How the New Quality Movement Is Transforming Medicine

By Abigail Zuger MD, July 29, 2008, The New York Times – There are more than 800,000 doctors in this country, more than two million nurses and several million other health care workers. Until recently no one really knew what any of them were up to. Hospital walls bulged with frenetic activity, but all the public saw were the happy successes and the occasional tragic complications.

Those days are pretty much over. From what has been called a perfect storm of disgruntled patients, legislators and medical professionals, the quality movement in health care has been born.

Thanks to its efforts, those hospital walls are slowly becoming transparent. Revealed is a world of tangled routines, many obsolescent, many downright stupid, that no one had carefully examined. The reformers are out to streamline the routines, retrain the workers and keep them permanently on display — an ant farm behind clear glass — to make sure things never get out of control again.

Their early work was invisible to the public, but even that is changing. Take, for example, the latest benchmark in transparency: on a Wednesday late last May, newspaper readers across the country could compare how local hospitals performed on two measurements of the quality of care, not by slogging through a news article but by scanning a large government-sponsored advertisement complete with graphs and a Web address ( for more details.

That is just the first installment of such data on display. Soon both hospitals and individual practitioners will be publicizing their own report cards. Insurers will be paying them for good grades, penalizing them for bad. Incentives to minimize errors, complications and inefficiency will mount. Health care will become perfectly safe, perfectly smooth, perfectly perfect.

How did this messianic movement arise and take root, and who are its prophets? These are the questions Charles Kenney valiantly tries to answer in what is the first large-scale history of the quality movement.

Mr. Kenney, a former Boston Globe reporter and editor who is a consultant for a Massachusetts health insurance company, has set himself a giant assignment. While the book is not a success — an uncritical paean to his subjects, it reads like a corporate annual report — he provides a reasonably complete and up-to-date picture of the ambition and complexity of the enterprise.

Part of the problem is that he is trying to describe a target in motion, with roots almost as tangled as the chaos it seeks to eradicate. Poor-quality health care takes a variety of forms, each attracting a different set of crusaders.

Some have taken on the big blunders — errors of misdosed medication and operations on the wrong leg. Some have tackled “complications,” like catheter infections, that were once thought to be inevitable risks of hospitalization and now seem entirely preventable.

Some have focused on the smaller inefficiencies — little details with costly consequences, like medical records that disappear just when they are most needed and laboratory results that vanish into giant black holes.

Some aim to rearrange the physician-heavy hospital hierarchy so that all health care workers, and even family members, have the opportunity to call the shots in a patient’s care.

Still others focus on getting sick people correctly cared for: tight blood-sugar control for diabetics, regular Pap smears for women, flu shots for all.

Government and industry have been sources of inspiration for these goals. Experts from NASA to Toyota have tutored health quality gurus in the basics, like needing to prevent errors rather than punish them and respecting the right of any worker to stop the assembly line when a mistake threatens.

Mr. Kenney is scornfully dismissive of unnamed physician naysayers who point out that “human beings are not cars” and shy away from health quality control. It is these doctors’ “crust of hubris,” he argues, that prevents them from seeing the merits of new algorithms. Indeed, it is hard to imagine how any sane person could fail to leap on the quality bandwagon as presented here; it is all so self-evidently fabulous.

But readers should be aware that Mr. Kenney’s story ignores a wide array of questions that have some thoughtful members of the health care world a little troubled by the quality evangelism.

What does quality care mean, for instance, in cases of hopeless illness? When the outcome of care will not be good, how should good care be redefined? Suppose patients sabotage their own care, as so many unwittingly do. Who takes the blame?

And most important, what does it mean when science impudently undercuts accepted quality benchmarks? Only this past spring, for instance, two giant trials suggested that for some diabetics, tight blood-sugar control did nothing to safeguard them against some feared complications of diabetes and might actually endanger them.

Quality is a clear goal in product development, but in health it is still a shimmering intangible. All credit to the quality mavens; they are certainly fighting the good fight, and most of them deserve every laudatory adjective in Mr. Kenney’s thesaurus.

