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Avoiding the #3 Cause of Death in the USA: US Hospitals & What You Need To Know About It – Part 2

The gauntlet had been laid.  Don Berwick and the Institute for Healthcare Improvement (IHI) had challenged hospitals in America to save 100,000 lives.  Time was ticking away, educational programs, mentoring, training had begun but would they achieve the goal?

Eighteen months later on June 14th 2006 at 9 a.m. – Dr. Berwick took the stage to announce the results: “Hospitals enrolled in the 100,000 Lives Campaign have collectively prevented an estimated 122,300 avoidable deaths and, as importantly, have begun to institutionalize the new standards of care that will continue to save lives and improve health outcomes into the future.”

But that was only the beginning.  Remember, if there are 5,723 registered hospitals in the US, this initiative got 2,300 of them to commit in the first few months.  By the end of the campaign 3,100 hospitals had enlisted.  But thousands of Americans were still dying in US hospitals from preventable causes each month.  So the IHI moved the goal – in December 2006, IHI launched a second, expanded effort, the Five Million Lives campaign.   At its formal close in December 2008, the Campaign celebrated the enrollment of 4,050 hospitals, with more than 2,000 facilities pursuing each of the Campaign’s 12 interventions to reduce infection, surgical complication, medication errors, and other forms of unreliable care in facilities. Eight states enrolled 100% of their hospitals in the Campaign, and 18 states enrolled over 90% of their hospitals in the Campaign.

In 2011 the Secretary of the Department of Health and Human Services Kathleen Sebelius and Dr. Berwick launched the Partnership for Patients, which brings together hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in an effort to make hospital care safer, more reliable, and less costly.  The Partnership for Patients aimed to decrease preventable hospital-acquired conditions by 40 percent by the end of 2013, resulting in approximately 1.8 million fewer injuries to patients and more than 60,000 lives saved over the next three years. It also sought to reduce hospital readmissions by 20 percent by decreasing the rate of preventable complications during transitions from one care setting to another. The Partnership was to be funded by up to $1 billion in federal money made available under the Patient Protection and Affordable Care Act, including $500 million through the Community-Based Care Transitions Program and up to $500 million through the Centers for Medicare and Medicaid Innovation.    At the core of this initiative are 26 Hospital Engagement Networks, with 3,700 hospitals, working with health care providers and institutions to identify best practices and solutions to reduce hospital acquired conditions and readmissions.  Early results are showing strong progress in 8 of the 10 patient safety priority areas of the Partnership for Patients, more findings are scheduled to be released soon.

But recall that only 3,700 of the 5,723 hospitals in the US are engaged, meaning that over 2,000 hospitals are not on board and thousands of Americans are still suffering unnecessarily.  And recognize that this is looking at the prevention of adverse events, not at which institutions are the best at different procedures.  The best spine hospital may not be (and often isn’t) the best heart surgery facility in your community.

So how do you find the right hospital?  It takes research and time. It also takes a willingness to sift through a lot of different data to tease out what information would be important to you. Let’s think through a visit to the hospital – the quality of the health care a patient receives depends on many things besides the skill of the surgeon. Many health care providers at a hospital will be directly involved in care before, during, and after surgery. The metrics a patient will want to know span a broad spectrum of considerations, from scientific data on mortality and complications associated with previous treatment of patients with the same condition to the more subjective data on how patients respond to the physician and staff managing their care.

A result of this complexity in defining a good hospital is the proliferation of information sites that exist. In addition to the payers websites (carriers who are often dependent on contracting agreements with the hospitals), patients can go to anything from yelp.com and Angie’s List (which also provide reviews on low complexity services like dry cleaning), to state report card sites or national sites such as Hospital Compare which may or may not have information on metrics associated with your condition. For heavier science aficionados, there are reporting agencies like CareChecks and The Dartmouth Atlas which may look at patient outcomes on a larger system level. Reports are also often put out by institutions such as the Kaiser Foundation or Commonwealth Fund that speak to hospital quality.  Somewhere in the middle of this very complex gamut are sites like Vitals or Health Grades. More traditional outlets such as Consumer Reports or the US News & World Report create hospital listings as well.

But it is not just the hospital.  The doctor and the care team he or she works with make a significant difference.  In the next blog we will consider how to find and use these “best in class” doctors.

Will You Die from the #3 Cause of Death in the USA?

