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Responding To ‘The Hidden Curriculum’: Don’t Forget About The Patient


April 3rd, 2014
by Rob Lott

Narrative Matters readers might remember Joshua Liao’s moving essay about the dangers of the Hidden Curriculum. Liao, a resident physician at Brigham and Women’s Hospital, wrote about the consequences of making a serious mistake as a medical student on an obstetrics rotation. He read the essay for the Narrative Matters podcast and it’s a great listen.

Liao’s essay, penned with Eric Thomas and Sigall Bell, also generated some compelling responses. It inspired Tim Lahey to write about his experience leading the curriculum redesign at Dartmouth’s Geisel School of Medicine. And when the Washington Post ran an excerpt of Liao’s essay last week, it led Franca Posner to remind readers about “one missing piece of this puzzle”: the patient’s perspective.

Posner was once in a similar situation, but it was she on the hospital bed: “I was that woman 20 years ago, only I was almost 40 and had a 5-year-old child and five miscarriages in my reproductive history,” Posner wrote in a letter to the editor published in the Post’s Health and Science section on March 31.

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Implementing Health Reform: Allowing Noncompliant Policies; Benefits And Payment Parameters Rule (Part 2)


March 7th, 2014
by Timothy Jost

Editor’s note: Part 1 of this post discussed the Department of Health and Human Services March 5 bulletin extending until October 1, 2016 its transitional policy permitting the renewal of ACA non-compliant individual and small group health insurance policies. Part 1 also began examining the final 2015 Notice of Benefit and Payment Parameters rule, issued on the same date. Subsequent installments will discuss two final rules also issued March 5 by the Internal Revenue Service regarding reporting by insurers of minimum essential coverage and reporting by employers on coverage under employer-sponsored health plans.

Reduced notice requirement for new state exchanges. The final 2015 Benefit and Payment Parameters rule requires states that would like to begin operating their own exchanges to notify HHS of this intention by June 15 of the preceding year. Earlier rules had required a year’s notice.

Consumer assistance and privacy. States may permit web brokers to assist individuals, employers, and employees with enrolling in qualified health plans (QHPs) through their exchanges. Agents and brokers must comply with privacy and security standards protecting personally identifiable information and may not use it for marketing. The SHOP exchange, and not the web broker, is responsible for aggregating premiums and forwarding them to insurers. Web brokers must display information on all available QHPs, although insurers may refuse to provide non-appointed brokers with certain information. Web brokers must also provide enrollees with a disclaimer noting that they are not the exchange and may not have full information on all plans.

State exchanges must comply with federal personally identifiable information requirements, but may seek the approval of HHS to use this information to ensure the efficient operation of the exchange if they secure the consent of the individual whose information is to be used. Exchanges that disclose personally identifiable information to non-exchange entities (such as certified application counselors, in-person assisters, brokers, QHP insurers or others) must enter into a contract with these entities ensuring protection of this information. Non-exchange entities that must independently comply with Health Insurance Portability and Accountability Act data privacy and security requirements (such as QHPs) may be deemed to be in compliance with exchange requirements by virtue of their compliance with HIPAA as long as the HIPAA requirements are at least as protective as the exchange requirement and if the entities also comply with additional ACA data protection requirements.

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The Dangers Of Quality Improvement Overload: Insights From The Field


March 7th, 2014

Editor’s note: This post is also co-authored by Ksenia O Gorbenko, Catherine van de Ruit, and Charles Bosk of the University of Pennsylvania.

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients. As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals. We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others. To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change, “you cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change. Front-line providers often bristle at expectations from those they believe have little understanding of the demands of their daily work. Requiring health care providers to improve on all mandated measures at once—in an atmosphere of reduced reimbursements and frequent staff shortages—is a goal that risks burnout, discouragement, and apathy – all signs of initiative fatigue.

