What Makes a Successful Hospital – Where Are the Tweakers???

First off, I don’t have a business degree (in fact, I’m a MBA drop-out) nor a degree in hospital administration (does chairing a hospital committee count?), but I do have an opinion (don’t we all) in light of having co-founded a bioinformatics company (iCORD, LLC) in the past based on a patent developed during my surgical residency… But I also admit that the company was ultimately unsuccessful if one measures success in terms of monetary profits, but I can say I succeeded in that my now defunct company’s “product” still lives on at Duke University Medical Center.

It is perhaps my mixed bag background of a few victories and even more failures that I learned a thing or two about what it means to become better… it is what I call evolutionary tweaking or to put it more bluntly… whining and doing something about it. But let’s stick with the “tweaker” euphemism.

Tweakers are annoying and may be a thorn in any administrator’s side, but they produce results. They tinker and tinker in an attempt to improve and better a situation they consider a problem whether it be an engine, a computer program, or an entire production system.

Based on Isaacson’s biography about Steve Jobs, he had it in abundance… even on medical care and devices during his last days.

Apparently, in his very last days of life, he went through 67 nurses before he found 3 he liked. He also refused to wear an oxygen mask due to a perceived poor design until he personally reviewed 5 different mask options and picked the one he liked best.

I’m certainly not promoting a culture where every patient, nurse, doctor, and administrator should start whining and complaining about everything. The hospital would shut-down.

BUT, there should be a culture where incremental tweaks are not only allowed, but encouraged with the expectation that many ideas will fail with monetary setbacks. However, just like survival of the fittest, the cumulative evolutionary cycles of keeping successful ideas and tossing ones that aren’t will lead to a better organization over time… continuously and cheaply.

Home run ideas should not be the goal. Batting consistent singles (or tweaks) are…

There are systems to describe this process: PDSA (Plan Do Study Act), Toyota Production System, Just-In-Time Production, Deming Wheel, Shewhart Cycle, Control Circle, etc.

Now I certainly am not the first to suggest this concept to hospital settings. In fact, I’ve seen PDSA posters tacked on a wall in hospital physician lounges in the past.

However, I have observed great variances in how different hospital systems incorporate this “controlled whining” into their culture and administration.

Some embrace this process wholeheartedly and have succeeded in abundance. Others give lip service and designate the “tweakers” as whiners to be shut-up with bureaucratic red-tape, offensiveness requiring peer-review, or worse.

Employees and staff are a hospital’s greatest assets both in terms of knowledge and production services. A hospital can either embrace trying to unlock the knowledge of what it already possesses or it can stifle them by punishing those who try to “tweak” thereby sending the message to everybody else to stay in the background… passivity being the rule… or voluntarily leave (or get fired).

The long-term success of a hospital system depends on how well it utilizes ALL its resources including not only encouraging an idea a hospitalist physician may have about telephone communication (allowing for faster patient care), but also trying to discover the knowledge trapped in a janitor’s head who just might know how to thoroughly clean a hospital floor in half the time (saving time and money), but is too afraid to say anything.

Adapt or perish. History is replete with immensely successful companies that failed to adapt and are now either bankrupt or nearing death… Eastman Kodak, Tower Records, Borders Bookstores, etc.

And how does a hospital adapt to avoid non-existence? Continuously tweak… even when things are going well. USE all your assets with all guns blazing rather than smothering them.

Celebrate the tweakers!!!

Singer George Michael With Tracheostomy

Reuters reported today that singer George Michael suffered from severe pneumonia and underwent a tracheostomy during his hospitalization. A tracheostomy is when a hole is made in the throat for a patient to breath through.

Here is a video of what his trach surgery may have looked like.

Michael apparently was in the middle of a tour when he became ill requiring him to cancel upcoming shows.

A tracheostomy is often performed whenever a patient has been intubated (tube down the throat) on a breathing machine for a prolonged period of time.

For more information on trachs, click here. Watch a video of a trach being performed here.

http://www.reuters.com/resources_v2/flash/video_embed.swf?videoId=227351807&edition=BETAUS

Reference:
Gaunt George Michael says “fortunate to be here” Reuters 12/23/11

Doctor Distraction Happens… It’s Mandatory!

I admittedly snorted out loud when I read a New York Times article  earlier last week regarding increased physician distraction due to electronic devices, especially with the advent of the smartphone with its emails, text messages, calls, and other alerts that ping intermittently throughout a typical work day.

There is no question that electronic devices distract physicians as the article pointed out… But that’s like complaining about a leaky faucet when there’s a flooded basement and a hole in the roof.

