THOMAS SCALEA’S PRESENTATION “REPAINTING THE CEILING: PATIENT SAFETY AND SATISFACTION IN THE ERA OF COMPUTERIZED MEDICINE” - JUNE 2016 AT THE LD BRITT SURGICAL SOCIETY, EVMS, NORFOLK VA.
A few weeks back I was fortunate to have attended Tom Scalea’s talk at the LD Britt Surgical Society Grand rounds titled: “Repainting the Ceiling: Patient Safety and Satisfaction in the Era of Computerized Medicine.” This was based on his recent personal experience as a patient as well as Greg Jurkovich’s Presidential Address to the Western Trauma Association in 1997 “Paint the Ceiling: reflections on Illness”. Highlights in Dr. Scalea’s talk were 1. Questions about quality measures and their influence on clinical decision making. 2. Reality of Patient Satisfaction 3. Reality of improvements made by the EMR and Resident Duty Hour restrictions. The first two of the topics seemed to really hit home with me- I have already discussed topics such as our dogmatic interpretation of “quality” measures and “patient satisfaction” scores with many others so I was very interested in this.
DO QUALITY MEASURES TRUMP EXPERIENCED EVIDENCE BASED CLINICAL DECISION MAKING? During his talk I asked myself “Why are we allowing outside reviewers to coerce our clinical decision making when we know we are doing the right thing?” Case in point, Dr. Scalea pointed out that most facilities have detailed report cards which includes SSI’s and other “quality” measures. After a negative “Peer” review letters and / or report card, we tend to alter clinical care based on these reports. In his example, he was faced with a prior report which criticized his lack of use of ileostomies as a cause of post colectomy SSI. For the same reason most of us to not use ileostomies, he reiterated that they are frequently hard to control, cause profound electrolytic and fluid imbalance, and inevitably require another operation. In spite of that he found himself performing a stoma in spite of his better judgement. Dr. Scalea noted that he has received correspondence from other providers who also confide that they find themselves making clinical decisions, not on the basis of actual clinical reasoning, but solely on the virtue of potential criticism if there was a bad outcome. Many surgeons can relate that they become fearful of these scores because they are inevitably used in the credentialing and privileging process (what if I want to go elsewhere and these scores look bad). There is also concern that since there is such a microscopic view over physician clinical decision making that academic faculty are frequently engaging in a microscopic approach themselves regarding patient care which essentially removes the house staff from the independent decision making process. How are our future surgeons going to learn if they cannot make any decisions?
Other examples included the independent enforcement of CLABSI and CAUTI score protocols. Concern was expressed that these scores are frequently tied to facility leadership and nurse manager incentives; so these are scrutinized continually potentially without thought to clinical consequences. Case in point: there appears to be so much an incentive to remove catheters that staff continually request to remove them even when a consistent and viable explanation is provided why they needed to stay in. Comparably, there seems to be minimal oversight on the number of peripheral IV’s inserted or monitoring of peripheral IV induced septic thrombophlebitis (or that matter inappropriate use of peripheral IV’s in specific patients such as mastectomy patients). In some places a physician order is not even required; Foley catheters are removed by “protocol” without providers’ approval (even when removal can yield untoward consequences such as the need to monitor a patient who may be in abdominal compartment syndrome). So the question arises as to how can we bring common sense back into clinical care regarding these measures?
DO PATIENT SATISFACTION SCORES REALLY EQUATE TO GOOD CARE? Dr. Scalea reminded us to use some common sense when interpreting the anticipated outcomes from processing patient satisfaction scores. It has been shown that a focus on patient satisfaction above quality measures can result in poor care if that is all facility leadership is focused on. This has already been the case in several institutions where the facility has outstanding patient satisfaction scores but the facility has major issues with readmissions, deaths, DVT, and complications in general.
Dr. Scalea pointed out that two factors seem to improve healthcare more than any: 1. Financial incentives and 2. Nurse staffing ratios. The only factor that seems to result in improved health care and improved patient satisfaction scores is better nursing staffing ratios. Better Nursing staff ratios resulted in reduction in mortality, improved quality of health, fewer failures to rescue, shorter hospital stays and fewer fatigue related errors (See Xu, Aiken et al below). In Dr. Scalea’s institution, implementation of the financial incentive program showed drastic improvement in turnaround times in the OR in 2013 (reduction in the incentive program was followed but worsening scores).
IS THERE A BETTER WAY TO IMPROVE PATIENT EXPERIENCE? Dr. Scalea pointed out that it really does not take much effort in the end to improve a patient’s experience. All you have to do is sit down when addressing a patient and spend 90 undistracted totally devoted minutes to the patient and their family and then they will be happy. If you stand while you are at the bedside, you give the impression you are ready to bolt from the room and not willing to listen to them. Additionally, the attending should speak with the families directly whenever possible and not speak thru the ICU staff. We need to be sure that the family clearly understands the information being given to them and that we are communicating in a language they can understand.
His summarized his presentation as follows:
• Many healthcare executives know little about health/caring and that we should be driving the bus.
• We cannot focus on the money, the computer or what we personally get out of the patient encounter.
• If we take care of patients the way we wanted to be cared for then we would solve 75% of the problems.
• If we spent the “quality” money on patient care and /or nurses we would be far ahead.
In the end he noted that we should remember that we are privileged to do what we do, so why should we be in a bad mood? If we remember that the people staring at the ceiling all day are the ones having a bad day we will provide a better experience for our patients.
At the end of this talk a few items came to mind.
1. VALUE IN HEALTH CARE VS PROVIDING PATIENTS THE CARE THAT THE SURGEON KNOWS IS THE RIGHT THING TO DO: I had a conversation in April with Bruce Ramshaw about “Implementation of Value in Healthcare” where we discussed the overall experience in care including quality, safety, satisfaction and cost of the entire cycle of care for each patient. How do Surgeons engage facility leadership and other surgeons in this concept? That is, Surgeons acknowledge that quality, safety, satisfaction and costs are all important if we want to provide excellent healthcare, but how do surgeons maintain some sanity in this whereby they can make appropriate decisions without being coerced into doing what we just do not feel is ethically right? (http://crisislead.blogspot.com/2016/05/implementing-value-based-clinical.html?m=1 )
2. WHAT IS OUR ETHICAL OBLIGATION WHEN WE KNOW WE ARE NOT ABLE TO PROVIDE THE HEALTHCARE WE SHOULD BE IN THE CONDITIONS PRESENT IN OUR FACILITY? J David Richardson pointed out recently the dilemma they face in Louisville due to staffing shortages (see link below). Where do physician ethical obligations end? What happens when surgeons feel that administrators look at patient care as a product? When do we stand up for the patients?
3. HOW DOES ONE ESTABLISH A COLLABORTIVE VENTURE WITH THE FACILITY LEADERSHIP, OVERSEERS OF QUALITY MEASURE DATA AND PROVIDERS? HOW DO WE AVOID BEING DOGMATIC ABOUT THESE MEASURES? HOW DO WE AVOID SURGEONS FEELING UNNECCESSARILY VICTIMIZED RATHER THAN LEARNING FROM A BAD EXPERIENCE AND IMPROVING UPON FUTURE PATIENT CARE?
. Jurkovich, Gregory Jerome MD Paint the Ceiling: Reflections on Illness
Journal of Trauma-Injury Infection & Critical Care: 1997;43(5):733-740.
. Xue Y, Aiken L, Freund DA, Noyes K. Quality Outcomes of Hospital Supplemental Nurse Staffing. Journal of Nursing Administration 2012;42(12):580–585.
Kenneth A. Lipshy, MD, FACS