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Cesarean Rates: A Global Perspective


February 24th, 2014
by Christine Spencer

As noted in a previous Health Affairs Blog post by Katy Kozhimannil and Ezra Golberstein, there is significant variability in cesarean delivery rates across the United States, but this is also true worldwide. Worldwide cesarean delivery rates have come under scrutiny and criticism since the World Health Organization (WHO) suggested in 1985 that the optimal rate should not exceed 10 to 15 percent.

Although currently there is no expert agreement on a single optimal level, a general consensus has emerged that extremely low rates (less than 5 percent) suggest underuse and higher rates (greater than 10-15 percent) suggest overuse. Globally, the average rate sits slightly above that recommended level at 16 percent. However, the mean value masks the underlying variability that exists across countries and the different issues inherent in the variation. Of countries which report at least some cesarean deliveries, the range of use runs from 1 percent (Niger) to 52 percent (Brazil) of live child births.

Middle and High-Income Countries

Cesarean rates in middle and high-income countries have continued to increase over the last decade (most are significantly over 15 percent). The average rate among the Organisation for Economic Co-operation and Development (OECD)-member countries is 26.9 per 100 live births (range: 14.7 to 49.0). Comparatively, the United States has a very high rate of cesarean delivery (31.4 per 100 live births). In Switzerland, for example, cesarean section rates varied in 2010 from less than 20 percent to over 40 percent in a region. Within a region, the rates also varied by hospital. A study in France found more cesarean sections were performed in for-profit hospitals than in public hospitals, which treat more complicated pregnancies, suggesting that financial incentives may also play a role in explaining excess cesarean deliveries.

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To Pay For Medicare SGR Repeal, Build On Bipartisan Health Care Policy


February 20th, 2014

Something unexpected is happening in Washington. As most eyes track partisan battles over immigration and the Affordable Care Act, key Congressional committees have been quietly advancing truly bipartisan legislation to strengthen Medicare.

Since 2002, an outdated Medicare cost control called the Sustainable Growth Rate (SGR) has repeatedly threatened drastic Medicare provider cuts. After a decade of temporary fixes, SGR repeal appears within reach. A bipartisan, bicameral agreement by key Congressional leaders announced on February 6, 2014 goes a step further by pairing repeal with bipartisan reforms that pay physicians for the quality and value of care they deliver, not the number of tests and procedures they order.

When one of every three health care dollars is wasted on care that does not improve patients’ health, transitioning away from volume-based reimbursement would be momentous. Few policy changes are more fundamental to containing health care costs and protecting the solvency of Medicare.

The challenge in Congress has shifted from getting a bipartisan agreement on new cost controls to paying for the repeal of the old one. The Congressional Budget Office (CBO) estimates the cost of the Senate version of the bipartisan repeal bill at $149 billion over 10 years.

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If A Drug Is Good Enough For Europeans, It’s Good Enough For Us


February 14th, 2014
 
by Paul Howard and Yevgeniy Feyman

Note: This post is coauthored by Paul Howard and Yevgeniy Feyman of the Manhattan Institute.

Meningitis is a terrible disease that can kill its victims in a single day. About 4,100 new cases are diagnosed annually in the U.S., with a mortality rate of more than 10 percent. Even with treatment, survivors are often left with serious side effects that can include brain damage and limb loss.

A recent meningitis outbreak at Princeton University was unique, however, because the vaccines typically required by universities don’t protect against the particular strain (serogroup B or “MenB”) of the outbreak. Luckily, Swiss drug manufacturer Novartis has developed a vaccine — Bexsero — that specifically targets this strain of meningitis; the drug has already been approved for use by the European Medicines Agency (EMA), the European Union’s equivalent of the Food and Drug Administration (FDA). And within about nine months the FDA allowed Princeton University to offer the vaccine on campus to its students.

Problem solved, right? Not so fast.

