Category Archives: hospitals

Ballooning Healthcare Costs

The prices of things are going up again (they call it inflation), but probably in no other area of industry is the inflation rate going up relentlessly year after year in the region of 10-15%. Take a look here:

healthcare-chart

The way things are going, this cartoon may not be that funny at all:

healthcare-nowadays4

Here’s my tips on how you can cut your healthcare costs (short of not receiving any!):

https://doctor2008.wordpress.com/cutting-your-healthcare-costs/

The World’s Best Hospitals – How To Be One

Lots of hospitals claim to have world-class facilities and boast of being the region’s best, but what really does it take to be one? The mere presence of a five-star hotel lobby with expensive chandeliers and smiling receptionists definitely is not one criteria. Lest we forget, people come to a hospital with a problem they want fixed; the rest are just superfluous and complementary.

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The lobby of Chiangmai Ram Hospital, Thailand.

The best medical centers for the most difficult patients – that’s how the US News & World Report decides which are the best hospitals in the US, for example. They have been publishing annual rankings of the best hospitals in the US since 1991. The latest list was released last week:

US News & World Report Top Hospitals Honor Roll 2013

1. Johns Hopkins Hospital, Baltimore, Maryland

2. Massachusetts General Hospital, Boston

3. Mayo Clinic, Rochester, Minnesota

4. Cleveland Clinic, Ohio

5. Ronald Reagan University of California–Los Angeles Medical Center

6. Northwestern Memorial Hospital, Chicago, Illinois

7. New York–Presbyterian University Hospital of Columbia and Cornell, New York City

8. University of California–San Francisco Medical Center

9. Brigham and Women’s Hospital, Boston

10. UMPC-University of Pittsburgh Medical Center, Pennsylvania

johns hopkins

Johns Hopkins Hospital,Baltimore,Maryland – rated top in the US despite its ordinary facade.

Its interesting to note from the above list that Johns Hopkins was displaced from its top spot only once – last year in 2012 – when it went to the current runner-up. All the top five have consistently retained their top five status.

The magazine awards points to hospitals based on the individual specialty rankings. In 12 of the 16 specialties, measurable performance in terms of quality of care, safety, and mortality accounts for two thirds of a hospital’s score. The institution’s reputation among specialists, ascertained by a survey, accounts for the remaining one third.

You can read more, including the best hospitals for each specialty here.

So what does it take to be a world-class hospital? Apart from good outcomes, the following are also important:

1. Innovation – A desire to practice in an environment that embraces evidence attracts nurses and other staff to these hospitals.

2. ‘Patient-first’ philosophy – a no-brainer really, but quite easily forgotten by hospitals who pay too much attention to the financial bottom-line. They often forget that its the patients (read ‘customers’) who are paying their salaries!

3. Collaboration – Teamwork creates better outcomes, and many of these  hospitals have embraced fostering greater collaboration between disciplines. Every discipline brings a special domain of practice, knowledge and skill to create a village of information.

4. Quality Improvement- Structured processes for clinical services allow  staff to define and sustain clinical practice standards and incorporate new findings into practice. Care processes and measures for success can be defined and measured via a balanced scorecard.

5. Quality Nursing Care – Patients come to the hospital expecting the best doctor and often, they will get one for their medical condition to be treated appropriately. What can make the difference is the nursing. When nurses add on compasssion on top of the usual nursing skills, they give that extra edge to that hospital’s reputation.

6. Positive Work Environment – Nurses form a key component in any hospital, and to retain and attract them, the hospital management has to create an environment where people will want to work in. In my experience, a good pay is important but this is not the be all and end all. Other factors come into play like professional satisfaction and empowerment.

7. Continuing Education – one of the factors enhancing point 6. We are looking not at just professional education, but also at  social skills like  complaints management.

8. Staff Engagement – When you engage people closest to the work , you  respect them.They want to know where the organization is going and what the driving value is, and you can demonstrate how their work contributes to that. That includes letting the staff know as and when new staff are brought in as part of succession planning.

In my years as a hospital manager, the above values keep on recurring time after time and quite often, many hospitals do not make it to the top quite simply because the above lessons are not assimilated. Let me reiterate, good clinical outcomes are a must.

 

Stroke..A Timely Reminder

Some friends asked me how can they know when someone has a stroke and what they should do about it. Its summarised quite well on this chart.

A few words about the last point –  stroke is a medical emergency. If given through the veins within three hours of the start of symptoms, a clot-busting drug called tissue plasminogen activator (tPA) can reduce long-term disability for the most common type of stroke, by dissolving the clot that caused the blockage.  In some cases, the stroke may be completely cured. As this drug can only be given in hospital, its important to transport a person suspected of a stroke to the Emergency Department as soon as possible.

