I came across a recent article in the New York Times that discusses the fact that american healthcare has in fact not made that much progress in quality improvement, that the disparities gap is not narrowing, and that patient safety may be declining. This report was released by the Agency for Healthcare Quality and Research.
This raises several interesting questions regarding the impact of interventions such as the campaign to save 5 million lives, CVL checklist to decrease catheter related infections, the introduction of rapid response teams, and numerous other quality interventions in the inpatient and outpatient arena. We should certainly be better off than we were a number of years ago.
Clearly shows the need for the Open School and the need to train agents of change among the next generation of health professionals so that quality improvement and patient safety are principles that are taught in school and connected with patient and system examples during the clinical years and beyond. The need for formal curriculum is quite evident at this juncture.
Best
Jay
May 20, 2009
Teach Us How to Let Go
In life, some skills are taught. They are passed down through parents, friends, and teachers. These include how to swim, ride a bike, multiplication, and even basic things like eating. And then there are some things that do not have a formal teaching process. We move through life reacting and observing to pick up these untaught skills. Building experience that will prepare us for the next time. One of these untaught skills is how to deal with the end of life.
It's a sensitive topic. The end of life means death is at the door, which carries with it for all involved a wide array of complex and oftentimes painful emotions. I'll admit that it has taken me at least 10x longer to blog about this topic compared to other posts I have written. In health care, the topic of end of life is very sticky.
Health and medicine is conventionally about curing illnesses, fixing problems, and prolonging life. And many of us enter the field of health care for those very reasons. However, end of life care makes most health care providers uncomfortable because it throws a twist on a core belief: medicine allows people to live life to their fullest potential.
In a WBUR special titled: "Quality of Death: End of Life Care in America: Inside Out," Jim Conway, an IHI Senior Vice President and chair of Massachusetts' Committee on End of Life Care, said, most in health care believe that "doctors are not in the business of death, they are in the business of hope." If I am not feeling well, I do anything possible to feel better and reach out to medicine for help and hope. When I've caught a cold and have difficulty breathing through my stuffed nose, I take some pills to decongest my nose. If I'm experiencing lower back pain, I seek physical therapy to help realign my hips and spine. In these cases, the medical remedies are restoring or enhancing my ability to live my life to its fullest potential. As Dr. Jim Januzzi was quoted saying in the WBUR special, "The default is to do everything. Americans view medicine as a way to avoid deaths."
Medicine is a business of hope. That's what we've been trained to believe. George Annas, Boston University professor of health law, as quoted in the WBUR special explains, "The longer we live the less comfortable we are with dying; the more we fear it and the more we look to medicine to try to cure it." Jim Conway, counters this conventional notion by stating, "A respectful death is also a form of hope." In our fear of death, we place great effort in treating people during the final weeks and months of their lives. What we often don't realize is that in doing so, we are exposing these people to unnecessary pain and suffering.
When is the right time to stop aggressive treatment? When should palliative care begin? Palliative care aims to increase comfort while giving patients and their families the opportunity to explore treatment options beyond aggressive medical care. It also helps patients and their loved ones come to terms with the inevitability of death. Palliative care includes pain management and psychological care.
From a numbers perspective, palliative care makes sense. Studies have shown that while the majority of people would like to die a quick and painless death at home surrounded by family and loved ones, 80% in the US die in hospitals, sometimes hooked up to machines. Studies have also shown that when patients are started on palliative care at an earlier stage, they use less medical care and are more satisfied in their final months. A third of Medicare's annual budget is spent on the last year of life. That's about $144 billion. 70% of health care costs are for the elderly. Unfortunately, the amount of care received does not translate to better outcomes. Research has shown that greater intensity of care at the end of life is not better for these elderly patients, but is actually worse care.
Palliative care also makes sense through the lens of patient-centered care. Elderly patients in seeking aggressive treatment oftentimes bounce back and forth between hospitals, nursing facilities, or home. Many times, the treatments leave patients feeling confused, agitated, and sick. Studies have shown that when patients and their loved ones discuss end of life issues early on, the patients are more likely to have a comfortable death and their loved ones are less likely to suffer from prolonged grief and depression.
