The Cost of Safety

At a time where the nation is struggling with a debt crisis driven in large part by the cost of our health care entitlement programs Medicare and Medicaid, the press reports of larger hospitals with fewer beds continue:

A southwestern Indiana hospital expects to start work in the coming months on a $100 million construction project to replace much of its existing facility that has parts dating back more than a century.

The master plan for the project approved by Good Samaritan Hospital's board includes a new 120-bed, five-story inpatient tower.

The completed project will see the hospital's capacity drop by 67 beds to 165, but Good Samaritan President Rob McLin said it will allow for growth in areas such as oncology, orthopedics and cardiology care.

You can never be too safe. Infection control requires single rooms with big screen TVs that have internet and personalized meals. Really it does.

No matter what the cost, it's safety, safety, safety. Entire institutes full of safety experts have sprung up the help hospitals make sure they keep the message coming and to fufill the lofty goal of never having a readmission. Hopsitals pay these institutions hefty sums to make sure they comply with mandated safety classes for all of their employees. In fact, these lessons is so important that they even give their directors millions of dollars of safety-inspired compensation packages to make sure their family members have a lifetime of safe health care after they retire.

And then there's that not-so-little issue of medical equipment expiration dates. Imagine if one of those foam headrests in the operating room were to expire! "You can't use those any more, doctor, they're expired!"

So we throw them away and order more.

In every hospital across our land this happens. Tons and tons and tons of medical waste because of expiration dates for things that, practically, shouldn't have expiration dates. But because we have regulations regarding how long things can sit on shelves in hospitals, we label them with expiration dates. "Order more, please." After all, if the Joint Commission finds expired headrests, hospitals might lose their accreditation. Our medical supply industry, full of middlemen like group purchase organizations that exist to get a better deal on bulk orders (really), is only too happy to comply.

My point here is not to speak badly of the need for safety in hospitals, rather a need to gain some equipoise on the subject. It is true that we've done a pretty good job improving surgical infection rates in America with things like pre-procedure antibiotics, antibacterial drapes, and good technique. But I wonder what's more expensive for our system in the long run, hand washing with soap and water or foam alcohol dispensers that have cannisters that have to be refilled and repurchased time and time again. what about all those plastic gowns we wear because a nasal swab shows traces of the genetic makeup of a single methicillin-resistant bacillus in a patient's nose? Or might all that plastic we purchase ultimately become more expensive to our health care system and environment in the long run?

These are not convenient questions to ask. But, given our concerns about the costs of health care and its affect on our economy, it seems to me that doctors AND patients had better start looking for (and demanding) ways to save money with the little things we do every day that might not be viewed as perfectly safe but rather, perfectly acceptable.

-Wes

Thievery, or Worse

Alright, they’ve gone too far.

I don’t ask for much, really I don’t. I come to work, I do procedures, I chart, I take call, I attend meetings and conferences, I send messages to hoards of people using e-mail, I teach. I do all that stuff doctors are supposed to do.

But I like my coffee.

And every day, I enter the cath lab break room and have a cup. Carefully brewed, always using 1 ½ packets of the coffee grounds supplied (need the extra ‘kick,’ you know), wait patiently for the brewer to deliver, then head on my way.

One small Styrofoam cup o’ Joe that I nurse ‘til its gone.

And I rushed off. I was in a hurry.

I needed to see a patient to see if they needed a pacemaker.

I walked up to the ward. Set down my coffee far from the computers, far from the monitors, and far from the patients’ rooms. Far from a place any mortal human being should be able to find. Then I reviewed the telemetry, used the jell goo on my hands and said “hi” to the patient. She needed the pacer after all. And then I returned to my cup.

But it was gone.

Gone, I tell you! I mean, who would do such a dastardly deed? Who’s messing with my psyche? My fix? Geez, I was just on call. Is this too much to ask? For goodness sake! This is a patient safety issue!

I looked around and saw her typing.

“Um, excuse me.”

“Yes?”

“Uh, have you seen a cup of coffee that I left over here.”

“Yes.”

“You didn’t throw it out did you?”

“Of course I did!”

“Why?”

“You didn’t hear?”

“No. What?”

“JACHO’s here.”

-Wes

Reconciliations

reconciliation
noun
1. the reestablishing of cordial relations
2. getting two things to correspond; "the reconciliation of his checkbook and the bank statement"

* * *
About a week ago, it was time to sit down and pay the bills. Being a computer nerd, I generally find that paying by bills on-line is quick and efficient. I use Quicken and pay bill after bill fairly quickly. The program then logs on to my bank and uploads by payment requests and downloads mysterious transactions that my wife performs throughout the week. I am glad she handles many of the family chores as efficiently as she does.