The bigger problem that should be mentioned is hospital bureaucracy which probably creates just as much if not more unintended distractions for physicians and nurses.

What many patients and lay public may not realize is that there is a TON of paperwork that goes into the care of a patient. Regulatory bodies like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that accredits hospitals have made it mandatory in many cases though I suspect hospital administration often carries it a step above and beyond what is truly necessary.

What all this “mandatory” paperwork means is that nurses are calling physicians all the time just so they can check a box on a form… and there are a LOT of boxes to check.

Take a simple ear tube placement. A procedure that takes about 1-2 minutes to perform under sedation in the pediatric population.

It takes about 15-20 minutes to fill out all the nursing and physician forms (whether paper or electronic medical records). When the surgery actually begins, the nurse is too busy filling out even more forms rather than paying attention to the surgery… and often the surgery is already over… and the nurse is still busy filling out forms.

Talk about distraction… a registered nurse has been relegated to being a mere secretary rather than helping (or paying attention) in the care of a patient.

I recently asked a nurse how much time they spent on actual patient care versus how much time filling out forms during a typical shift.

It saddened my heart when I was told 60-70% of a nurse’s time is spent on filling out forms (whether notes, chart documentation, medication reconciliation, etc) and only 30-40% on actual patient care. This time disparity was not always true in years past.

OR… ask any physician how many times they get called during a typical day because some form or paperwork was not completed or needs completion or just remind to get it completed by nurses who themselves are the main individuals who suffer under the crush of mandatory documentation in a hospital setting.

It is irritating to say the least to get a phone call during the middle of an operation, say dissecting a tumor off the facial nerve during a parotid cancer resection, by someone who wanted to remind me to sign off on a medication list on a patient I’ve already provided prescriptions for.

Another classic experience of mine was when the anesthesiologist had trouble intubating a patient who started to suffer a severe lack of oxygen. I was immediately called to the bedside and performed an emergency tracheostomy.

Of course, the nurse (well indoctrinated in form completion) involved in the case immediately instructed me to STOP performing the trach and to get consent as per the regulations… which is true 99% of the time… but never mind that. Heaven forbid we now can’t check that little box that states “consent obtained prior to surgery.” But in the interest of patient care, I did suggest that it would be better if the patient lived with an unconsented trach rather than died due to time spent obtaining consent.

Though electronic devices may be considered a “distraction” analogous to a mosquito buzz that comes and goes, one must not forget the avalanche of paperwork which is a much more pervasive and insidious distraction that DELIBERATELY takes attention away from the care of the patient. I understand the need for documentation, but at some point when the documentation itself dominates the majority of heathcare rather than the actual administration of care, there’s something fundamentally wrong going on.

It’s probably why medical missions are so gratifying to participating nurses and physicians where 90%+ of the time is in actual patient care.

Reference:
As Doctors Use More Devices, Potential for Distraction Grows. NYT Dec 14, 2011.

Want to See a Specialist Doctor Who Does Not Take Your Insurance? There Are Options…

It is not unusual nowadays that a patient may want to see a specific medical specialist who unfortunately does NOT participate with their health insurance plan. This doctor is what is known in insurance parlance as a “non-par provider.”

In this situation, there are two options.

1) The patient pays the medical bill (self-pay) and forwards the receipt to the insurance company who hopefully will reimburse the patient.

2) The patient can request a “Letter of Medical Necessity” from the primary care doctor to submit to the health insurance company requesting temporary non-participating provider (non-par) insurance coverage.

What does such a letter of medical necessity entail?

The best way to illustrate this course of action is to provide an example. In my practice, I offer several services that many other ENT specialists do not. As such, there are a large number of patients who travel from even as far away as Florida and Arizona to be seen in our Virginia office. Needless to say, many patients have health insurance plans that I do not participate with.

One such procedure is tonsil cryptolysis.

A sample “Letter of Medical Necessity” that a patient can request from their primary care doctor to submit to their insurance company is as follows (the same concept can apply to any type of procedure or specialist evaluation):

John Smith, MDCountry Lakes Family Practice

Dear [Insurance Company]:

I am writing this letter on behalf of my patient, Mary Smith (DOB: 01/01/1965), who has a 10 year history of cryptic tonsils with production of tonsiliths (tonsil stones) on a daily basis. 

Though this problem occurred intermittently during adolescence, it has recurred during adulthood and has become a chronic problem which has affected her overall quality of life.  These stones consist of debris collected in the crypts of the tonsils together with sulfur-producing bacteria which account for the acrid odor and taste.  