 

By DrScott – Posted on March 13, 2014 on www.compassphs.com

In the 2013 September edition of Journal of Patient Safety Article Asks: Will You Die from the #3 Cause of Death in the USA?

Ask most people what the #1 & #2 causes of death are and they will usually know they are heart disease and cancer. Ask them for the #3 cause and you are likely to hear infections, trauma, or pneumonia but few guess American Healthcare.

But the correct answer is the Hospitals in the US. The Journal of Patient Safety in September of 2013 revealed that between 210,000 and 440,000 people die from hospitalizations in the US each year. Here’s how they come to this conclusion:

To begin, it is important to understand the concept of preventable adverse events (PAE’s). These are unexpected and harmful experiences that occur because high quality, evidence-based medical care was not delivered during hospitalization. PAE’s can be:

  • Immediate – a side effect of a drug, or
  • Delayed for months – contracting hepatitis from dirty needles a few months after hospitalization, or
  • Delayed for years – getting pneumonia because a pneumonia vaccination was not given to a patient receiving a splenectomy years prior.

PAE’s are further categorized into:

  1. Errors of Commission – the wrong action or right action performed incorrectly on a patient.
  2. Errors of Omission – an action needed by a patient was not performed; for instance, a medicine was indicated but not given in a vital situation.
  3. Errors of Communication – for example, two providers failing to communicate clear instructions during surgery; or a provider and patient inadequately reaching an understanding of discharge instructions.
  4. Errors of Context – an example is when a patient is discharged but is unable due to cognitive ability, to perform tasks needed for their safety.
  5. Diagnostic Errors – resulting in delayed, incorrect, or ineffective treatment such as mis-identifying a tumor biopsy as benign when it is actually malignant.

To identify these PAE’s, a systematic review of medical records was performed at hospitals by trained personnel with the Global Trigger Tool (GTT), developed by the Institute for Healthcare Improvement (IHI). The results were then validated by one or more physicians. Four studies with a total of 4,252 records revealed 38 total deaths associated with adverse events. The ratio equates to a death rate from adverse events of 0.89%.

As previously referenced, the September 2013 The Journal of Patient Safety article indicated that there were an estimated 34.4 million hospital discharges in 2007, and the average percentage of preventable adverse events was reported at 69%. Thus, the best estimate from combining these 4 studies is 34.4M discharges × 69% with PAEs × .89% death rate = 210,000 preventable adverse events per year that contribute to the death of hospitalized patients.

According to the Center for Disease Controldeath statistics in the US are:

  1. Heart disease: 597,689
  2. Cancer: 574,743
  3. Chronic lower respiratory diseases: 138,080
  4. Stroke (cerebrovascular diseases): 129,476
  5. Accidents (unintentional injuries): 120,859

As you can see, 210,000 deaths puts US Healthcare squarely in the #3 position for annual cause of death.

But even this may be an underestimate.

This conclusion is based only upon medical records. This fails to account for confounders such as poor documentation, complications managed by non-hospital facilities or in the outpatient setting, the “wall of silence” of health professionals altering or omitting critical data when mistakes occur, and the fact some medical errors are not known by clinicians and only come to light during autopsies (rarely performed), to name a few. Thus the actual number of deaths is significantly underestimated by at least 50%, based upon chart reviews, given the high probability of these confounders. The Journal Article therefore estimates the actual number of deaths is closer to 440,000 deaths per year, making medical inpatient errors the number three cause of death in the US by a significant margin.

A scary conclusion to say the least. What can be done to protect ourselves, and our employees, from this challenge? Join us for next week’s blog.

It is Time to Bend the Healthcare Cost Curve & Receive Higher Quality Care

By DrScott – Posted on March 11, 2014 on www.compassphs.com

Companies in America spend billions of dollars on medical care expecting high value, safe and evidence based care. But are they getting it? Transparency data suggests they are not. Specific areas being questioned include:

  1. Are patients getting too much care? How can employers and employees minimize excess care?
  2. Is 30% to 50% of the care delivered worthless? How do we avoid these costs and reduce healthcare spend dramatically?
  3. Is US Healthcare really the #3 cause of death behind heart disease and cancer? How can employers and employees avoid being killed by American Healthcare?
  4. Do up to 80% of bills submitted to insurance companies contain errors, requiring time, energy and money for employees to correct? How can employees avoid paying incorrect bills?
  5. Are employees actually being driven into bankruptcy due to the medical care they are receiving? How can employers protect their employees from the time, energy and distraction of huge, and at times inappropriate, financial challenges from health care bills?