But the other day a great big “cash advance” was noted on my debit card. Hmmm. “This just happened yesterday,” I thought. Wow, it’s for an awful lot of money – way more than I thought I could withdraw on my card. And it was cashed at a USAA Bank. Hmmm.

“Honey?”

“Yes, dear?”

“Did you withdraw some cash (to the tune of well over a $1000 – exact amount not to be disclosed) to a USAA Bank?”

“No.”

So I called USAA Bank and gave them the cryptic series of numbers on the electronic transfer and asked if I happened to be at their bank yesterday if I received a cash advance. They had no recollection of such a transaction and noted I did not have an account with them.

“And where are your banks?”

“We only have branches in Texas.” Hmmm. Now maybe this was the same yahoo that tapped into GruntDoc’s account, I don’t know, but I live in Illinois.

“We suggest you call your credit card company.”

Which I did. St. Elsewhere Bank in St. Elsewhere. I gave them that cryptic number on my bank statement.

“Just a moment,” the helpful person said on the other end of the line. A few minutes later she said, “this is was withdrawn from your credit card that ends in the digits, 2212 (not the real numbers).”

“Uh, I don’t have such a credit card from you.”

“Just a moment.”

Well now I’m pissed. But it could have been much worse. I luckily learned that my account had been violated under 24 hours prior. By mere luck, I had logged on and noticed the transaction and called my bank. I learned in all my escapades that debit cards (even debit cards you don’t own) have a limit on how long you can be before notifying the bank about fraudulent charges – 48 hours. Unlike credit cards, they are not as “secure” and the odds of getting any money back after using a non-signature card is much less likely than with a signature card. Fortunately, my card company has credited by account with a “provisional deposit” pending the investigation for the amount transferred, but I was lucky. And I also have learned about this problem with TJX Companies (TJ Max, Marshalls, HomeGoods, etc) - it seems they had a massive intrusion into their computer systems. My wife shops often at these stores. And her name, address, driver's license number and social security number and 45.7 million credit cards have likely been lifted. Needless to say a police report has been filed (may they please see who did this on the USAA Bank video…).

SOOOOO, what the heck does all of this have to do with MEDICINE???

Well, yes Virginia, there’s more. It seems we ALL have to do more reconciling – every day. Oh, not of bank accounts. No.

Of medications.

Yep. In case you haven’t heard, the Joint Commission has decided that ALL patient medication lists must be reconciled ANY time there is a transfer of patients between ANY facilities, care units, or providers. It’s part of their 2007 National Patient Safety Goals. Sections 8A and 8B, to be specific. And we’ve heard their “dropping in” on facilities around our area to see how well folks are complying.

What, you don’t know about this? Either did I until today, when the 17-page ’frequently asked questions’ about this initiative landed in my hands from a nurse. She was “pleased” to say the least.

“What are we gonna do about this? It says we have to give the patient a printed list of all of their medications with easy-to-read instructions when they leave the clinic or hospital any time there is a change to those medications. How are you going to DO this, doctor? Why does this fall on US?”

Well, I certainly understand the need to reconcile things, especially after my bank statement fiasco, but boy, have we got another time-consuming and tedious task just handed to us. Many of my patients have over 12 medications, not to mention vitamins, and occasional vaccinations, and in some cases, even fluoride treatments, that we are supposed to reconcile EVERY TIME a patient leaves our clinic or hospital. I’m not kidding. There’s even a flow chart on what to do. Will patient’s even want this list? Worse still, what impact will repetitive lists sent to referring physicians have in the outpatient care arena – will these notifications eventually be treated as spam in their inbox? Delete. Delete. Delete.

But it’s all in the name of safety and all during a 20-minute follow-up patient visit or every time a patient transfers between care arenas.

But perhaps there is a tacit agenda at play here. Perhaps this initiative is another means of driving a stake into the heart of the paper medical record. After all, only an electronic form of information can make this initiative even possible. Who the heck has the time to manually write a long list of medications each time the patient leaves their office after a single medication change?

While many of the 2007 National Patient Safety Goals of the Joint Commission are based on a sound premise, that is, reduced medical errors and improved safety for our patients, every one of these initiatives has the potential to impact other areas of health care delivery. This requirement, while noble, may also drive a stake in what little remains of the doctor-patient relationship and in effect, be anti-reconciliatory, since doctors will spend more time documenting and less time looking and speaking to their patients.

-Wes