Going Into A Hospital? Never On A Weekend If You Can Help It..

Understandably, who wants to get admitted to a hospital? But life is such, and in the unavoidable event that this is to happen, it would be wise, if possible, not to get in on a weekend.

Increased Deaths on Weekends - shortage of Specialists Seems to be the cause

The British Independent newspaper highlighted this under the ominous headline, “Weekends worse for hospital deaths” recently. It pointed out that an NHS London study found patients admitted to hospital at weekends were more at risk of dying than those treated during the week, largely due to a lack of hospital consultants at weekends.

Quite frankly, most hospitals throughout the world operate on skeleton staff during weekends  just to provide the basic services on-site.  On the occasion where an urgent specialist referral is required, a duty roster is in existence to summon the specialist from his home, but this usually takes some time. If an emergency procedure is required, there is bound to be a time lapse before all available personnel can be summoned.

Skeleton staffing contributes to higher incidents during weekends

Many hospitals cut off ‘non-essential services’ after office-hours. You’ll be hard-pressed to find dieticians , physiotherapists and some specialists on weekends.The reason is largely pure economics – having then around means paying overtime wages which in the long run may not be economically feasible. Economics aside, hospital staff are basically human and require their rest and ‘me time’ like the rest of us.

It may seem unfair, but hospitals do charge an ‘overtime fee’ or surcharge if services are provided after office-hours, to compensate for the overtime charges of their staff on duty. A CT scan can easily cost double the usual charge if done on weekends. Its okay, the insurance will pay for it, you may say. But third-party payors are getting wise; and, apart from co-payments (where a percentage of the hospital charge has to be paid by the consumer), insurance companies have been known to refuse to pay if such procedures are deemed (in their eyes) to be of a non-emergency nature.

For elective procedures, one would be well-advised to have then done during weekdays, if only to ensure that the full staff complement is at hand, should the need arise for their involvement.

Choosing The Right Doctor

When it comes to finding out which doctor or hospital is the best for one’s needs, many are quite at a loss. In fact, I’ve been asked this question many times. Here are some pointers:

  • Look for a hospital with a good safety record as well as those possessing a recognised accreditation standard (such hospitals voluntarily undergo screening by a recognised review body, such as the JCI, in order to provide services of a certain minimum quality).
  • Find out from your doctor where he sends his relatives to. What’s good enough for a doctor is usually a stamp of approval. Why, even nurses in the hospital may be able to suggest the right doctor if one cares to ask.
  • Look for a doctor who’s busy. Sure, it means long waiting times, but this might be worth it in the long run.
  •  Some health department websites do provide statistics on how many specific operations are done in a year and what the complication rates are. This way one can opt for the best hospitals for a particular procedure. Here’s a  website that provides info of the best hospitals in the US, for instance –  click here.

    This magazines does yearly surveys to seek out the best

  • At the end of the day, its important that you click with the doctor – a good doctor-patient relationship is extremely important  and contributes a long way to a good outcome..

High Hospital Bills? Here’s How To Pay Less

There may be economic recession, but healthcare inflation goes on unbridled, with annual inflationary rates in excess of 10%! Often, I’ve been asked how to reduce medical bills once they are incurred. Of course, the best method is prevention. The next? Getting a good healthcare insurance cover (click here to know more).

But what happens when you’ve already incurred the bills? Here’s some pointers:

1.Choose when to be hospitalised – emergencies aside, its better to be admitted during office-hours and during weekdays. Why? Because many hospitals cut off ‘non-essential services’ after office-hours. You’ll be hard-pressed to find dieticians , physiotherapists and some specialists on weekends. It may seem unfair, but hospitals do charge an ‘overtime fee’ or surcharge if services are provided after office-hours.

2. Review the bill – go through the charges. Are they accurate? Extra charges and miscoding can occur, intentional or otherwise. If there are disputes, hospitals have standard grievance procedures (more of this in a future blog article) where such disputes may be resolved.

3. Negotiate – everything is  negotiable. Talk to the service provider to see if they will offer a discount for the various items charged on the bill, especially if you’re paying out of pocket. Some hospitals have  provision for a discount – if you ask for it.

4. Ask for a payment plan – if you cannot pay in a lump sum, ask for instalments. Some hospitals will allow this, at no interest charge. Put it in writing and if you cannot keep to the schedule, re-negotiate.

5. Charity begins not at home – many not-for-profit hospitals have a subsidy program or a foundation which will pay or subsidise for deserving cases. You will be interviewed by a financial counsellor who willmassess whether you deserve one. Such programs are understandably poorly publicised, so do not be afraid to ask.