But fortunately for us all, most of them are smart enough to realize that human beings are not cars.

The Best Practice

How the New Quality Movement Is Transforming Medicine.
By Charles Kenney. Public Affairs Books. 315 Pages. $26.95

By Joe Vanden Plas, July 28, 2008 – Electronic medical records have been designed to assist physicians, radiologists, and labs, but a partnership between two Milwaukee institutions and a medical software developer is shifting some of that focus to decision support for nurses.

The partnership of Aurora Health Care, the University of Wisconsin-Milwaukee College of Nursing, and Cerner Corp. has reached the go-live phase of an evidence-based nursing initiative. The objective is not only to improve health outcomes by reducing variation in nursing care, but make the nursing profession more attractive at a time of personnel shortages and possibly help Aurora respond to federal action to eliminate payments for avoidable health events.

“Across the country, very few companies and very few places were able to really focus on nurses and nursing care, and yet nurses are the ones that are most involved with data and data management,” said Norma Lang, a professor and former dean of the University of Wisconsin-Milwaukee College of Nursing, and a professor in the University of Pennsylvania School of Nursing. “When you think about the amount of data that nurses have to handle today, it’s pretty awesome.”

Evidence-based nursing

According to project leaders, stakeholder alignment was not difficult to achieve because each entity stands to benefit. The UWM School of Nursing conducted most of the research into actionable evidence-based practices, which have been built into the workflows of Aurora nurses via Cerner software and could, according to Lang, serve as the basis for curriculum development.

As the technology partner, Cerner will be able to share the evidence-based findings with clients, and feed the data into a clinical data repository from which business intelligence can be extracted.

Aurora, which has a longstanding relationship with Cerner, serves as the laboratory for the project and will use the evidence-based information and business intelligence to drive continuous improvement and give its nurses more time to care for patients.

As the project began several years ago, there was a considerable amount of evidence-based research, but it wasn’t in actionable form or in a form necessary for building software. “The thinking was that we could advance the work faster together than if we were trying to do it alone,” Lang said.

The project reached the deployment phase with a July 21 launch of evidence-based protocols at two Aurora St. Luke’s Medical Center nursing units. The protocols are for fall risk, prevention, and management, plus medication adherence and activity intolerance.

Upon admission, nurses conduct a bedside assessment of patients, and the assessment drives care interventions that show up on a computer screen as task lists. For example, if a patient used a cane or walks with a gait, they are at a higher risk for falls. If they have brittle bones or use blood thinners, they run the risk of serious injury or excessive bleeding as a result of falls. The nurses can refer to the software for evidence-based practices that help prevent falls.

“The whole point of documenting electronically was not just to replace paper, it was to provide information to the frontline person,” said Karlene Kerfoot, vice president and chief clinical officer for Aurora Health Care.

Business considerations

Starting this year, the Centers for Medicare and Medicaid Services will not reimburse hospitals for certain preventable medical errors, including certain types of falls, pressure ulcers, and catheter-associated urinary tract infections. The list is likely to grow each year. Several more avoidable events are under consideration for 2009.

These events represent considerable cost. In a study of people 72 and older, the average healthcare cost of a fall injury was $19,440, according to the Centers for Disease Control and Prevention.

Lang believes pay-for-performance considerations are a motivating factor. Kerfoot, however, said CMS reimbursement decisions are not necessarily a business driver for Aurora, but they could be. “We didn’t necessarily align it with pay-for-performance, but in the future we certainly can,” she said, noting that eventually CMS might not pay for any hospital-acquired complication.

In the past, Kerfoot said, nurses have entered data into EMRs but got nothing out of it. Electronic records placed the additional burden of data entry upon nurses and took time away from patient care.

While the jury is still out on whether the system adds more time for care, nurses already see benefits. Jan Mills, a registered nurse for 25 years, said Aurora nurses have been developing care plans on computers for a while, but with this system, care plans can be mapped to the best health outcome for individual patients, and if the patient assessment changes, new alerts are fired off to provide additional decision support.