I believe Mary is a candidate for a minimally-invasive procedure called tonsil cryptolysis (coblation therapy).  This procedure uses a radio-frequency energy in combination with a conductive medium to form a low temperature (40-80° C) localized plasma field which allows the precise removal of affected tissue while maintaining the integrity of surrounding, healthy tissue.  This results in decreased pain and a significantly shorter recovery time as compared with more traditional methods of treatment.  This procedure can be done in the office under local anesthesia on eligible adult patients.

After an initial evaluation for candidacy, tonsil cryptolysis can be done in an office setting under local anesthesia.  Most patients (70%) require one session for complete amelioration of symptoms. 

As there are no area specialists offering tonsil cryptolysis, I recommend that Mary be evaluated and treated by a non-par provider, Dr. Christopher Chang of Fauquier ENT Consultants located in Warrenton, VA. Please provide temporary insurance coverage in order for Mary to be seen by Dr. Chang.

Sincerely,
xxxxxxx
Dr. John Smith

That’s it!

If insurance declines coverage, than you are stuck with option #1 to self-pay if you really want to see a specific non-participating provider.

In any case, some unique services our office provides for which patients have requested non-par provider coverage include:

• Video/Audio Nasopharyngoscopy for Velopharyngeal Insufficiency
• Endoscopic Staple Diverticulostomy for Zenker’s Diverticulum
• Botox Injections for Spasmodic Dysphonia
• Chronic Cough Evaluation
• Phlegmy Throat
• Chronic Throat Clearing
• Allergy Drops

Fauquier ENT Now Participates with Chase Health Advance Flexible Payment Options

Due to popular demand, our office now participates with Chase Health Advance. This plan is for those patients without insurance coverage or to help pay for uncovered procedures/services. Flexible payment options are offered only if total charges exceed $1000 (cost can be as low as $48 per month over 24 months). Depending on the promotion offered by Chase Health Advance, there may even be no interest charged! Click here to calculate your monthly payments.

United Kingdom Ends $17 Billion Electronic Medical Records Initiative

The Wall Street Journal on Sept 23, 2011 reported that the United Kingdom will scrap the entire electronic medical records (EMR) initiative that has been 9 years in the making with nearly 6.4 billion pounds already spent.

That action was hinted at back in August 2011 after a scathing parliamentary report stating the initiative to be wasteful and incapable of delivery.

I’m not surprised…

It’s hard enough to get a group of doctors in one hospital to agree with a treatment plan let alone agree to a medical records system. The problem is exponentially more difficult when applying it to an entire country.

Physicians practice medicine differently… just like teachers have their own unique way of teaching kids. A method that may work for one doctor or teacher will not work for another. Even the method may change depending on how “busy” things are (teacher with a class of 5 kids versus 30 kids) so a doctor in a busy inner-city emergency room will have different flows and needs from an electronic medical records than a rural family practice with a sedate pace. Furthermore, the needs of a dermatologist is very different from a pediatrician. One can’t expect a single EMR system to meet the needs of both perfectly just like one cannot expect a math teacher to use the same teaching methods as a singing teacher.

Forcing physicians to use a single standard electronic medical records without adapting to these realities is bound to fail no matter how much time, training, software, and hardware you throw at it.

A better alternative (my opinion), is to treat electronic medical records like the computers they reside on. There should be many different types of EMR systems just like there are MANY different types of computer models, speeds, makes, cost, sizes, etc.

However, unlike current EMR systems, in spite of who makes a computer and what operating system software it runs, it has standardized components… USB, Firewire, HDMI, VGA, BlueTooth, etc. as well as a universal communication medium called the “internet” that works with phones, computers, laptops, etc regardless of who makes it and what software it is on.

You would think that an EMR system given its digital essence would be able to easily communicate with other systems… but no… they don’t communicate at all… which is why paper reports still exist… which are than scanned into the EMR.

Rather than the government (whether the United Kingdom or the United States) dictating what physicians must do and mandating EMR initiatives, I believe the money would be much better spent on mandating inter-operability and communication standards. The free market will create the best EMR systems and physicians will pick the one that best meets their need.

The other more insidious side of EMR is the over-reaching health goal mandates which means well, but runs into the same problem of applying standards to all physicians. Take “meaningful use” set by the Centers of Medicare and Medicaid Services (CMS). One of the core measures of meaningful use is adult weight-screening and follow-up.

Now as an ENT specialist, I see patients specifically for earwax. Why in the world would I want to perform a weight-screening when all I want to do (and what the patient only wants me to do) is get earwax out???

Makes no sense.