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Connected Health And America’s War On Error


February 5th, 2014
 
by Joseph Smith and Michael Johns

Editor’s note: For more on connected health, see Health Affairs‘ newly published February thematic issue on the subject. The issue was discussed at a Washington DC briefing this morning, keynoted by the new National Coordinator for Health Information Technology, Karen DeSalvo. The Office of the National Coordinator and West Health Institute are cosponsoring a conference tomorrow on developing an interoperable health care system.


recent analysis, the annual losses are worse than any other war in our nation’s history, including the Civil War, World War II and our War on Terror. It is an undeclared “war on error” within our healthcare delivery system. It is the most deadly war we have ever waged, with errors and resultant harm in hospitals contributing to the death of nearly 1,000 people each day in the U.S., potentially more than 400,000 a year.

As with any other war, there is an enormous economic burden. The U.S. spent approximately $2.8 trillion on health care in 2012, with about 30 percent of total health care expenditures attributed to hospital services. That’s just over $800 billion annually, making America’s war on error not only the deadliest, but also the most expensive.

Until now, this war has often been waged in hospitals, where small, poorly outfitted groups of combatants have used simple, unconventional means like prompts for hand washing, autographing surgical sites and implementing ‘no interruption zone’ for medicine preparation – with limited success. But now, new technologies like integrated sensor networks, fully integrated electronic medical records (EMRs), clinical-decision support systems and algorithm-based care, all embedded in smart and learning systems, may finally provide the tools needed to win the war.

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The Hidden Curriculum: Changing The Water In Which We Swim


January 31st, 2014
by Tim Lahey

Editor’s Note: This post is a response to Joshua Liao, Eric Thomas, and Sigall Bell’s essay, “Speaking Up About The Dangers Of The Hidden Curriculum,” published under Narrative Matters in the January issue of Health Affairs.

As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Liao and colleagues overcome that challenge in the January issue of Health Affairs, making an eloquent call for better dialogue about how the hidden curriculum can undermine patient safety. They point out, rightly, that, “The difference between what we say we do and what we actually do as doctors and teachers can be stark.” Such verbal disconnects can undermine the culture of patient safety, a dilemma fixed first through awareness and then through the courage to speak up.

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Nursing Homes Are The Solution On Readmissions


January 17th, 2014
by David Gifford

A recent report from the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) argues that skilled nursing care centers, or “nursing homes,” should be better monitored by the federal government when it comes to how frequently they send patients back to the hospital. OIG recommended that the Centers for Medicare and Medicaid Services (CMS) develop a quality measure to track and publicly report nursing centers’ hospitalization rates and to have state survey agencies review the measure as part of the survey and certification process. As the largest association representing skilled nursing care centers in the country, the American Health Care Association (AHCA) agrees. In fact, we do not think OIG goes far enough. We support linking Medicare payments to skilled nursing care centers based on their hospital readmission rates.

Frequent trips to the hospital are disrupting to seniors and put them at greater risk for complications and infections. It is also costly to the system, as the OIG report demonstrates. AHCA came to the same conclusion and is already acting on the issue. AHCA wrote to Congress earlier this year in support of measuring and publicly reporting hospitalization rates among skilled nursing centers when the legislative body requested comments on how to reform Medicare post-acute care payments.

We also support the expansion of CMS’ new inspection process, the Quality Indicator Survey (QIS), which includes a process to review a center’s hospitalization rates unlike the old survey process. However, only 26 states presently use the QIS process after CMS suspended nationwide implementation due to potential budget constraints. AHCA supports CMS continuing its expansion of the QIS to all states as designed, which will have surveyors review centers’ hospitalization rates as recommended by the OIG.

We’re not just encouraging measuring and reporting; we have also developed a hospitalization measure, which we have shared with the federal government. AHCA partnered with the data analytics company, PointRight, to calculate risk-adjusted hospital readmissions during the first 30 days of a skilled nursing stay. Previously, this data was not available to individual providers and was not risk adjusted. Instead, it was reliant on Medicare claims data which did not account for individuals covered by other insurance such as Medicaid, managed care, commercial insurance, or private pay, and resulted in a two-year lag time before data were available.