The alerts come into play throughout hospital care. “Without the technology and the alerting piece embedded into the workflow, you can’t retain a high-reliability organization,” said Ellen Harper, an RN and healthcare executive director for Cerner. “It’s not intended to remove the critical thinking skills of the clinicians; it’s to augment them.”

“Patients that are informed of their risk factors become involved in their care,” Mills said, “so you’re really partnering with that patient.”

Laura Burke, an RN and director of system nursing research and scientific support for Aurora, said the system already is helping nurses more quickly identify potential problems. “A lot of nursing is about prevention, not actually treating things,” she noted.

Once a nurse chooses an intervention, this information goes into the data repository, which already is being populated by Cerner. With the help of business intelligence software from Business Objects, that data repository eventually will produce operational information that drives continuous improvement in clinical processes.

Eventually, participants hope to learn enough to remove unnecessary, time-consuming steps in nursing workflows. “Everybody knows in the quality world that if you do it right the first time, it’s the most cost effective way to do it,” Lang noted. “So we’re interested in putting in the right steps, the right processes of what we call nursing action.”

By Tara Parker-Pope, July 29, 2008, The New York Times – A growing chorus of discontent suggests that the once-revered doctor-patient relationship is on the rocks.

The relationship is the cornerstone of the medical system — nobody can be helped if doctors and patients aren’t getting along. But increasingly, research and anecdotal reports suggest that many patients don’t trust doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

The Internet is bristling with frustrated comments from patients. On The New York Times’s Well blog recently, a reader named Tom echoed the concerns of many about doctors. “I, as patient, say stop acting like you know everything,” he wrote. “Admit it, and we patients may stop distrusting your quick off-the-line, glib diagnosis.”

Doctors say they are not surprised. “It’s been striking to me since I went into practice how unhappy patients are and, frankly, how mistreated patients are,” said Dr. Sandeep Jauhar, director of the heart failure program at Long Island Jewish Medical Center and an occasional contributor to Science Times.

He recounted a conversation he had last week with a patient who had been transferred to his hospital. “I said, ‘So why are you here?’ He said: ‘I have no idea. They just transferred me.’

“Nobody is talking to the patients,” Dr. Jauhar went on. “Everyone is so rushed. I don’t think the doctors are bad people — they are just working in a broken system.”

The reasons for all this frustration are complex. Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive.

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

Others say the problem also stems from a grueling training system that removes doctors from the world patients live in.

“By the time you’re done with your training, you feel, in many ways, that you are as far as you could possibly be from the very people you’ve set out to help,” said Dr. Pauline Chen, most recently a liver transplant surgeon at the University of California, Los Angeles, and the author of “Final Exam: A Surgeon’s Reflections on Mortality” (Knopf, 2007). “We don’t even talk the same language anymore.”

Dr. David H. Newman, an emergency room physician at St. Luke’s-Roosevelt Hospital Center in Manhattan, says there is a disconnect between the way doctors and patients view medicine. Doctors are trained to diagnose disease and treat it, he said, while “patients are interested in being tended to and being listened to and being well.”

Dr. Newman, author of the new book “Hippocrates’ Shadow: Secrets from the House of Medicine” (Scribner), says studies of the placebo effect suggest that Hippocrates was right when he claimed that faith in physicians can help healing. “It adds misery and suffering to any condition to not have a source of care that you trust,” Dr. Newman said.

But these doctors say the situation is not hopeless. Patients who don’t trust their doctor should look for a new one, but they may be able to improve existing relationships by being more open and communicative.

Go to a doctor’s visit with written questions so you don’t forget to ask what’s important to you. If a doctor starts to rush out of the room, stop him or her by saying, “Doctor, I still have some questions.” Patients who are open with their doctors about their feelings and fears will often get the same level of openness in return.

“All of us, the patients and the doctors, ultimately want the same thing,” Dr. Chen said. “But we see ourselves on opposite sides of a divide. There is this sense that we’re facing off with each other and we’re not working together. It’s a tragedy.”

