My hospital asked me to lead a quality initiative for rectal cancer using the ProvenCare model. ProvenCare uses evidence-based best practices to reliably give the best care to every patient. The goal is to reduce unnecessary variation in care, ensure all patients receive essential components of care and optimize patient outcome.
In 2003 Elizabeth McGlynn of the RAND Corporation published a study in the New England Journal of Medicine on the quality of care delivered in the US. Despite readily accessible standards of care in the literature, 45% of patients do not receive recommended care. This deficit in care is a threat to the health of Americans. It also represents unwarranted variation and inconsistency in care delivery, increases costs and affects clinical outcomes. Wouldn’t it be better if every doctor gave every patient the proper care at the right time, all the time?
My hospital rose to the challenge. With the help of a its electronic health record, it re-engineered the complex processes of care, reduced unwarranted variation and reliably delivered evidence-based care for specific diseases.
The ProvenCare model was first developed for elective coronary artery bypass grafting and hit the airwaves with revelation of a sort of money back guarantee. It has been used for bariatric surgery, hip replacement, cataract surgery, coronary stenting, lung cancer, with many other projects underway. Notably the lung cancer model was adopted by the American College of Surgeons’ Commission on Cancer and is being studied in 12 centers. The model came up with 38 elements of care based on evidence-based guidelines. Initial results show the initial six participating hospitals followed 90% of the 38 elements of care.
While some argue, mere compliance with process measures does not translate into better outcome, for many of the above diseases, Provencare has resulted in:
- Increased adherence to evidence-based guidelines
- Improved clinical outcomes
- Increased patient engagement
Rectal cancer represents a unique challenge. About 40,000 new rectal cancers are diagnosed yearly in the US and half will die from this cancer. While some may think most of these patients are treated at major cancer centers by colorectal specialists, only a small percentage receive such care. Most rectal cancer patients are treated by non-specialists in low-volume hospitals. As a result, there is a great variation in how the care is delivered and a great variation in the outcome. The literature shows that local recurrence can be as low as 0% and as high as 37%. Surgical mortality varies between 1.4% to 7% at the high end. The colostomy rate also varies throughout the country. Rectal cancer surgery is difficult as the cancer can be low, confined by a narrow bony pelvis. This can result in incomplete removal leading to local recurrence and death or hinder making an anastomosis (putting the rectum back together).
In addition to the surgical problems, patients should have high quality imaging of the tumor with either endorectal ultrasound or pelvic MRI but many hospitals do not have these tools. Some patients may need radiation and chemotherapy before or after surgery and may never receive it. Some could benefit from a multidisciplinary approach where each patient’s case is reviewed by a team of surgeons, medical and radiation oncologists and other providers. If that patient’s hospital does not have such a team, that team approach is not offered. After surgery accurate assessment of the tumor stage and the margin (how deeply the cancer invades the rectum) affects prognosis and treatment planning. Ideally this is best done by specially trained pathologists which can ensure the quality of the surgery.
So with a team of ProvenCare specialists, the rectal cancer project is underway. This plan will take about 40-50 weeks, with a meeting every week. The project is in 7 stages and presently we are reviewing the literature to identify the ‘best practices’ of rectal cancer care.
As each stage unfolds, I will continue to write about the process.
Today I was notified by Medical Records at my hospital that one of my OR/surgery reports was incomplete. I had done hemorrhoid surgery on a patient 6 weeks ago. Someone in the medical records department flagged a deficiency in my OR note. I had left out the “drain” section – whether a drain was used or not. For my lay readers, you need to know that while drains can be used in abdominal surgery, I have never used one for hemorrhoid surgery in 27 years. In fact I can’t think of any colorectal surgeon ever using a drain for hemorrhoidectomy. In any case I was in violation as the hospital Medical Record Procedure Committee stated that Drain recording is a requirement and has to be addressed in the Operative report. I was directed to Rules and Regulations page 14. Was the documentation of drains a ‘requirement’ of the committee because of government regulatory agency rules or did the committee feel that drains should be used in hemorrhoidectomy? I doubt anyone sitting on this committee knows anything about anal surgery, so it’s likely a misinterpretation or misapplication of a badly written regulation. If this documentation of drains is required, then this should be mentioned in all surgery despite clinical relevance or common sense. Taking this to a ridiculous end in my hospital, drain use should be documented for anal fissure surgery, removal of rectal foreign body and colonoscopy performed in the OR in spite of logic that drains are never used in these procedures. It is thoughtless mindless enforcement of such ‘rules’ and regulations which lead to more and more doctors leaving medicine in frustration.