Asked another way: Are employers paying billions for often inappropriate, misguided and expensive care?

What can be done to reverse this trend and to protect the employees and the financial bottom line?

In the next weeks we will explore these questions and discover how Don Berwick and the Institute for Healthcare Improvement (IHI) inspired hospitals to save over 100,000 lives in 18 months. We will also discover how to avoid paying 300% more for tests and services, how to protect yourself from incorrect billing practices, and how to avoid being hassled and bankrupted by the medical industrial complex.

One key is to make sure your employees are seeing the best providers.

Switching Employees On: Using Video to Entertain, Engage, and Educate

By DrScott – Posted on March 4, 2014 on www.compassphs.com

Third in the Switching Employees On: Using Video to Entertain, Engage, and Educate Series

Truck drivers can’t watch videos while they drive! So one company’s president created a series of short 3 minute audios to educate and entertain his drivers while they drive throughout the US. This creative, educational, and motivational series follows all three of the major themes laid out in Switch, How to Change Things When Change is Hard by Dan and Chip Health. The rider is directed to take the next “baby steps” for health, the elephant is motivated with emotional stories – some funny, others tragic, and the path is made clear to stop by the onsite clinic, contact the Health Pro, and follow the other simple steps to qualify for the “I Care” health plan. Listen to the audio done by one president here.

Switching Employees On: Using Video to Entertain, Engage, and Educate

By DrScott – Posted on February 27, 2014 on www.compassphs.com

Second in the Switching Employees On: Using Video to Entertain, Engage, and Educate Series

Heart disease is the #1 killer of Americans. The problem is that we often “feel fine” until it is too late – 50% of men and 66% of women die the first time they feel chest pain, according to the American Heart Association. To “turn the elephant” toward a new path away from unnecessary heart attacks and strokes to a long vital life requires creative interventions. In this video all three principles from Switch, How to Change Things When Change is Hard by Dan and Chip Health are addressed.

  1. The rider is directed to “get your biometrics and screening done even though you feel fine”.
  2. The elephant is motivated because “wonderful people who ‘felt fine’ did not get to be there for their spouse and children”.
  3. The path to better care is made clear by “contacting your Health Pro if you do not know what tests are recommended for you, or you need a high quality doctor.”

Using this and other tools this employer has been able to increase annual physicals among its insured members over time. Watch the video here

Switching Employees On: Using Video to Entertain, Engage, and Educate

By DrScott – Posted on February 25, 2014 on www.compassphs.com

First in the series on Switching Employees On: Using Video to Entertain, Engage, and Educate Series

Engaging and activating employees challenges every company. Creating videos has become less expensive and can be a very effective way to communicate change to employees. Chip and Dan Heath in Switch, How to Change Things When Change is Hard, point out the need for three major principles to be honored (see previous blogs). The rider must be directed, the elephant must be motivated, and the path must be clear. In this video two of the three major principles outlined in Switch are used – directing the rider on exactly what to do, and laying out a new, simple, clear, and more convenient path. Thus the chance of “turning the elephant” from expensive, lower value care to higher value healthcare is increased. Click here to see the video.

Charting a New Path. Why Creating New Habits Saves Money at Work.

By DrScott – Posted on February 11, 2014 on www.compassphs.com

Sixth in the How to Switch On Your Employees Series

For one Compass client, “Contact your Health Pro” became the mantra.

  • “Which plan should I choose: the PPO, HMO, or high deductible plan?” Contact your Health Pro.
  • “Who is a great female family doctor near my home?” Contact your Health Pro.
  • “Where do I get my colonoscopy done by the best doctor?” Contact your Health Pro.
  • “How do I find the best, lowest cost place to get an MRI of my back?” Contact your Health Pro.
  • “My doctor says I need glasses, how do I use the vision plan?” Contact your Health Pro.
  • “I have a 3 month prescription and I don’t know how to do mail order.” Contact your Health Pro.
  • “Where is the best cancer center and which doctor should I see?” Contact your Health Pro.
  • “Do I qualify for a weight loss program?” Contact your Health Pro.
  • “Have I met all the requirements for the best health plan next year?” You guessed it: Contact your Health Pro.

