Quality in the Health Care Industry

[Charmed]

Five questions by Wes

Dear Wes:

Let me try to answer two of the five questions posed (Just my humble opinions.)

Question 1:

I think this medical errors crisis is largely a matter of perception. Not politics, or socioeconomics, but steming simply from the misuse of simple y/x ratios and an imprecise understanding of what x should be used.

Question 2:

More thorough analysis of the "raw" data on deaths due to medical errors is requried. The medical and the health care industry should do what the NHTSA has been doing.

The difference between the ratio y/x and the rate dy/dx, as it applies outside physics must be understood. In the tax problem, for example, the tax rate, also called the marginal tax rate is the slope of the graph of (taxable income) versus taxes owed. The defining equation is y = hx + c where the constant c is negative except for those with the lowest taxable incomes. If you are in the 25% tax bracket h = 0.25. If you are in 33% tax bracket, h = 0.33 and so on. Since c is always negative the ratio y/x = h + (c/x) always seems to be increasing as x increasing with the range for which the constant h applies. I think of the ratio y/x as the "tax burden". This is always increasing as income x increases. The same considerations apply to many problems including traffic fatalities and medical errors that we have started discussing here.

I find the report of Traffic fatalities reports by NHTSA very informative. The same format is used year after year. I can go almost to the same table no. and even to the same page and cross check and compare data for each year. As an example of how new conclusions can be drawn by testing alternative models, I have attached my analysis of the traffic fatality data for the years 1996 to 2002. The Microsoft Excel file should be self-explanatory. If there is interest I would be happy to provide a written text.

I will leave it up to others here to answer the other three questions you have posed. I hope you will be kind enough to entertain my other posts. With my warmest regards.

Charmed

 

[Wes Bucey]

In Quality,we make a distinction between MAJOR nonconformances and MINOR nonconformances. MAJOR generally means either a life, health, safety issue or the product will not function. MINOR generally refers to issues that do not prevent a product from working.

We require ZERO defects on MAJOR nonconformances. We may track and try to improve ratios on MINOR nonconformances.

In a health care setting, we might consider MAJOR anything that results in death. MINOR might be inconveniences like waiting three hours past a confirmed appointment. Everything else would fall somewhere on that spectrum.

There are times when statistics come into play, but some statisticians are like a kid with a hammer - everything begins to look like a nail.

We don't want to fall into the trap bean counters created at GM when they decided a number of deaths of Corvair drivers and passengers was "statistically acceptable" rather than implementing known remedies to prevent those deaths.

 

[Charmed]

ZERO DEFECTS in Health Care

Dear Wes:

To Quote:

We require ZERO defects.

We don't want to fall into the trap bean counters created at GM when they decided a number of deaths of Corvair drivers and passengers as "statistically acceptable" rather than implementing known remedies to prevent those deaths.

I agree. Nothing less than Zero Defects should be acceptable, especially in the Health Care Industry. Every physician would agree.

Is society willing to bear the costs though? That's the "core" of the Health care debate and here, I think, many opinions will be expressed, by employers and their bean counters (since they are paying at least part of the health care costs). In many poor countries (in Africa, in India and China, etc.) quality health care remains a luxury only for the rich. Often, as you know, there is no access to any health care facility, period. May be the last is off topic, if we want to focus on the U.S. Healthcare Industry, in this thread.

Charmed

P. S. I guess we cannot forget those who do not have any type of Health Insurance or cannot afford it, and therefore do not have access to quality health care that some others have. (Dick Gephardt, during his brief recent campaign for President, was talking passionately about the superb health care benefits enjoyed by those serving in the Congress and Senate as opposed to health care benefits enjoyed by others in the rest of society.)