6. Seek out support groups – especially cancer support groups. They will be well-placed to advise on charities or foundations who might be able to access funds.

7. Government assistance programs – many pension or annuity schemes will allow withdrawal for payments of critical illnesses. Yes, it will dwindle your savings, but at least you will not be deprived of adequate medical care.

They Shoot Doctors Too, Don’t They?

..and I don’t mean shooting oneself in the foot, which many people, including doctors may do at some time or other  ;-). Yesterday’s shooting of a doctor by an irate relative in one of the world’s top hospitals, Johns Hopkin’s, has shocked many and raised the call of whether there is adequate security in today’s healthcare facilities.

Johns Hopkins Hospital,Baltimore - scene of the shooting

The Shot Doctor - Dr David Cohen

About the shooting – it appears that the dictum “Don’t shoot me, I’m only the messenger” was not adhered to. It turned out that the assailant had been looking after his bed-ridden mother for months in the hospital and had consented for the mother to be operated on to fulfil her wish to be able to walk again. The operation did not go according to plan and the doctor, an orthopaedic surgeon, was in the process of explaining that she might not be able to walk again when all hell broke loose and he was shot. Later, police found the assailant and his mother both dead, the consequence of a murder-suicide theory.

In actual fact, the shooting incident is on a long list of hospital shootings or attacks on health-workers (see here). It appears that hospitals are fast becoming a hostile environment, not least of which because a large number of people are highly stressed. More than half of the 3,465 health workers surveyed last year by the US Emergency Nurses Association reported they’d been hit, spat on or physically assaulted while on the job.

The high-risk locations in hospitals where security issues are common include:

the emergency/trauma department (gang fights, vendettas, domestic conflicts, child custody conflicts, VIP patients);

infant care area (infant abduction);

pharmacy/drug storage area (narcotic theft);

operating rooms (opportunistic thefts),

psychiatric care area (staff/patient violence);

Could This Be The Scene in Hospitals Next?

Already, in the aftermath of this high-profile shooting incident, there are calls for airport-style screening with metal detectors but this will present a logistic problem, as hospitals have several doors and entrances with a few thousand visitors a day. As it stands, most large hospitals already use alarm systems, access control systems, photo identification, CCTV, two-way voice communications which many consider more than adequate, taking into account also the cost implications.

Perhaps a more practical approach would be to have scenario planning and implementing emergency drills, so that medical staff are better-prepared to handle such emergencies. This appears to have been the case in the Baltimore incident.

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The World’s Best Hospitals – How To Be One

There are a lot of hospitals who claim to be among the world’s best – but has anyone ever listed what it takes to be one?

One good guide is the US News ranking based on set criteria, where it ranked the best 14 hospitals in the US:

List of US News’ Honor Roll Hospitals

1 Johns Hopkins Hospital, Baltimore
2 Mayo Clinic, Rochester, Minn.
3 Massachusetts General Hospital, Boston
4 Cleveland Clinic
5 Ronald Reagan UCLA Medical Center, Los Angeles
6 New York-Presbyterian University Hospital of Columbia and Cornell
7 University of California, San Francisco Medical Center
8 Barnes-Jewish Hospital/Washington University, St. Louis
9 Hospital of the University of Pennsylvania, Philadelphia
10 Duke University Medical Center, Durham, N.C.
11 Brigham and Women’s Hospital, Boston
12 University of Washington Medical Center, Seattle
13 UPMC-University of Pittsburgh Medical Center
14 University of Michigan Hospitals and Health Centers, Ann Arbor

Johns Hopkins Hospital in Baltimore,Maryland - named as the top hospital in the US for brain diseases

Larry King speaking at the Cleveland Clinic - ranked as the best in the US for heart diseases

The following eight factors were found to be common themes in explaining their success:

1. Innovation – A desire to practice in an environment that embraces evidence attracts nurses and other staff to these hospitals.

2. ‘Patient-first’ philosophy – a no-brainer really, but quite easily forgotten by hospitals who pay too much attention to the financial bottom-line. They often forget that its the patients (read ‘customers’) who are paying their salaries!

3. Collaboration – Teamwork creates better outcomes, and many of these  hospitals have embraced fostering greater collaboration between disciplines. Every discipline brings a special domain of practice, knowledge and skill to create a village of information.

4. Quality Improvement- Structured processes for clinical services allow  staff to define and sustain clinical practice standards and incorporate new findings into practice.Care processes and measures for success can be defined and measured via a balanced scorecard.