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A Call To Arms: Support For Emergency Care Isn’t Making The Grade


January 16th, 2014
 
by Jon Mark Hirshon and Alex Skog

Emergency departments (EDs) play a critical role within the American health care system, delivering life and limb saving care daily to thousands of patients. On January 16th 2014, the American College of Emergency Physicians (ACEP) released America’s Emergency Care Environment: A State-by-State Report Card to assess support for emergency care. This Report Card, the third edition of this report, assesses the current state of the acute care system on both a national and on a state-by-state level. This most recent edition provides an alarming evaluation of the support for the emergency care system in the United States, which is particularly concerning given the current state of change and uncertainty that is pervasive throughout the US with regard to health care.

The ACEP 2014 Report Card uses objective data to track various aspects of the acute care system in order to provide a better understanding of the trajectory the overall emergency care system. It is not a report on individual hospitals or health systems, but rather a grade of the policies, regulations and governmental activities that are important supports for emergency care.

The Report Card’s greatest value lies in its ability to validate on a detailed level the recent claims that have been reverberating throughout the U.S. and the international community related to the important role and need for inclusion of acute care within health systems. In a recent WHO Bulletin article, an Academic Emergency Medicine consensus conference proceedings, and most recently in the entire December issue of Health Affairs, experts argue that an emergency care system is a vital aspect of a mature, functioning health system; yet, is it frequently neglected and is not receiving enough attention. While these publications have used the best data available to validate their claims, this national report provides the most current and comprehensive data that support for the system is not only fraught with deficiencies but is headed in a downward trajectory.

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Cesarean Rates: Shifting The Focus From Increases To Variability In Use


January 15th, 2014
 
by Katy Kozhimannil and Ezra Golberstein

At 1.3 million procedures each year, the Centers for Disease Control and Prevention (CDC) lists cesarean delivery as the most frequently-performed inpatient surgery in the U.S. Both public and private insurance programs pay more to hospitals for childbirth than for any other condition, and Medicaid programs fund nearly half of all U.S. births.

Cesarean delivery is a potentially life-saving intervention that can hasten delivery in order to avoid adverse outcomes for women or infants, but it carries distinct risks as compared with vaginal delivery, including infant respiratory illness and maternal complications in future pregnancies. Cesarean rates increased dramatically from 20.7 percent in 1996 to an all-time high of 32.9 percent in 2009, but have since remained stable. New data from the CDC indicate a shift in gestational age for cesarean births between 2009 and 2011, with a decrease in births at 38 weeks gestation and an increase in births at 39 weeks, consistent with the increasing policy focus on avoiding non-indicated delivery before 39 weeks gestation. The use of cesareans is changing, and clinicians, policymakers, and researchers should now shift from a sole focus on the “relentless rise” to additionally considering unwarranted variations in cesarean rates.

What We Know

Three notable patterns emerge from the available data on cesarean rates. 1) Cesarean rates are highly variable; 2) changes in cesarean rates are not correlated with changes in infant mortality; and 3) prior research shows that patient and clinical factors do not account for variation in cesarean use.

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The Moral Imperative To Disclose Medical Error: Doing The Right Thing


January 7th, 2014

Editor’s note: For more on Ascension Health’s initiative to disclose unexpected events to patients, see Ascension Health’s Demonstration Of Full Disclosure Protocol For Unexpected Events During Labor And Delivery Shows Promise, part of a cluster of articles on alternatives to medical malpractice litigation in the January issue of Health Affairs.

Over a decade has passed since the majority of health care and practitioner accreditation and certification groups mandated the full disclosure of unexpected events and medical errors to patients and their families. Yet full disclosure, an element of establishing a ‘just culture,’ is still not the norm for most providers. Disclosure is difficult and there are impediments at the systemic and practitioner levels.

