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Yesterday I spent 2 hours with the Director of Research (incidentally, his PHD thesis was about how best to get adults to learn) at the #1 teaching hospital in my country. He has spent the last 2 years addressing the key issue of doctor inconsistency in practice and treatment. They do full simulations with doctors, interns, and students on working dummies to show the effect of correct and incorrect administration of drug doses etc. Simulations are an important part of learning what symptoms present from incorrect drug doses or procedures/processes. This is not part of medical training. Also they have to correct deficiencies - gaps- in learning due to the culture of the hospital (eg anatomy is a practical as well as a book learned subject and having access to theater can range from highly possible to virtually impossible in various hospitals). Simulations of procedures and processes provide attending physicians with a baseline by which they can monitor 'real time' patients and proceed to administer the correct procedures and drug practices. They also have an Operating Theater where they practice on dummies (in the main) to perfect their techniques, processes, and procedures. The good news is there are people, out there, actually doing useful things to improve the delivery of health care within my countries' systems. Where his hospital urgently needs reform is in the design and administration of their revenue models. His hospital has some wards with empty beds - these can not be reopened at present because of the way the hospital is funded - simply put the criteria set for the use of their monies have a short-term and short sighted bias. Funding of institutional care is a key area for reform in my countries' health care system - it is clear to 'blind Freddie' that less is being done about that aspect of health care than would be EXCELLENT and so patients suffer.

Posted by Richard Lipscombe at June 30, 2008 7:32 PM

Physicians, in fact, spend a tremendous amount of time involved in simulations and in real-world situations as part of their medical training, especially during their clerkships and residencies.

A certain degree of variability is an expected part of any reliable process.

The issue, as we know, is the degree of unexplained variation in current processes.

In our own system, the "right course of action' is apparent to the physician, but many times is not performed. For example, it is well-understood that drugs called beta-blockers improve outcomes after heart attacks. Nevertheless, the percentage of patients that actually receive these drugs after a myocardial infarction approaches only 50%.

The major improvements here are not about intelligence, nor are they about awareness of the latest data and recommendations.

Simulations, practice, and testing won't solve this and related problems.

Significant results can only be achieved by looking at the systems within which care is delivered, such that they account for human factors.

Example: Primary care physicians are responsible for the majority of wellness and care within a given health system, including the US. Sadly, as expensive high-tech and interventional procedures are valued to a greater degree in the US than are the cognitive skills of primary care physicians, reimbursement rates have continued to decline for a variety of reasons. These physicians are trying to survive by making up the shortfall through increasing the volume of patients seen. As the volume of patients seen increases, so does the likelihood of system "failures".

Until we move away from a culture in which blame is placed on individuals for bad outcomes, and towards one in which we examine the systems and processes that lead to undesirable outcomes, we will not see significant improvement in health care (both in the rates of patients actually receiving proven and recommended services, and in the rates of patients not receiving things that are unproven, harmful, and generally not recommended).

The average healthcare CFO, unfortunately, has to deal with similar systemic influences. As it stands, we continue to increase our revenue (and thus income) based on the number of services and interventions we provide. The sicker people are, the more we make. Any efforts to optimize financial performance in this context will ultimately come into conflict with efforts towards wellness and reduction in hospitalizations, testing, and interventions.

Wellness (and the philosophy behind primary health care) is in conflict with the current reimbursement incentives.

Without significant reform in financial incentives, even the inexpensive solutions will be doomed (as they currently would result in a negative impact to the revenue streams of many stakeholders).

Simple and inexpensive solutions are great. But their widespread adoption will be limited by broader systemic issues.

Think systems. Train people to think in systems.

If there were one message I would give to the members of HFMA, this would be it.

Posted by Manoj Pawar at July 7, 2008 12:14 AM best price on viagra with prescription

These days are something taken for granted that went out of service. Why the administration of health-care is not okay? Is it believes that R&D+Innovation don’t apply to this type of organizations?

Are they demoralized? Are they really thinking and acting linearly for their disgrace? Thinking systems (holistically) or reincarnate!

Posted by Andres Agostini (Andy) at July 8, 2008 9:24 AM