Sunday, October 21, 2012

Arrogance, Ignorance and Incompetence: The State of Practice in Medical Care?

A 2010 Stanford piece on "How Teaching Hospitals could lead Medicine's Metamorphosis" details their processes for improving Patient Safety, Quality Improvement and reducing costs/improving Productivity.

I was struck by a simple question about the Stanford protocols, especially in the ICU:
If they aren't the minimum standard for non-teaching hospitals everywhere, then what do they know that Stanford doesn't?
I think that, especially in ICU, there is now no excuse for hospitals anywhere not to be following, albeit with a delay, the Best Practices researched and adopted by leading teaching hospitals. Reasonable practice would be: pick just one, or two, major teaching hospitals and mirror exactly what they adopt, but delayed by 12-18 months. You get the benefit of pick others' brains and having them iron out the bugs in the protocols for you...

For any management, including the CEO, responsible for hospitals' Quality of Care and Patient Safety, isn't ignoring known, documented Best Practice either Ignorance, Negligence, or Indolence? Any of which you'd hope in an ideal world, would be cause for instant dismissal.

I can't see how any modern hospital system could condone allowing proven, documented improvements to not be used.
Quality, Safety and Cost-Effectiveness are linked:
fewer preventable errors and injuries means a lot less time, money and resources are wasted.
Delaying implementing proven improvements doesn't save money, it can only cost money.
Just who is seeing a benefit? And what is that benefit? I don't get it...

Which lead to some questions about the Queensland Public Hospitals Commission of Inquiry, initiated by Jayant Patel, the "Dr Death" of Bundaberg Hospital:

  • The Commission didn't calculate the whole system cost effects of Patel's poor practice.
    • They resulted in increased local revenue, but what about the costs for Queensland Health and the Queensland Government, paying for the expensive Commission of Inquiry.
  • The Commission didn't demand or recommend that their recommendations would be implemented.
    • Some of the findings were in the same areas, on the same problems resulting in the same recommendations.
    • This would, prime face, seem to be a serious abrogation of Fiduciary Duty towards both Patients and the Queensland Government by many levels of management in Queensland Health. Most importantly, the various Health Ministers and heads of Qld Health who are ultimately responsible for implementing Governance and Accountability systems and checking they perform.

Quotes from the article, which starts with a case-study on the Stanford's twice overuse of blood compared to a peer teaching hospital:
Now in health-care circles, “quality” means standardization based on evidence-based protocols, and in the last few years, the number of protocols has multiplied. There are guidelines for running ventilators and modulating blood sugars, and there are control measures for infections, for sedation, for nutrition and for care of patients who suffer cardiac arrest. The hospital board of trustees now has a committee specifically to review how well quality measures are being followed. Rizk chairs another twice-monthly meeting for the ICUs to consider new protocols and to assess how they’re working. In fact, there is now a backlog of protocols waiting to be posted on the hospital’s intranet, he says, noting that while it would be good to have them up more quickly, it is also a sign of the tremendous appetite for enacting evidence-based medicine.

Equally important is the transparency that hospitals are practicing in conjunction with these protocols. Hospitals’ performances on certain practices are being regularly tracked and shared not just within the hospital, but also with the public.

One way that teaching hospitals are likely to adapt is by putting more emphasis on research into what’s known as “comparative effectiveness.” It involves doing studies that compare drugs, medical devices, tests, surgeries or ways to deliver health care and then using the evidence from that research to guide care provided by physicians and hospitals. The goal is to provide the basis for new standards and protocols that will not only improve quality, but also cost-effectiveness and efficiency.

Although you might think that the treatment you receive has been carefully evaluated, all too often it has not. “When you shop for a new car, phone or camera, you have lots of information about your choices,” explains the U.S. Agency for Healthcare Research and Quality on its website. “But when it comes to choosing the right medicine or the best health-care treatment, clear and dependable information can be very hard to find.”

Title borrowed from:

Other People's Money: A chronicle of arrogance, ignorance and self-delusion
Other People's Money: The Complete Story of the Extraordinary collapse of HIH
Andrew Main, (Harper Collins, 2003), ISBN: 0732276659

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