In a survey by the Agency for Healthcare Research and Quality’s (AHRQ) survey of hospital culture, some revelations came to light. It was disturbing that 26% of health care workers say whenever pressure builds up, managers want them to work faster, even if it means taking shortcuts. Fifty percent said they work in a “crisis mode”, trying to do too much too quickly and disturbingly, 36% report that safety is sacrificed to get more work done. Safety does not seem to be the priority when managers/administrators exhort workers to do more and overlook repetitive safety problems.
This is probably the tip of the iceberg. Each hospital is already under financial stress. They are placing higher unattainable financial targets in order to clear their overhead expense and try to break even what with the government cutbacks, increasing expense of business, etc.
It is hoped that with evolution in healthcare funding, there will be less emphasis on volume and more on good outcomes and results from the care delivered.
Complications can occur when a patient receives care. In fact, some patients develop a complication such as a wound infection after surgery. When that happens I don’t feel it is due to a mistake or error but many hospitals approach this in a punitive way. An email/letter is sent to the doctor but to get the point across it is also sent to the Department Head, Chairman of Surgery, and various administrators, so the complication is for all to view. All this does is make doctors reluctant to report errors.
Dr. Lucien Leape from Harvard in testimony to congress said, “the single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”
Only by developing a “Just Culture” and transparency like the airline industry where errors are reported without punishment will lead to improvement in healthcare safety. Continuing to push providers and punish the bad outcomes will leave healthcare mired in the last century.
Many doctors are leaving private practice and becoming employees of giant hospital systems. This is not because they want to but because of financial hardship – the cost of private practice is rising while payments and revenue are shrinking. According to the New York Times in 2002 70% of medical practices were physician owned and this dropped to below 50% in 2008.
I know a surgeon employed by a hospital on the East Coast. He finds that working for “the man” is not all that rewarding. He likes the certainty of income, avoiding the issues of hiring/firing and he no longer has to worry about billing and collections. This hospital like many around the country has emblazoned everywhere slogans about quality, “patient first”, and excellence. This surgeon feels these are false messages, more a form of advertising or proclamations.
The reality is that the hospital wants increasing efficiency and higher patient volumes. Like all his ‘partners’ he has a target he has to meet yearly so that his employer (the hospital) will pay him his full salary. Every time he sees a patient in consultation or operates, he generates a certain number of RVUs (Relative Value Units). A more complex consultation or more difficult operation is rewarded with more RVUs.
In private practice he ran 2-3 clinics a week where he could spend an hour or more with new patients. As an employee he can’t run more one clinic a week, as the department of surgery has a limited budget. It can only hire a small number of nurses and physician assistants all of whom are busy helping the other surgeons. In his one clinic he is given ½ hour for new patients and less time for follow-up visits. The financial targets are increased every year so all the surgeons have to generate ever more RVUs. In order to increase efficiency, my colleague was encouraged to see more patients in his clinic and cut new patient encounters down to 15 minutes. On most clinic days, he has no time for lunch. He was instructed find other ways to generate more RVUs, but his department would not be hiring any more staff to support this goal because of budget constraints. His busy schedule and lack of support also limits his availability to help colleagues when urgent consults arise.
He wonders if the same ‘higher-ups’ and administrators exhorting him to do more, could do their job with similar limitations in their support staff.
These factors are eroding his satisfaction at work and leading him to ponder leaving or retirement. When he told his supervisor, he was informed there would be no changes, the work volume and lack of support would persist and he like other doctors who have already left, could be replaced.
That is not the best method to make employees feel valued. The doctors and staff feel little respect from the ‘system’.
This constant push for more production really flies in the face of the proclamations posted everywhere about “patient first” and quality. There is a pathologic obsession with RVU production. Perhaps a move to a Value Based RVU system may help http://www.nejm.org/doi/full/10.1056/NEJMp1310583.
My overall sense is that those considering moving from private practice to becoming a hospital employee should carefully investigate the philosophy of the organization first.
Click on this link to read it – Moral Duty to Buy Health Insurance
This article in JAMA was pointed out to me by my son. Tina was his fellow classmate in the Yale Philosophy Phd program. I understand this article caused a stir among celebrities.