 

[Wes Bucey]

Back to the original discussion

The original questions are:
Now the questions for comment:

1. Is the seeming crisis in healthcare quality real or merely a matter of perception?
2. If not real, how should the healthcare industry correct the misperception?
3. If real, what would be your guess as to root cause or common cause (that is, where would you start your investigation for root cause or common cause?)
4. Since the situation seems to pervade both socialized and privatized medical systems, is it fair to eliminate the payment system from the primary consideration for cause?
5. Is Deming right? Is this situation really a management responsibility, not employees?
6. Finally, are there any public reports of Health Systems (single location or geographic region) where the situation is under control?

Remember, no political diatribes, let's just discuss this from a Quality viewpoint.

In another thread, we cover the topic of change management and introduce the concept of organizational culture.

If the seeming crisis (we haven't confirmed that, yet, just anecdotal stories so far) is real, what cultural change would be necessary as a first step?
I heard a speech over the weekend which postulated how much folks could cut down on the spread of colds by just washing their hands more frequently and thoroughly (the speaker suggested singing one verse of "Happy Birthday" for the correct duration of washing.)

Can things really be that simple?

 

[Charmed]

Health Care Crisis

Dear Wes:

After your post, I checked out the Healthgrade Inc. website to see if I could find any hard data to support the assertion that the medical errors crisis is getting worse.

Many news stories seem to be merely repeating what Healthgrades is saying. The 1999 Institute of Medicine (IOM) report estimated 98,000 preventable death per year due to medical errors. Many measures were promised (by IOM, supposedly acting on behalf of the medical community). The new study by Healthgrades now says the situation is much worse. It is now 195,000 preventable deaths per year.

However, so far, I have found no detailed justification yet for these numbers, and how they were arrived at. Still searching and would like to hear more.

Charmed

 

[Charmed]

45% of Specialists report medical error

Dear All:

I found the following "data" on medical errors. This is based on a survey conducted by a concerned physician who experienced a near-miss in his own medical practice. The full article may be found at the following link.

(broken link removed)

Notice the estimate of 9 deaths (4 %) based on responses from 466 physicians, with a total of 2500 being surveyed. Of these 210 physicians reported a serious medical error in their own practice within the past six months.

From the persepctive of a "Quality" professional (3.4 defects per million opportunities in Six Sigma methodology), the figure of 4% seems extremely high. Some of the reasons for medical errors are discussed in the article. One of the hospital systems here in the Metro Detroit area has recently announced a Six Sigma initiative (aimed more at cutting costs, reducing waste, and improving general quality, rather than medical errors, specifically).

Charmed


*********

45% of specialists report a recent medical errorPosted on Tuesday, August 03, 2004 @ 12:11 PM PDT by bjs


Otolaryngologist Dr. David Roberson has first-hand experience with medical errors. He remembers one near-miss in a patient about to receive a cochlear implant -- and says it typifies the kinds of mistakes he and his colleagues have turned up in a national survey. ''I looked at the CT scan carefully to determine if the cochlea would accept the implant,'' recalls Roberson, from the Department of Otolaryngology and Communication Disorders at Children's Hospital Boston. ''I asked a colleague to look at it also, and he commented that the auditory nerves looked small. I then ordered an MRI which showed the patient had no auditory nerves on either side. I came close to performing surgery and putting a major device in a child's head when there was no possibility of benefit, since she had no auditory nerve. I didn't look carefully enough at the entire scan.''

From Children's Hospital Boston :

In national survey, 45% of specialists report a recent medical error

Authors provide a 'top ten' list of safety recommendations

Otolaryngologist Dr. David Roberson has first-hand experience with medical errors. He remembers one near-miss in a patient about to receive a cochlear implant -- and says it typifies the kinds of mistakes he and his colleagues have turned up in a national survey.

''I looked at the CT scan carefully to determine if the cochlea would accept the implant,'' recalls Roberson, from the Department of Otolaryngology and Communication Disorders at Children's Hospital Boston. ''I asked a colleague to look at it also, and he commented that the auditory nerves looked small. I then ordered an MRI which showed the patient had no auditory nerves on either side. I came close to performing surgery and putting a major device in a child's head when there was no possibility of benefit, since she had no auditory nerve. I didn't look carefully enough at the entire scan.''