The human resources staff had only a few employees. The new outcomes based program had too many variables, something had to change. In the past employees called HR, they were given the phone number for the insurance plan, the wellness program, the PBM, the vision program, and so forth. But the number of phone calls and the complexity was too much. Often in frustration employees just gave up, the HR staff members were exhausted, participation in programs was low, and costs were not coming down.

A new concierge program was brought in. The Health Pro concept, telephone number and website link, were introduced through a number of communication venues that included:

  • Through open enrollment communication materials and meetings.
  • At company meetings.
  • On the back of the health, vision, and dental cards.
  • On the corporate intranet site.

Involvement in the program and services dramatically increased. Every contact was tracked, behaviors were followed, and results documented.

The results were significant:

  • Calls to the HR department went down 25%.
  • Over 40% of employees contacted their Health Pro.
  • Participation in mail order prescriptions, the employee assistance plan, smoking cessation and weight loss programs all increased by double digits.
  • Health care costs for CT scans, MRI scans, and colonoscopies were reduced by 50% for dozens of employees.
  • Use of the “Designated Physicians” who met quality and cost metrics increased by over 25%.

The financial return on investment for the new Health Pro program was reported quarterly and varied from 5:1 to 8:1. In addition, the Net Promoter Score for the Health Pro was 72 – the highest for any vendor the company used.

As Chip and Dan Heath share in Switch, managing the path forward required shaping a new path. The employees had to change their habit from relying on the HR department for all the answers to contacting their Health Pro first. They were beginning to use all of their benefits, and to provided cost and quality transparency information. The “herd” had made the turn and actually encouraging each other on this new path.

The third key ingredient in making the “switch” was successfully navigated and momentum was building. By managing the three aspects of change, the question was not “if” but “how much” success would occur each year. In the next blog we will complete this series and review how to successfully navigate to a high performance, outcome based system.

Motivating Employees. More Than Providing Direction

By DrScott – Posted on February 6, 2014 on www.compassphs.com

Fifth in the How to Switch On Your Employees Series

An employee from a remote office location stopped by the office of her President at the corporate headquarters. Unsure of the exact purpose for the visit, the CEO thanked her for stopping by and her years of loyal service. Once seated, he paused and asked “how can I help you today?”.

She looked at her hands folded in her lap and said, “Two years ago you announced that we were going to have to get our biometrics done, see our doctor, and get our cancer screening done to qualify for the best health plan. I was really angry. I am 28 years old, a single mother of two children, and frankly, I can barely get everything I need to do done and catch a few hours of sleep at night. To tell me I had to do more felt unfair. But I also could not afford to pay more for my health insurance, so I complied. At my exam the doctor found a breast lump and sent me for a mammogram. I then found out that I had stage one breast cancer. To make a long story short, it was a real hassle, but I got my treatment and the doctors say that I am now cured.”

She paused, obviously straining to maintain her composure. She looked at him directly and continued, “I can tell you that without you requiring me to get my screening I would have put it off another five years. The doctor told me that if I had waited even one more year my cancer would have spread and my chance of surviving would have been a lot less. So I came here today to tell you thank you. Thank you for caring enough to require me to do the right thing, even though it costs the company more money and you didn’t have to. Thank you for saving my life, and thank you for giving my kids their mom; they are still young and would have been alone if I had died.”

Surprised, the President expressed his appreciation at her stopping by to share her story and the great news that the doctor thought she was healed from her cancer. This was the second time in a month an employee had contacted him to thank him for helping discover early cancer.

Their health plan had gone from just another requirement, to a campaign to catch disease early, and to save employees lives. Employees were inspired, and morale was better than ever. They had even begun a program to support “Health Champions” who encourage and support their employees in taking the ‘Baby Steps’ to go from reactive to proactive lifestyles, and to create a culture of wellness.

Chip and Dan Heath in their book, Switch – How to Change Things When Change is Hard, point out the need for three major principles to be honored in order to promote successful change (see previous blogs). The rider must be directed, the elephant must be motivated, and the path must be clear.  In this instance, the company provided employees motivation to move down a different path to a new destination. The employees not only understood the task at hand, but also found the feeling that motivated them to change. The change had been broken into realistic small steps, and employees gained more knowledge and experience in proactive wellness. A new mindset was emerging. It had taken two years but success was no longer in question.