We at Ascension Health used our core values of truth and justice and our identity as a healing ministry to transition to a just culture that puts the priorities of those we serve above our own. We believe that these core values and identity are not unique and that all providers have a moral compass. Thus, we put forth a call to action for all health care providers to achieve the goal of establishing a just culture with 100 percent full disclosure by 2018.

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A National Initiative To Reduce Central Line-Associated Bloodstream Infections: A Model For Reducing Preventable Harm


September 23rd, 2013
by Peter Pronovost

Editor’s note: A full list of coauthors and their affiliated institutions appears at the end of this post.

The work to prevent central line-associated bloodstream infections in intensive care units is one of few national efforts to use empiric data to document a decrease in patient harm across the United States. A notable contributor was the On the CUSP: Stop BSI national initiative, which built upon the work at the Johns Hopkins Hospital and in the state of Michigan. This initiative spread to 1100 hospitals in 44 states, the District of Columbia, and Puerto Rico. The rate of an infection fell to 1 infection per 1000 line-days in the majority of hospitals, a rate deemed impossible just a few years ago.

In this post, we summarize the fractal infrastructure and overall results of the initiative, explore lessons, and offer policy recommendations for other national efforts to reduce preventable patient harm.

Background

Many efforts contributed to the national decline of central line-associated bloodstream infections (CLABSI) in intensive care units (ICU). (See here, here, here, here, here, and here.) Instrumental in these efforts were the Centers for Disease Control and Prevention’s (CDC) guidelines and infection control strategies, and hospital epidemiology and infection control. This impressive change offers an example of how the collaborative efforts of many, which were informed by evidence, research and valid measurement, can achieve widespread reduction in preventable harm.

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Federal Incentives Drove E-Prescribing Increase


July 10th, 2013
by Max Sow

There has been an ongoing debate regarding the efficacy of financial incentives in convincing physicians to move into the digital age, trading in their paper-based systems for electronic health records. Thanks to new research, we can now point toward firm evidence that shows financial ‘carrots’ make a tremendous difference in bringing 21st century modernization to the doctor’s office.

A study published in this month’s edition of Health Affairs shows that the practice of e-prescribing among office-based prescribers including physicians, physician assistants, and prescribing nurse practitioners increased substantially after Congress authorized financial incentives for the practice in 2008. (See Exhibit below.) This is the first research study that analyzes actual prescribing data — from the Surescripts data network, which handles over 90 percent of the nation’s e-prescribing traffic to community pharmacies — to paint a clear picture of how doctors can be motivated to change how they manage information within their practices.

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Narrative Matters, The Next Chapter: ‘As She Lay Dying’


July 3rd, 2013
by Jonathan Welch

Editor’s note: With this post Health Affairs Blog launches a new series: “Narrative Matters, The Next Chapter.” Narrative Matters essays often capture part of a larger, ongoing story; in this periodic series of HA Blog posts, Narrative Matters authors will update readers on the “next chapter,” discussing personal, professional, and policy developments that have occurred since – and sometimes as a result of – their “policy narratives” published in Health Affairs. First up: Jonathan Welch, a physician who told the story of his hospitalized mother’s death of an untreated infection in “As She Lay Dying.”

In an earlier Health Affairs Blog post, S. Allan Adelman and Lewis Morris set forth the questions that hospital leaders should ask themselves to prevent the sort of substandard care that Welch’s mother received.

When we fail to form partnerships with patients and families within the health care system, we squander opportunities to improve. I’m a physician, but I learned this devastating lesson from an outside perspective, when my mother died of an untreated systemic infection while admitted to my hometown hospital. I wrote about the experience in the Narrative Matters essay “As She Lay Dying” in the December 2012 issue of Health Affairs. While I was shocked to witness multiple errors in the course of my mother’s care, afterward I was equally surprised at how difficult it was to partner with the hospital where she died to make it a safer place. Since writing “As She Lay Dying,” I’ve continued to work toward bringing patients, families, and the healthcare community together on a path toward improvement.

