Care Redesign – Its Time Has Come
My dog has kidney disease. She’s had it for some time and it really hasn’t changed her life. Once a couch potato, always a couch potato. She is on the maximum doses of drugs for the disorder, which she takes begrudgingly. On her last visit to the nephrologist (yes, she has a nephrologist), an ultrasound was
suggested as part of her care plan. I questioned the need – would it change the current treatment? No – it would just tell us what the kidneys looked like so no ultrasound.
Isn’t that what care redesign is all about? Reviewing what is being delivered, determining if specific treatments contribute to an improved outcome and assessing whether there is a better way – a better practice. So often I hear “that’s the way we have always done it”.
A recent poll by the Robert Wood Johnson Foundation (2014) showed that almost three quarters of physicians polled said that the frequency of unnecessary tests and procedures is a very or somewhat serious problem. And almost 50% indicated they order such tests if the patient insists. We need to step back from these attitudes and look at what we are doing.
The first step can be small – identifying where issues exist is a good place. One hospital found that every critical care patient had a chest x-ray performed every morning regardless of clinical indication. At another, a review of the charts of patients with diabetes revealed that hemoglobin A1c levels were being drawn on several occasions throughout the hospitalization. In the first case, patients were being unnecessarily exposed to radiation with little clinical benefit (Value of Routine Daily Chest X-rays in the Medical Intensive Care Unit (Strain, Kinasewitz, Vereen, George, 1985) (National Guideline Clearinghouse). In the second, lab costs were inflated without cause (hemoglobin A1c levels require 3 months to show clinical benefit of treatment (National Institute of Health). In both cases, by redesigning the care and educating staff and physicians, the hospitals were able to reduce costs while maintaining or enhancing the care being provided.
It is not easy to change behavior – old habits die hard and all that. But in this era of declining reimbursements, value rules. But for now, I have to go walk the dog!
References
American College of Radiology. (2011). ACR Appropriateness Criteria® . Reston, VA: ACR.
National Guideline Clearinghouse. (n.d.). Retrieved from U.S. Department of Health and Human Services: http://www.guideline.gov/content.aspx?id=35151
National Institute of Health. (n.d.). Retrieved from MedlinePlus: http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm
Robert Wood Johnson Foundation. (2014, May 1). Survey: Physicians are Aware that Many Medical Tests and Procedures are Unnecessary, See Themselves as Solution. Robert Wood Johnson Foundation. Retrieved from http://www.rwjf.org/en/about-rwjf/newsroom/newsroom-content/2014/04/survey–physicians-are-aware-that-many-medical-tests-and-procedu.html
Title: Corporate Regulatory Officer
Organization: Temple University Hospital / Temple University Health System
This story has been my life: personal and professional. The first portion about the dog, I can relate to about my mom, myself and my husband with unnecessary care/treatement/tests. The medical community has a visercal reaction when you say no to a test or treatment.
The system allows unnecessary testing. I can’t tell you know many meetings I have been to about these issues throughout my career as a quality professional. It is sad but true, change is hard and care redesign is even harder. Data is telling and physicians react to data; once they stop telling you how their patients are sicker and that the methodology for collection and analysis is wrong. Geri is right on target.