Roberson and colleagues sent a brief, anonymous survey to 2,500 members of the American Academy of Otolaryngology-Head and Neck Surgery, and received 466 responses (19 percent). Of these, 210 physicians -- 45 percent -- reported that a medical error had occurred in their practice in the past six months. Errors occurred in all phases of patient care; 78 (37 percent) caused major injury or harm, and 9 (4 percent) were fatal. Both adults and children were affected.

*******************

P. S. The "data" here also highlight the mathematical and philosophical difficulties that I had noted in an earlier post in this thread. The 4% figure is arrived at by converting the ratio y/x = 9/210 = 0.043 to a percentage. The numerator y is the number of errors that led to a fatality. We can be very sure about this. We know how to count the number of preventable deaths. The figure to be used for the denominator x, on the other hand, is far from certain. In the example here, 466 physicians responded to the survey but only 210 reported a medical error in their practice. Perhaps, we should use x = 466 which reduces the percent deaths to just 1.93%.

The situation is similar to that with traffic fatalities, discussed in a separate thread. We drive everyday without getting into an accident. Should the assessment of traffic fatality be based on miles traveled (which is what the National Highway Traffic Safety Administration, NHTSA uses), or should we look at the number of fatalities y that occur in x crashes. This figure tells us something about the chances of surviving a crash, given that you are in a crash. Similarly, given that a medical error has occurred what are the chances that it is fatal. The higher percent should be used, if we are trying to determine the likelihood of a fatality as a result of a medical error.

Unfortunately, (my impression, is that) the data itself might be "faulty". We must, first of all, develop a rigorous methodology for compiling data (NHTSA Traffic Safety Reports provide a very good model). In the recent Healthgrades Inc. report 16 different types of Patient Safety Incidents (PSI) were examined and the x and y values are available for study and analysis. However, I draw somewhat different conclusions from the same data (outside of scope here).

 

[Jen Kirley]

Here's another brick for the quality in health care foundation-building effort.

(broken link removed)

Study: Long hospital shifts, sleep deprivation can kill
Posted 12/11/2006 10:46 PM ET
By Kathleen Fackelmann, USA TODAY
Medical residents are routinely scheduled to work shifts that last 24 hours or more, yet a study out today suggests that these sleep-deprived doctors are at high risk of making medical mistakes that can harm or even kill patients.
"Working for more than 24 hours is hazardous," says sleep researcher Charles Czeisler at the Harvard Medical School. Scores of studies show that people who stay awake for 18 hours straight can have trouble thinking clearly and can zone out or nod off suddenly.

In July 2003, the Accreditation Council for Graduate Medical Education, a Chicago group that accredits medical residency programs, limited work schedules to no more than 80 hours in a week. But the rules still allow marathon shifts that last up to 30 hours.

Many medical residents must pull these extra-long shifts twice a week — a schedule that leads to extreme fatigue, says Simon Ahtaridis, president of the Committee of Interns and Residents, a 12,000-member union calling for more reform of work hours.

Czeisler and his colleagues had 2,737 first-year medical residents complete a monthly survey that asked detailed questions about their work schedule, sleep and days off. During the year-long study, the residents also were asked to report any medical errors they'd made while on duty.

The researchers found that when residents reported working five marathon shifts in a single month, their risk of making a fatigue-related mistake that harmed a patient increased by 700%. And the risk of making an error that resulted in a patient's death shot up by 300%. The report appears in the journal Public Library of Science (PloS) Medicine.

The residents in this study reported making 156 fatigue-related errors that injured a patient and 31 mistakes that led to a death, Czeisler says. About 100,000 medical residents in the USA routinely work these extended shifts, Czeisler says. "These data suggest there are tens of thousands of preventable injuries to patients annually."

Richard H. Bell Jr., assistant executive director of the American Board of Surgery, contends that 24-hour shifts are sometimes necessary to provide patients with crucial continuity of care. For example, residents might need 24 hours to get a patient through surgery and then to pass on the details of the case to the next resident, he says.