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.
Having just returned from Mayo where I could freely drink from the Social Media waters, it seems a letdown to return to my hospital where access to Facebook, Twitter, Pinterest, Slideshare etc is blocked. Even email updates about our internal private Yammer network are filtered out by their spam filter.
At the recent Mayo Social Media Residency I shared my views with representatives from Lehigh Valley, City of Hope, American Acedemy of Orthopedic Surgeons, Baylor University, The Doctors Company, Sutter Health, the list goes on and on. They were amused about my system’s inability to embrace Social Media.
While the meeting was underway, we were broadcasting live Tweets, Blogs, and posting videos to social media sites. That is not possible where I work.
This is not likely to change soon.
At the Residency we were shown a video of a speech by Mayo’s CEO Dr. John Noseworthy who in 2009 exhorted the clinic to accelerate effective application of social media throughout Mayo Clinic. A year later the Mayo Clinic Center for Social Media was launched. The rest is history for all to see on the Internet, unless you are at my hospital (I attempted to look at the Slideshare Mayo Social Media history but my access was blocked).
My health system can and should do this. The change will have to bubble up from us minions at the bottom driven by progressive loss of our digital footprint to other more progressive health centers.
If we wait for the change to come from above, I fear I will then be closer to reaching Medicare eligibility.