5. Quality Nursing Care – Patients come to the hospital expecting the best doctor and often, they will be given the treatment they need for their medical condition to improve. What makes the difference is the nursing. When nurses add on compasssion on top of the usual nursing skills, they give that extra edge.

6. Positive Work Environment – Nurses form a key component in any hospital, and to retain and attract them, the hospital management has to create an environment where people will want to work in. In my experience, a good pay is important but this is not the be all and end all. Other factors come into play like professional satisfaction and empowerment.

7. Continuing Education – one of the factors enhancing point 6. We are looking not at just professional education, but also at  social skills like following up on complaints.

8. Staff Engagement – When you engage people closest to the work , you  respect them.They want to know where the organization is going and what the driving value is, and you can demonstrate how their work contributes to that. That includes letting the staff know as and when new staff are brought in as part of succession planning.

In my years as a hospital manager, the above values keep on recurring time after time and quite often, many hospitals do not make it to the top quite simply because the above lessons are not assimilated.

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Nowadays, Doctors Stop Work As Soon As Their Shift is Over

Its not unknown  for doctors in EU countries to down their tools immediately when their shift-time is up, even if they were in the middle of performing a surgery! A 37 year-old English consultant related his experience here when the doctor assisting  him said he had to go as it was his ‘home time’…right in the middle of a laparotomy. Ostensibly, the main reason for this is the implementation of the European Working Time Regulations (EWTR) in August 2009, which resulted in a reduced working week of  48 hours. (btw, ‘conventional’ hospital doctors work at least 60 hours, including weekends).

Insufficient training posts and shorter training time..are today's doctors insufficiently trained?

Imagine the uproar if this were to occur in non-EU countries, where such a law would be considered primitive! I can imagine human rights activists decrying the ‘lack of professionalism among the materialistic-minded doctors’.

Doctors trained to be specialists in the  1990s will remember that their working hours were necessarily long because they were matched with training time – the more time you had, the more training you received. Nowadays, this is no longer valid and the path for training to be a consultant is now shortened considerably. The main reason given is that there was (and still is) a lack of training posts. Fair enough.

Sociologists have an alternative explanation for this type of behaviour – that the X and Y generations treasure their personal quality time more than just slogging away at work. They don’t live for work, they work to live“. Read more here.

Old-time surgeons will have difficulty understanding the work ethics of their junior counterparts unless they fully grasp the workings of the minds of the Y generationers. Already, there are fears that the new EU rules are going to produce a generation of European doctors who will be  “lazy, clock-watching junior surgeons”.

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So What Errors Can Hospitals Make?

An article in the Los Angeles Times attracted my attention recently. Datelined January 28 2010, it reported that the California State Department of Health had fined 13 hospitals for committing medical errors  that in some cases seriously injured and even killed patients.

Some of the errors included:

-the death of a patient  who was supposed to be restrained and supervised, but was instead left to repeatedly pull out his tracheotomy tube until he was found unresponsive in his bed.

ICU Monitors are Indispensable..but require monitoring too!

-intensive care nurses failing to monitor a woman’s oxygen levels; the patient passed out and had to be placed on a ventilator.

-the death of a patient treated in the emergency room for a heart attack where nurses failed to notice that the man’s heart monitor had disconnected and the volume on the patient’s heart monitor alarm was not loud enough to alert staff.

-staff leaving a surgical sponge in a patient. She got so sick she had to undergo a second operation.(Yes,people, it also happens in the US!)

But perhaps the most bizarre medical error reported was the case of a patient on a metal stretcher being sucked in by an MRI machine’s magnetic force, resulting in the patient  fracturing her leg and foot. Just so to remind ourselves that such MRI-related injuries are not uncommon, a similar incident was shown in Episode 15 of ER which was screened a year earlier in 2008!

Clip from ER,episode 15: note the patient sandwiched between the metal stretcher and the MRI machine

MRI scans have gained in popularity in the last decade with its crystal-clear images and with no radiation involved. It uses magnetic waves instead, but the strength of these waves can be as much as 50,000 times the earth’s gravity. So much so, any metal objects within distance can be pulled with such force to the machine’s magnets to be able to cause serious injuries. Incidents such as scissors flying and oxygen canisters hitting with such force to cause fatal injury have been reported. Not to mention the data on credit-cards being wiped out  to render them useless! In fact, those with heart pacemakers and certain artificial heart-valves are usually not permitted to undergo MRI scans.

Yet, despite risk reduction strategies and safety protocols, such untoward incidents do continue to happen. One of the main reasons for this is that many – including healthcare workers -are unaware that the magnets in the MRI scanner are always “on” even though there are no patients inside.

Read here to find out more on the Joint Commission’s recommendations for MRI safety procedures for healthcare workers.

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