Recently, a close friend of mine, whom I’ll call Judy, suffered a heart attack and went into shock.  Without reversing the shock, she would die.  The on-call cardiologist saved her life by opening up the blocked artery and inserting a temporary pump to assist her heart until it was able to maintain a normal blood pressure on its own.  He saved Judy’s life for which we were all extremely grateful.

Exemplary care so far.  But…

My friend began to have misgivings about this cardiologist who didn’t see her the next day, and, when he did see her, it was difficult to communicate with him.  The nurses also indicated that they continually had communication issues with this doctor.  Based upon this, Judy was determined to find another cardiologist after her hospitalization.

More Questionable Quality

While she was in the hospital, several other incidents left Judy doubting the quality of the care she was getting.  One incident occurred while she was trying to get some sleep at night.  Because she was cold she covered her head with a blanket.  About an hour later a Nursing Assistant (NA) took her temperature with a device that measures the temperature of the patient’s skin.  It should be taken on exposed skin, ideally the forehead.  Instead the NA checked the temperature on my friend’s neck that had been covered by the blanket.  Naturally, the temperature was high suggesting my friend had a fever.  Rather than checking it again later after the blanket had been off, she charted that Judy had a fever.  Because an infection after a procedure can cause serious complications, doctors often write standing orders for their post-procedure patients specifying what tests should be performed and what treatments should be given if a patient develops a fever.  So, charting that “fever” set the ball rolling and that included a chest x-ray, blood draws for blood tests, blood cultures and getting a urine sample.  All this happened in the wee hours of the morning so Judy couldn’t get any sleep.

What added insult to injury was the fact that shortly after the erroneous temperature was recorded in the computer, a Registered Nurse (RN) rechecked my friend’s temperature and it was normal.  But the nurse said she couldn’t stop the testing once it was charted.  Consequently, Judy was needlessly inconvenienced and unnecessary charges were generated that her insurance will have to pay.

Here are the areas that raised questions about quality during this 3 day hospital stay from Judy’s perspective:

• Poor communication by the physician
• Lack of training & common sense on the part of the Nursing Assistant
• Either lack of training on the part of the Registered Nurse on how to override the computer, or
• Poorly devised computer system that doesn’t allow for legitimate overrides

Since it’s true that the most important thing was the fact this doctor and the care at this hospital saved Judy’s life, someone might say that these few quality concerns should be overlooked.  Indeed, most of these concerns really fall under the category of Customer Care or Service.  How important is customer care in the delivery of health care?  Does poor customer care trump technical clinical quality?

In my next post, I’ll explore customer service and health care.  Please share your thoughts on this topic.

For Your Health – Dr. Bob

It’s been months since my last post.  I apologize for the delay, but I’ve been busy working as the Medical Director for an Accountable Care Organization (ACO) since August and think some of my experiences can offer some insights about new developments in our health care system –  insights that everyone can use.  In this post, I’ll give you a brief overview of Accountable Care Organizations.

CMS through regulations found in the Patient Protection and Accountable Care Act is encouraging the formation of ACOs to address some of the problems in our health care delivery system through innovation that moves us from a fee for service to fee for value.  Here’s the definition from the Centers for Medicare & Medicaid Services (CMS):

“ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.”

They are focused on achieving the Three-Part Aim of:

• Improving the experience of care
• Improving the health of populations
• Reducing per capita costs of healthcare

To make sure that quality is enhanced, ACOs must report 33 quality measures within the following 4 areas:

• Care coordination & patient safety
• Preventive health services
• Care for at-risk populations
• Patient & caregiver experience of care

In my next post I’ll talk about some of the opportunities for ACOs to improve how care is delivered for Medicare patients, many of which are applicable to the entire U.S. population.

For Your Health – Dr. Bob

This is a complicated question since it goes beyond your satisfaction as the patient.  Certainly your satisfaction with the services you receive is extremely important, but since you are probably not an expert in every aspect of medicine, you may not know whether the test or treatment you receive is the most appropriate for your condition.  In most instances, you are reliant on the physician to give you the correct diagnosis for your medical problem.  Today, I want to talk about the importance of satisfaction in assessing the medical care you receive.

Over 20 years ago, in 1990 the Institute of Medicine (IOM) gave a definition of quality of care that has been useful ever since.  In their publication, Medicare: A Strategy for Quality Assurance, they defined “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”  Though referencing Medicare, this definition works for all healthcare.  I feel that if you are not satisfied with your experience, whether it is an office visit with your PCP, an x-ray procedure or a surgical procedure, it can lead to your questioning the appropriateness of the other aspects of your care where you aren’t the expert.

I would suggest you measure each part of your healthcare experience by asking this simple question: “Did this encounter meet or surpass my expectations?”  When evaluating your experience, for example a PCP office visit, consider everything about it:

• Courtesy of the front desk staff
• How long you waited in the waiting room
• Courtesy of the person who escorted you to the examining room or doctor’s office
• How long you waited to see the doctor
• How well the doctor communicated with you
• The thoroughness of the examination
• The clarity of the diagnosis and treatment plan
• Your comfort level of being able to communicate with the physician should you have any questions

Please submit your comments, such as, how would you rate your satisfaction with your physician and other health care providers you’ve seen?  How can things be improved from your perspective?  I’ll talk more about other quality measures in my next post on Using the Healthcare System.

For Your Health – Dr. Bob