Raising the Bar on Quality

The plaintiff attorneys in healthcare must be salivating. The infamous legal standard of care — how physicians are generally expected to practice in a community — may be changing rapidly. The San Diego Union-Tribune reported July 28, 2005, on a study in The New England Journal of Medicine that rated San Diego regional hospitals low in the care of acute myocardial infarction, heart failure, and pneumonia (1, 2). Best practices have been publicly identified for these and other conditions, and physicians and hospitals are being measured and compared by the Centers for Medicare and Medicaid Services (CMS) (3), JACHO (4), The Leapfrog Group (5), and other organizations (6). Pay-for-performance measures are financially incentivizing physician groups to achieve good outcomes. When it comes to patients’ being harmed or having avoidable complications, will there by any way to justify not providing current best practice?

We now know how to drive surgical site infections down to near zero (7). How can a physician and hospital defend a case in which one occurs, especially if the surgical site infection rate at that hospital is higher than a new national standard? The same can be said for central line infections and ventilator-associated pneumonias. How will these complications be defended in the future?

Outcomes after acute myocardial infarction (AMI) are greatly improved if aspirin is given on admission and beta blockers are used early. Standing order sets are available to ensure that all patients with an AMI receive the most recommended care. About 10,000 AMIs occur annually in San Diego County. Any physician caring for one of these patients had better be plugged into this best practice, or good luck with your defense if the patient has a poor outcome.

The waiting times in many of our emergency departments are over six hours for patients who do not come in unstable on a gurney. Outcomes for pneumonia are improved if patients receive antibiotics within six hours. How will the hospital and treating physician defend themselves if a patient has a poor outcome and initial treatment is delayed? How about the patient who dies of pneumococcal pneumonia and was never vaccinated?

I could go on with examples for longer than any of you would want to read. My point here is not to scare anyone or describe the current situation as depressing or hopeless. My point is that we can no longer be casual about what the standard of care is in the community. Complications are easy to defend if it can be shown that the providers followed best practice guidelines. That reflects the new standards of care.

Patient care the old-fashioned way was fine in its day but has errors and poor outcomes at a rate no longer acceptable. Maybe in the past we could defend these as simply being consistent with the community standard of care, something that changed gradually. That time is gone. As a new information age hits medical practice, the quality of care is expected to rise, and medical errors should greatly reduce. No longer will care that does not meet currently recognized best practice be justified.

Quality improvement is everyone’s urgent issue today. Physicians, nurses, pharmacists, and all healthcare professionals and administrators must meet regularly to ensure that the best safety and quality systems are in place. The public deserves nothing less. The public expects nothing less, and what care should be delivered is now knowable by anyone.

I do not think San Diego physicians can wait much longer in moving toward an electronic health record that centralizes all patient data and makes it readily available. Such a record should have current drug-drug interactions built into the work flow and other clinical decision support such as current best practice guidelines. No one can consistently deliver best practice without digital support tools.

Our local hospitals are now on alert that they must rapidly conform to current best practices for many clinical conditions measured by public agencies. A frequent comment that I hear from hospital personnel is that the physicians are reluctant to get on board with these changes. Physician autonomy and the desire to continue to do things the familiar and comfortable way are used as excuses for not cooperating with a hospital’s desire to standardize best practices. Certainly, all patients need to be carefully evaluated as individuals, and some practices will always vary, but no longer will a lack of physician cooperation be tolerated.

The good old days of casual, thoughtful medical practice are rapidly coming to an end. Think of the airline pilots who actually once flew the planes on their own. We all want pilots who are talented and knowledgeable but who also carefully go through all the system checks and conform to the latest safety standards. They are still professional and widely respected. So will it be for physicians. The future may feel heavily standardized and even industrialized, but consistently great patient outcomes certainly make it worth it. Keeping the plaintiff attorneys at bay is also a good reason to get on this bus of quality improvement in medicine.

References:

1. http://www.signonsandiego.com/uniontrib/20050728/news_1n28care.html
2. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. Hospitals: The Hospital Quality Alliance Program. New England Journal of Medicine. 2005;353:265–274.
3. http://www.hospitalcompare.hhs.gov
4. http://www.jcaho.org/quality+check
5. http://www.leapfroggroup.org
6. http://www.healthgrades.com
7. http://www.ihi.org/ihi/programs/campaign