However, despite all of these rational reasons, I think it is still easier to talk about treatment options instead of palliative care and hospice options. Health care tends to attract type A overachieving personalities. So, how do you train future health care professionals to understand that palliative care does not mean you are giving up or that you are accepting failure? How do you let go? How do you make the transition from treatment to comfort? When is the right time to make that transition? It's not easy as a family member to watch loved ones pass, so I'm sure it is just as difficult for health care providers. I am no where near practicing medicine on my own, but I am already dreading the time where I'll have to initiate the palliative care conversation with my future patient and his/her family.
This complicated situation really should have a manual, but none exists. Since there is no manual, we must rely on experience. But, we can't wait till we start practicing independently to begin learning how to navigate these situations. Conversations about end-of-life care should be happening now while we are training. We need to experience it before we start running the show. End-of-life care should formally be included in our curriculum. A rotation in hospice or a nursing facility? We should all have the privilege to join a care team that is caring for an elderly patient nearing the end-of-life. At the very least, our professors and mentors should not hesitate to initiate discussions about end-of-life care with us. Only with this experience and support will we be able to deliver the care our patients truly want and deserve.
Help us build our experience. Prepare us for the next time.
Listen to the WBUR special titled: "Quality of Death: End of Life Care in America: Inside Out. In this documentary, special correspondent Rachel Gotbaum investigates end of life care in the US. What prevents many patients from having a dignified death? What kinds of challenges do patients, providers, family, and society face when dealing with end of life care? Click here to listen.
It's a sensitive topic. The end of life means death is at the door, which carries with it for all involved a wide array of complex and oftentimes painful emotions. I'll admit that it has taken me at least 10x longer to blog about this topic compared to other posts I have written. In health care, the topic of end of life is very sticky.
Health and medicine is conventionally about curing illnesses, fixing problems, and prolonging life. And many of us enter the field of health care for those very reasons. However, end of life care makes most health care providers uncomfortable because it throws a twist on a core belief: medicine allows people to live life to their fullest potential.
In a WBUR special titled: "Quality of Death: End of Life Care in America: Inside Out," Jim Conway, an IHI Senior Vice President and chair of Massachusetts' Committee on End of Life Care, said, most in health care believe that "doctors are not in the business of death, they are in the business of hope." If I am not feeling well, I do anything possible to feel better and reach out to medicine for help and hope. When I've caught a cold and have difficulty breathing through my stuffed nose, I take some pills to decongest my nose. If I'm experiencing lower back pain, I seek physical therapy to help realign my hips and spine. In these cases, the medical remedies are restoring or enhancing my ability to live my life to its fullest potential. As Dr. Jim Januzzi was quoted saying in the WBUR special, "The default is to do everything. Americans view medicine as a way to avoid deaths."
Medicine is a business of hope. That's what we've been trained to believe. George Annas, Boston University professor of health law, as quoted in the WBUR special explains, "The longer we live the less comfortable we are with dying; the more we fear it and the more we look to medicine to try to cure it." Jim Conway, counters this conventional notion by stating, "A respectful death is also a form of hope." In our fear of death, we place great effort in treating people during the final weeks and months of their lives. What we often don't realize is that in doing so, we are exposing these people to unnecessary pain and suffering.
When is the right time to stop aggressive treatment? When should palliative care begin? Palliative care aims to increase comfort while giving patients and their families the opportunity to explore treatment options beyond aggressive medical care. It also helps patients and their loved ones come to terms with the inevitability of death. Palliative care includes pain management and psychological care.
From a numbers perspective, palliative care makes sense. Studies have shown that while the majority of people would like to die a quick and painless death at home surrounded by family and loved ones, 80% in the US die in hospitals, sometimes hooked up to machines. Studies have also shown that when patients are started on palliative care at an earlier stage, they use less medical care and are more satisfied in their final months. A third of Medicare's annual budget is spent on the last year of life. That's about $144 billion. 70% of health care costs are for the elderly. Unfortunately, the amount of care received does not translate to better outcomes. Research has shown that greater intensity of care at the end of life is not better for these elderly patients, but is actually worse care.
Palliative care also makes sense through the lens of patient-centered care. Elderly patients in seeking aggressive treatment oftentimes bounce back and forth between hospitals, nursing facilities, or home. Many times, the treatments leave patients feeling confused, agitated, and sick. Studies have shown that when patients and their loved ones discuss end of life issues early on, the patients are more likely to have a comfortable death and their loved ones are less likely to suffer from prolonged grief and depression.