Does it to you???

Reference:
U.K. Scrapping National Health IT Network. InformationWeek Healthcare. Aug 4, 2011

U.K. Ends Health-Service IT Upgrade. Wall Street Journal. Sept 23, 2011

Smoker’s Kids Have More Ear Infections

Although not entirely new news… a new review paper which collated the results of 61 past studies has reaffirmed that smoking around kids increases their risk of ear infections dramatically.

Just how much?

Kids living with a smoker had a:

• 37 percent higher risk of ear infections and hearing problems
• 62 percent higher risk of ear problems if the household smoker was their mom
• 86 percent more likely to undergo ear surgery than kids without secondhand smoke exposure

Read a MSNBC story on this here.

So don’t smoke for your own health as well as your kids’ health!!!

Reference:
Parental Smoking and the Risk of Middle Ear Disease in Children. Arch Pediatr Adolesc Med. Published online September 5, 2011. doi:10.1001/archpediatrics.2011.158

Fauquier ENT Now Participates with Optima Health Insurance

For those patients who have not yet heard…

Fauquier ENT now participates with Optima Health insurance with one caveat… We only participate with the PPO plan only.

For the full list of health insurance policies we participate with, click here.

Do Cell Phones Pose a Health Hazard? Do Cell Phone Companies Know About Them?

With all the recent news about increased glucose metabolism in the area of the brain in proximity to cell phone antennas (study abstract here), I thought it worth re-printing this blog article I wrote back in November 2010 regarding the possibility that cell phone makers may know more about health risks associated with cell phone use than they may be letting on. There’s another blog article I wrote regarding what studies ARE already out there regarding risk of developing brain tumors that I felt worth re-printing below as well.

It is true that some people may find this recent research good news for some young people as it may be the only stimulation their brain gets (joking!), but it does bring some additional concerns that may merit limiting cell phone use as well as how it is used.

I quote (myself)…

Recently, there has been much speculation on whether cell phones pose a health risk.

What I find interesting is that the cell phone makers may actually know more about these risks than they are letting on or even have evidence for them.

If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. The picture of how the Verizon ad guy is using the cell phone is exactly how you are NOT supposed to use the cell phone (cell phone pressed against the face).

For example, in the iPhone 4 small print booklet that comes in the box with the phone, go to page 5 under the section “Exposure to Radio Frequency Energy.” I quote:

“When using iPhone near your body for voice calls or for wireless data transmission over a cellular network, keep iPhone at least 15 mm (5/8 inch) away from the body, and only use carrying cases, belt clips, or holders that do not have metal parts and that maintain at least 15 mm (5/8 inch) separation between iPhone and the body.”

Now, when I use a phone and answer a call, I have the phone right up against my ear just like the Verizon ad guy. I do not keep it 5/8 inch away from my ear/head.

Now why would a cell phone maker care whether the phone is right up against the ear (so you can hear better) or not unless there is some concern that there may be a danger due to proximity/contact?

Perhaps they are protecting themselves from any possible lawsuit that may occur in the future due to health problems that will occur with phone use over time?

Kind of reminds me of the tobacco industry who for years denied that smoking posed any health risk. Now we know better.

It would be ironic if Paul Marcarelli, the actor of the “Verizon Guy” character, develops a brain tumor due to cell phone use and sues the wireless industry just like the family of David McLean, the actor of the “Malboro Man,” sued the tobacco industry for wrongful death when he developed and died from lung cancer caused by smoking.

Something to think about…

So are there studies out there suggesting that cell phones and wireless phones can lead to brain tumors like astrocytoma, malignant gliomas, and benign acoustic neuromas? Several studies published since 2009 containing long-term (10+ years) follow-up have lent support that it does.

The group at greatest risk for development of brain tumors have the following characteristics:

1) Use of cell/wireless phone younger than age 20 (the younger the age with first use, the worse the risk)
2) Use of cell/wireless phone for more than 10 years
3) The more hours of cellular phone use over time, the higher the risk of developing brain tumors
4) Risk higher with analog cell/wireless phones (instead of digital)
5) Risk higher with increased overall total exposure

By some estimates, subjects who used cell phones for at least 10 years had a 2.4-fold greater risk of developing a brain tumor.

Though unclear how exposure to a phone’s microwave radiation leads to brain tumors, it is known that the cell signal is absorbed up to 2 inches into the adult skull. Even more worrisome is that the depth of penetration is even deeper in children.

The risk is not just to the brain, but even the parotid gland which sits just in front of the ear. In one study published in 2008 revealed an increased risk of parotid gland tumors with cell phone use. Also, contact allergy is another not uncommon risk with cell phone use.