Implementing Outcome Based Wellness – Making the Switch

By DrScott – Posted on February 4, 2014 on www.compassphs.com

Fourth in the How to Switch On Your Employees Series

How does a company switch directions to a plan that will actually improve the health of their employees and reduce health care costs? Using the paradigm for effective change from the book Switch by Chip and Dan Heath, the analogy of a rider changing the direction of an elephant as it walks down the well-established (less desirable) path, they reveal that it is not a single strategy that insures success, but multiple concurrent strategies that are needed.

In this blog we are going to focus on the first of these factors; the rider. The “rider” must know:

  1. The exact destination (To change, the rider must know where to go):
    • In health benefit terms, employees must:
      • get their biometrics done,
      • get their numbers to goal, and
      • identify and see a high quality primary care doctor for US Preventive Services Task Force (USPSTF) wellness, cancer screenings, and fulfill diabetes and heart disease recommended guidelines.
  2.  Script the critical moves (The rider must understand the specific steps to complete):
    • The employee learns where they must go to accomplish required steps and where to get more information:
      • Biometrics will be done at certain locations without charge for employees throughout the year, or get biometrics done at their primary care doctors and send in a required form;
      • Seeking out a high quality primary care doctor and following recommendations;
      • Being directed to the list of USPSTF age and gender appropriate tests that are available on line.
  3. Why go to this destination? (The rider must know why the change is necessary):
    • Treating conditions early, or preventing conditions, improves and saves lives, and also saves money.
    • Just acting based on if an employee “feels fine” delays identification of early diabetes, heart disease, and cancer. Early disease must be addressed before symptoms appear.

The rider is much smaller than the elephant and therefore must exert significant energy to change its direction. Clarity, commitment, and a well-designed plan are vital. Otherwise, the resources needed to promote change without such clarity, commitment or a well-designed plan make having to attempt to “turn the elephant” a second or third time cost prohibitive in both resources and energy, and usually without the desired sustainable results.

There must be a sense that the journey is attainable. If the destination seems too far away, or the required change is too drastic, the rider can lose enthusiasm and focus. Laying out realistic and attainable “baby steps” allows the rider to stay focused.

Insure the “rider” of your change efforts knows exactly what to do and how to do it. Breaking the steps into smaller manageable steps increases the likelihood of change being successful. But the rider is only one part of the equation. In the next blog we will look at motivating the elephant to stay on the right path.

Making the Turn – Changing to Outcome Based Wellness

By DrScott – Posted on January 28, 2014 on www.compassphs.com

Third in the How to Switch On Your Employees Series

Recently an HR team met to plan next year’s health benefits. It started with a review of last year’s changes and outcomes. Health costs went up 5%, but the projection for this year was closer to 10% with the new Accountable Care Act changes. Their President made it clear that the company could not tolerate a 10% increase and they had to find a way to better manage the situation.

There was a general sense of frustration around the table. Catastrophic costs driven by diabetes, surgeries, cancer, and heart disease again were the top challenges, and little headway had been made. The wellness program had paid out thousands of dollars to encourage employees to eat better, exercise more, and get their biometric screenings, but participation was still in the low 30% range. The HR team knew they had to make a significant change to make progress.

They studied other companies that had been successful in managing costs and decided that the keys for success were for every employee and their spouse to do the following:

  1. Get their biometrics and normalize any that were not to goal,
  2. Get age and gender appropriate wellness tests and exams recommended by the United States Preventive Services Task Force (USPSTF) performed by a high quality primary care doctor (preferably a patient centered medical home), and
  3. Get the USPSTF recommended screening for cancer and treatment for diabetes, and heart disease performed at high value providers

All employees were to be moved to a high deductible health plan to increase their involvement and to create a personal investment in making sure they took care of their health and had “skin in the game.”

The HR team was really concerned about the reaction by the employees when this was announced. They appreciated their President wanting to save money on health care and wanted to have this go off without a hitch.  Therefore, they reached out to the HR staff at several companies that had successfully made this change and got their advice on how to roll out the plan.

In the next few blogs we will review how they decided to roll this out to insure success. To make it more accessible, and interesting, we will use the paradigm laid out in the book Switch by Dan and Chip Heath. We will explore how to change the direction of the “elephant” walking down the old familiar path, directing the rider, motivating the elephant, and re-shaping the path.

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