However, despite all of these rational reasons, I think it is still easier to talk about treatment options instead of palliative care and hospice options. Health care tends to attract type A overachieving personalities. So, how do you train future health care professionals to understand that palliative care does not mean you are giving up or that you are accepting failure? How do you let go? How do you make the transition from treatment to comfort? When is the right time to make that transition? It's not easy as a family member to watch loved ones pass, so I'm sure it is just as difficult for health care providers. I am no where near practicing medicine on my own, but I am already dreading the time where I'll have to initiate the palliative care conversation with my future patient and his/her family.
This complicated situation really should have a manual, but none exists. Since there is no manual, we must rely on experience. But, we can't wait till we start practicing independently to begin learning how to navigate these situations. Conversations about end-of-life care should be happening now while we are training. We need to experience it before we start running the show. End-of-life care should formally be included in our curriculum. A rotation in hospice or a nursing facility? We should all have the privilege to join a care team that is caring for an elderly patient nearing the end-of-life. At the very least, our professors and mentors should not hesitate to initiate discussions about end-of-life care with us. Only with this experience and support will we be able to deliver the care our patients truly want and deserve.
Help us build our experience. Prepare us for the next time.
Listen to the WBUR special titled: "Quality of Death: End of Life Care in America: Inside Out. In this documentary, special correspondent Rachel Gotbaum investigates end of life care in the US. What prevents many patients from having a dignified death? What kinds of challenges do patients, providers, family, and society face when dealing with end of life care? Click here to listen.
Talk Health IT with Dr. John Halamka and Dr. Brian Robson on WIHI
Did y'all get a chance to tune into WIHI's discussion about hospital readmissions with Dr. Amy Boutwell and Dr. Thomas Lee? If you did, I'm sure you can't wait for the next installment of WIHI.
Well, you need not wait any longer! Tune in TOMORROW with Madge Kaplan for a discussion on Health IT and electronic medical records (EMR) with Dr. John Halamka, Chief Information Officer of Beth Israel Deaconess Medical Center, and Dr. Brian Robson, Clinical Director for eHealth across NHS National Services Scotland, at 2PM. Don't forget to register here.
Just a reminder:
WIHI is an exciting new audio program from IHI. It’s free, it’s timely, it's interactive, and it’s designed to help dedicated legions of health care improvers worldwide keep up with some of the freshest and most robust thinking and strategies for improving patient care.
Each episode is 60 minutes and there's a new broadcast every other week. You can listen to WIHI live— via computer or telephone or both — or you can download an archived audio file for listening later (see the Technology tab for more information). All you need to do is register in advance.
The WIHI broadcasts will be hosted by IHI’s Madge Kaplan, who brings a wealth of experience to WIHI from her years reporting on health care for public radio. IHI’s Director of Communications since 2004, and the regular “voice” of the 100,000 Lives and 5 Million Lives Campaign conference calls, Madge is known for her ability to create a shared space for lively and enriching discussions.
Click here for more details about registering and listening in on WIHI.
Past WIHI broadcasts are archived and available for download here.
May 19, 2009
Health Reform: What Can YOU Do?
President Obama said X about health reform. Secretary Sebelius makes Y announcement about health reform. Senators Baucus and Grassley consider Z, A, B, and C in regards to cost-saving and health reform. Finally, physicians, employers, nurses, insurance payors, and many other stakeholders are sitting at the same table to discuss health reform. But, what can you do?
Join this free webinar hosted by The Commonwealth Fund and the Institute for Healthcare Improvement this Friday May 22nd, at 11AM to discuss how physicians and others can help create a health care system that offers high-quality, affordable care for all Americans while containing costs. Click here to register. Panelists will include:
The panelists will address quality improvement, integrated delivery, and payment reform as well as cost-saving measures that can help finance the coverage of the uninsured. Don't miss out and hope to see you on the webinar!
Join this free webinar hosted by The Commonwealth Fund and the Institute for Healthcare Improvement this Friday May 22nd, at 11AM to discuss how physicians and others can help create a health care system that offers high-quality, affordable care for all Americans while containing costs. Click here to register. Panelists will include:
- Dr. Don Berwick, president and CEO of the IHI and professor in the Department of Health Policy and Management at the Harvard School of Public Health
Karen Davis, president of The Commonwealth Fund
Dr. Elliott Fisher,professor and associate director of Population Health and Policy at the Dartmouth Institute for Health Policy and Clinical Practice
The panelists will address quality improvement, integrated delivery, and payment reform as well as cost-saving measures that can help finance the coverage of the uninsured. Don't miss out and hope to see you on the webinar!
