician Blogging and Patient Privacy

Here's the link, featuring, among others, celebrity blogger Kevin, M.D., as well as yours truly, batting clean-up. Although the privacy concerns raised by the story are real, personally I thought the psychiatrist went a bit overboard when she said,"If you are unhappy with the people that you're supposed to be serving and taking care of, you probably need therapy," she says. "You don't need to be venting your frustrations in a public manner like that. That's very inappropriate and unprofessional."Re-read my last post on resuscitating 90-year-olds with metastatic cancer and dementia. Do I need a head shrinker?

Absurd: Resuscitating 90-year-olds with Dementia or Metastatic Cancer

Last month on the wards, I unilaterally told two patients’ families that we were not going to resuscitate their loved ones. My residents were horrified – this violated the DNR playbook – but the alternative seemed both immoral and absurd. What do you think? In deference to HIPAA, I’ve altered a few clinically irrelevant factoids, but here’s the gist: In both cases, the patients were elderly Asians. One was a 92-year-old nursing home dweller with severe dementia; prior to admission he was bed bound and could not recognize his family members. He was admitted with pneumonia and ARDS, and had been intubated for nearly a month when I assumed his care. My predecessor had held a number of family meetings; in each, the family insisted on doing “everything,” and that’s precisely what we did. The family continued to demand the full court press, even as his organs shut down, one…

And Speaking of the Unintended Consequences of Quality Measurement…

I must have "you can't manage what you don't measure" on the brain – here's a piece I wrote this week for AHRQ's Guidelines/Quality Measures Clearinghouses called "Is the Measurement Mandate Diverting the Patient Safety Revolution?" Well, of course it is.In it, I make the point that our hunger for measurable targets – generally a good thing – automatically diverts us from that which we don't or can't measure. In the quality and safety world, this means that we're spending a lot of time documenting smoking cessation counseling and very little on avoiding transition errors; a huge amount of energy on preventing ventilator-associated pneumonia and precious little on improving teamwork; and, most perniciously, oodles of effort making sure that we complete a group of measurable processes, some of only marginal importance, and almost none on making correct diagnoses. As I wrote in the piece, ...as long as a system or…
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