More Stupid Hospital Documentation Rules

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.

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Patient Safety vs Just Culture

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.

#AcadSurg14 Academic Surgical Congress Association for Academic Surgery San Diego 2014

I just attended the Association of Academic Surgery (AAS) meeting in San Diego. This was my first time there and I enjoyed the meeting very much. Many of the surgical papers showed a trend away from randomized controlled trials, with more focus on large patient databases such as NSQIP, National Inpatient Sample, SEER, National Cancer Database, etc.

Some had told me that AAS meeting attendees tended to be cool, almost aloof, but my experience was the opposite. Because the AAS provided lunch during some of the meetings, I was often seated with many whom I did not know. On many occasions, I found a ready handshake and easy conversation.

I did notice a few things about the meeting. The Hyatt hotel was large, hosting at least 3 or other meetings, so I noticed that once inside the building there were no signs to point out the registration desk. After I was directed from the 3rd floor to the main floor lobby and wasted 15 minutes, I found the AAS meeting. I would suggest that certain folks be easily identified to help those of us who are new to find our way. Improving signage would also help.

In addition to many new face to face contacts, the AAS also provided electronic means of connecting. Twitter opened the attendees to collaboration opportunities between different centers. There were sessions devoted to media, communication skills, career advancement, billing, global surgery, and political issues like Obamacare and Gun Control. To my delight a great deal of focus was on Social Media with even one paper presented on Twitter use. The slides from that presentation were uploaded to SlideShare for all to see. Some attendees wore a Twitter ribbon indicating they were going participate heavily by Tweeting during the meeting. Many conversations were started through Twitter. This surgery meeting was probably one of the first not to demand attendees to turn off their phones which were busily used to engage via Social Media.

It is nice to see a surgical society come into the digital age by embracing these Social Media tools.

I will return.

How I Use Twitter

With all the buzz online and in the news about the Twitter – how it should be used, the stock, can it make a profit, I decided to write about how I came to embrace Twitter. Before October 2013, I knew nothing about Twitter. I only started an account after attending a course in Social Media at the Mayo Clinic.

Around that time everyone, everywhere was chatting about the upcoming Twitter IPO. People asked what was Twitter, what was its role, how could one use it. Many predicted the IPO would not do well as it had yet to make a profit and some felt its growth was slowing.

I read “Hatching Twitter” by Nick Bilton who wrote there “were two completely different ways of using Twitter. Was it about me, or was it about you? Was it about ego, or was it about others? In reality, it was about both.”
For some, like celebrities, it is about sharing status, where they are, or what they are doing. For others it is about sharing news, more a “communication network, not just a social network” Bilton writes.

This disagreement underpinned that of two Twitter founders, Evan Williams and Jack Dorsey, which lead to each falling out as friends and partners.
I don’t care if Twitter ever makes a profit. I am happy to use it my own way as each and everyone of you can use it as yours.

As a professional, I avoid Tweeting about myself as much as possible. I use Twitter to post links to interesting articles about my work, health care and surgery. I can always go back to these references later. In that way, Twitter is a catalogue of my online professional musings and learning.

I attend several medical conferences a year. Twitter allows me to share what I learned from these meetings and some have gone so far as to say that social media tools like Twitter may make attendance at these meetings obsolete. I hope not. While at a meeting, I use Twitter to share information, start conversations, and share my adventure as a tourist with pictures of local sights, restaurant finds, and discussions of things to do.

On a personal note, I do use Twitter as a form of a diary. It matters little to me if my followers read it as I am tweeting for myself. I spend a lot of my leisure time travelling, eating out, reading and at the movies. Sometimes I forget what I did or when I saw something or travelled somewhere. I attribute this to age. So I record most of my day on Twitter so I can reflect back on these experiences and memories later. I expect that with time and a growing number of posts, going back to review these will become more difficult.

How you use Twitter will not be the same as how I do it. Perhaps you want chat about a topic, investigate an interesting topic, market or sell something. I wanted to write about the particular way I use this social tool.

In Major Hospital Systems, Is it Truly Patient First?

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.

Healthcare – The Moral Duty to Buy Health Insurance

Click on this link to read it – Moral Duty to Buy Health Insurance

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.

Overcoming fragmentation in health care (Mayo Clinic CEO John Noseworthy)

Overcoming fragmentation in health care (Mayo Clinic CEO John Noseworthy

Mayo’s CEO talks about our fragmented health care system where quality of care is variable, which cannot sustain high spending on the Harvard Business Review.