JAMA's "A Piece of My Mind"
May 15, 2009
Truth-telling: what did you think?
At some point you may see something going wrong in a patient's care. What are you supposed to say? How should you say it, and to whom?
Sociologist Parker Palmer, Dr. Paul Batalden, Dr. David Leach, and Dr. Emma-Samelson Jones (a newly-minted physician) tackled this question during today's On Call. David Leach presented a case in which a resident was on her twelfth day on the ward, single-handedly overseeing 34 patients. A transplant patient under the resident's care faced complications and died during her shift. Later, a group of residency directors was asked, "Who was the moral agent in this case?" The question was met by silence.
Emma then told a story from her student days, recalling a patient who, in her view, was being treated unfairly. When Emma spoke up on the patient's behalf, her preceptor "got a stony look on his face."' The relationship never recovered, and Emma requested to work at a different clinic. She did not see the patient again. In this story, Emma was the moral agent -- but her agency was unwelcome.
1. Do you have a story like Emma's or the resident's? What happened?
2. Have you ever challenged a senior colleague? Did it make you feel more empowered or more discouraged in your profession?
3. Have you seen someone in your organization act as a “moral agent?”
4. How can educators change their teaching to empower students to bring their values to work?
Join the discussion by clicking the "comments" link below. The audio recording of this call is coming soon to www.ihi.org/openschool. In the meantime, check out these related resources written by the presenters:
Change Magazine article by Parker Palmer: A New Professional: The Aims of Education Revisited
Activity by Paul Batalden and David Leach: Becoming a "Moral Agent"
Organ donation case submitted by Paul and David: Knowing Is Not Enough
Pulse Magazine article by Emma Samelson-Jones: Brain Cutting
Sociologist Parker Palmer, Dr. Paul Batalden, Dr. David Leach, and Dr. Emma-Samelson Jones (a newly-minted physician) tackled this question during today's On Call. David Leach presented a case in which a resident was on her twelfth day on the ward, single-handedly overseeing 34 patients. A transplant patient under the resident's care faced complications and died during her shift. Later, a group of residency directors was asked, "Who was the moral agent in this case?" The question was met by silence.
Emma then told a story from her student days, recalling a patient who, in her view, was being treated unfairly. When Emma spoke up on the patient's behalf, her preceptor "got a stony look on his face."' The relationship never recovered, and Emma requested to work at a different clinic. She did not see the patient again. In this story, Emma was the moral agent -- but her agency was unwelcome.
1. Do you have a story like Emma's or the resident's? What happened?
2. Have you ever challenged a senior colleague? Did it make you feel more empowered or more discouraged in your profession?
3. Have you seen someone in your organization act as a “moral agent?”
4. How can educators change their teaching to empower students to bring their values to work?
Join the discussion by clicking the "comments" link below. The audio recording of this call is coming soon to www.ihi.org/openschool. In the meantime, check out these related resources written by the presenters:
Change Magazine article by Parker Palmer: A New Professional: The Aims of Education Revisited
Activity by Paul Batalden and David Leach: Becoming a "Moral Agent"
Organ donation case submitted by Paul and David: Knowing Is Not Enough
Pulse Magazine article by Emma Samelson-Jones: Brain Cutting
May 11, 2009
On Call Audio Conference: Truth-Telling
On Call Audio Conference Speaking Up for Yourself and Your Patients
Friday, May 15, 200911:00 AM - 12:00 PM Eastern Time
Friday, May 15, 200911:00 AM - 12:00 PM Eastern Time
You’ve witnessed a patient receiving care that isn’t optimal.
You want to say something.
But how?
In this call, sociologist Parker Palmer, Dartmouth Medical School Professor Paul Batalden, medical student Emma Samelson-Jones, and former ACGME executive director David Leach discuss the role of truth-telling and moral agency in health care.
You'll learn:
- How a failure to speak up can lead to tragic outcomes
- Ways to respond when you see something going wrong
- How to cultivate the self-awareness and courage required to speak up
- How to engage your advisors and peers in an ongoing conversation around these issues
Join this free call! Advance registration is required.
For callers outside of the US, please use the 412 number you are given upon registration. You can also join the call via Skype, an online service that may cost less than dialing by phone.
Suggested reading before the call: A New Professional: The Aims of Education Revisited, by Parker Palmer.
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