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Facilitating Quality Improvement: The Future Of The National Quality Forum


June 19th, 2013
by Christine Cassel

In just a few weeks I will take on the role of president and CEO of the National Quality Forum. I’ve gone on a brief listening tour as I start this new challenge and I’m heartened by the conversations I’ve had. Whether payer, provider, patient or policymaker—everyone has thoughts on what NQF has accomplished, what the current state of quality measurement is and what the future holds.

The feedback is helpful, because above all, the National Quality Forum is indeed a forum, dedicated to sharing ideas. Its nearly 450 members span diverse perspectives, as purchasers (whether they are consumers, employers, health plans) sit side-by-side with those who provide care.

For more than a decade, NQF-endorsed measures have been an important tool for those in the federal, state and private sectors to use to assess and improve health care quality. However, bringing people together to understand systems of measurement, and how they can be used to improve quality, may be needed just as much right now as identifying what the most effective measures are.

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The Latest Health Wonk Review


May 24th, 2013
by Chris Fleming

Over at Wright on Health, Brad Wright presents the latest edition of the Health Wonk Review. Brad includes a Health Affairs Blog post by Al Adelman and Lew Morris reacting to an earlier Health Affairs Narrative Matters essay by Jonathan Welch. Welch’s mother received “indifferent” hospital care and eventually died; Adelman and Morris believe that this substandard care reflected systemic deficiencies, and they urge hospital leaders to ask hard questions about their institutions that address those factors.

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Where Was The Leadership? The Questions Raised By Jonathan Welch’s Narrative Matters Essay


May 21st, 2013
 
by S. Allan Adelman and Lewis Morris

Dr. Jonathan Welch’s Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.

While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.

As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated. Those questions, which the leaders in all hospitals should consider, include the following:

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The Human Face of Hospital Readmissions


March 14th, 2013
by Risa Lavizzo-Mourey

The numbers are disturbing and disappointingly familiar. According to the federal government, one in five elderly patients winds up back in the hospital within 30 days of leaving. The cost is troubling, too. The readmission of Medicare patients alone costs $26 billion annually, $17 of which is spent on return trips that wouldn’t need to happen if patients received proper care during their first visit.

The Centers for Medicare & Medicaid Services calls avoidable readmissions one of the leading problems facing the U.S. health care system, and in an effort to turn things around is now penalizing hospitals with high rates of readmissions for patients with certain conditions.

In America, we should be doing better. We need to pinpoint why this problem persists. What are the human factors behind these numbers?

That is why the Robert Wood Johnson Foundation commissioned a report, “The Revolving Door: A Report on U.S. Hospital Readmissions,” to take a closer look at the issue of readmissions through the eyes of those grappling with the problem. The report is part of our Care About Your Care initiative, devoted to improving the transition from hospital to home.

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Howard Koh On Health Literacy: Proposing A New Model Of Care


February 28th, 2013
by Chris Fleming

Health literacy is the essential backbone of informed patient engagement, said Howard Koh, Assistant Secretary for Health at the Department of Health and Human Services, at a February 6 Health Affairs briefing. The event was held to unveil the journal’s February issue, “New Era Of Patient Engagement.”

Health literacy is particularly important now as tens of millions of Americans are faced with new choices about coverage and treatment under the Affordable Care Act, said Koh, a physician who also has a master’s degree in public health. Yet only about 12 percent of Americans have the skills necessary to navigate the health care system, leaving the vast majority of Americans at greater risk for unnecessary hospital admissions and readmissions, medication errors, and failure to manage their health conditions effectively.

Physicians and other health care providers often assume that patients understand what they are told unless they indicate otherwise, Koh noted. But the health system has gotten so complex that it challenges the comprehension even of sophisticated patients. The answer is to change the paradigm from a focus on correcting individual deficits in understanding to a systems approach: “The assumption is that everybody is at risk for not understanding, and that we should institute what we call ‘health literacy universal precautions.’”

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