Symptoms that a patient may exhibit that may suggest a brain tumor are subtle and include hearing loss or ringing of the ear on the same side the phone is used on.

It should be noted that all currently published results are based on retrospective studies and ideally, prospective studies will be required to provide more definitive results. However, that will take a long time and perseverance on both the researchers as well as the subjects since ideally, many of the study subjects should be children who are currently using cell phones (which it seems to be nearly all kids nowadays).

In any case, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset (not wireless), or avoid altogether if at all possible, especially in children.

References:
Effects of cell phone radiofrequency signal exposure on brain glucose metabolism. JAMA. 2011 Feb 23;305(8):808-13.

Risk of Brain Tumors From Wireless Phone Use. Journal of Computer Assisted Tomography, 2010; 34 (6): 799 DOI: 10.1097/RCT.0b013e3181ed9b54

Cell phones and brain tumors: a review including the long-term epidemiologic data. Surg Neurol. 2009 Sep;72(3):205-14; discussion 214-5. Epub 2009 Mar 27.

Mobile phones, cordless phones and the risk for brain tumours. Int J Oncol. 2009 Jul;35(1):5-17.

Cell phone use and acoustic neuroma: the need for standardized questionnaires and access to industry data. Surg Neurol. 2009 Sep;72(3):216-22; discussion 222. Epub 2009 Mar 27.

Cellular phone use and risk of benign and malignant parotid gland tumors–a nationwide case-control study. Am J Epidemiol. 2008 Feb 15;167(4):457-67. Epub 2007 Dec 6.

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Wireless and Cell Phones Increase Risk of Brain Tumors

In an ongoing controversy regarding whether cell phones and wireless phones can lead to brain tumors like astrocytoma, malignant gliomas, and benign acoustic neuromas, several recent studies published since 2009 containing long-term (10+ years) follow-up have lent support that it does.

The group at greatest risk for development of brain tumors have the following characteristics:

1) Use of cell/wireless phone younger than age 20 (the younger the age with first use, the worse the risk)
2) Use of cell/wireless phone for more than 10 years
3) The more hours of cellular phone use over time, the higher the risk of developing brain tumors
4) Risk higher with analog cell/wireless phones (instead of digital)
5) Risk higher with increased overall total exposure

By some estimates, subjects who used cell phones for at least 10 years had a 2.4-fold greater risk of developing a brain tumor.

Though unclear how exposure to a phone’s microwave radiation leads to brain tumors, it is known that the cell signal is absorbed up to 2 inches into the adult skull. Even more worrisome is that the depth of penetration is even deeper in children.

The risk is not just to the brain, but even the parotid gland which sits just in front of the ear. In one study published in 2008 revealed an increased risk of parotid gland tumors with cell phone use. Also, contact allergy is another not uncommon risk with cell phone use.

Symptoms that a patient may exhibit that may suggest a brain tumor are subtle and include hearing loss or ringing of the ear on the same side the phone is used on.

It is interesting to note that it is just possible that the cell phone industry is aware of these risks even as it denies any risk of health problems with phone use. If you look in the small print booklet that comes with your cell phone, cell phone makers state that phones should not be in contact with your body or skin and should be kept a certain distance away when in use or when carrying around. Read more about this here.

However, all currently published results are based on retrospective studies and ideally, prospective studies will be required to provide more definitive results. However, that will take a long-time and perseverance on both the researchers as well as the subjects, since ideally, many of the study subjects should be children who are currently using cell phones.

In any case, to be on the safe side, it is recommended to talk on speakerphone or use a wired headset (not wireless), or avoid altogether if at all possible.

References:
Risk of Brain Tumors From Wireless Phone Use. Journal of Computer Assisted Tomography, 2010; 34 (6): 799 DOI: 10.1097/RCT.0b013e3181ed9b54

Cell phones and brain tumors: a review including the long-term epidemiologic data. Surg Neurol. 2009 Sep;72(3):205-14; discussion 214-5. Epub 2009 Mar 27.

Mobile phones, cordless phones and the risk for brain tumours. Int J Oncol. 2009 Jul;35(1):5-17.

Cell phone use and acoustic neuroma: the need for standardized questionnaires and access to industry data. Surg Neurol. 2009 Sep;72(3):216-22; discussion 222. Epub 2009 Mar 27.

Cellular phone use and risk of benign and malignant parotid gland tumors–a nationwide case-control study. Am J Epidemiol. 2008 Feb 15;167(4):457-67. Epub 2007 Dec 6.