Disabled by a painful skin condition, Robert Clark says, “I was a basket case who couldn’t put two and two together.”
Photo Credit: By Paul Connors

By Sandra G. Boodman, July 29, 2008, The Washington Post – Even before he entered the examining room to meet his new patient, dermatologist Howard Luber was confident he knew what was wrong with the man.

The diagnosis was so obvious, Luber recalled, that his nurse suggested it after taking Robert Clark’s history and looking at the angry, encrusted rash that blanketed nearly every inch of the 64-year-old’s body except his face.

Luber’s certainty was all the more surprising because of who the patient was and what he’d endured: A physician who specialized in infectious diseases, Clark had seen numerous doctors, including three dermatologists, immunologists, internists and infectious disease experts, all of whom had been stumped by the cause of his ferocious, uncontrollable itching. He had undergone two skin biopsies and taken countless drugs, but he would still awaken with fingernails bloody from scratching his skin raw. Doctors who had treated him for more than a year couldn’t decide whether his problem was severe eczema, a rare cancer, an unusual fungal infection, an autoimmune disorder or an unspecified allergy.

“It’s pretty hard to believe,” said Luber, who called Clark’s malady “bread and butter dermatology. I don’t have a good explanation” for why his problem went undiagnosed for so long. Maybe, he suggested, doctors were focused on more severe disorders and the skin’s worsening appearance camouflaged the underlying problem. “If you’re not thinking of it, you could miss it.”

Clark, a former researcher at the National Institutes of Health who lives in the Phoenix area, has a different perspective: He didn’t attempt to second-guess his doctors. “I just acted like a patient, and that’s what got me in trouble,” he said. “I never at any point until the end of this illness suspected they didn’t know what they were doing. Dr. Luber saved my life.”

Clark’s problem, which he called “devastating” and “life-changing,” began in 2004, when he developed an itchy rash on his left side. His internist wasn’t sure what was wrong but prescribed the usual treatment for such maladies: an antihistamine, cortisone cream, various ointments for dry skin and oatmeal baths. When the rash got worse, he sent Clark to dermatologist number one, who performed a skin biopsy and then prescribed Elidel, a topical medicine used to treat eczema.

That didn’t work, nor did the other antihistamines the dermatologist prescribed. By the time Clark got to dermatologist number two he was having trouble concentrating. Some nights he donned thick ski gloves or thin white cotton ones to try to prevent his furious scratching; he often awoke with lacerated skin or to find drops of blood on his sheets.

Several months later a new symptom arose: a painful fuzzy rash on Clark’s feet that was diagnosed as a rare fungal infection. Doctors also noticed that his eosinophil count, a measurement of a type of white blood cell, was extremely high, suggesting either a rare skin cancer or an allergy. But to what? No one could say.

The rash now covered much of his body, and dermatologist number three, along with two infectious disease specialists, an immunologist and an endocrinologist, wasn’t sure what was wrong. One doctor suggested chemotherapy. Another thought the problem might be a drug reaction. A third prescribed a high dose of prednisone, a steroid Clark took for six months. It blunted the itching but led to severe pain in his hips, which was diagnosed as avascular necrosis, permanent bone damage linked to long-term use of corticosteroids.

Clark said he was so disabled by the pain and itching that he had stopped practicing; he is now retired. In an effort to give him some relief, the immunologist prescribed narcotic pain medication and insisted that Clark see dermatologist number four: Luber. Clark balked, but the immunologist insisted, so he went, after canceling an initial appointment.

Clark recalled that Luber “was in the room less than a minute when he said, ‘You will be feeling better in a few days.’ ” The dermatologist gently scraped Clark’s inflamed, leathery skin and then had him look at the slide under the microscope.

The problem was immediately obvious: The skin sample was teeming with a common parasite called scabies, a tiny mite passed from direct contact with an infected person. The eight-legged mite thrives in overcrowded conditions or among people with substandard hygiene, but it can affect anyone, according to the American Academy of Dermatology.

Outbreaks have plagued humans for more than 2,500 years and can occur in institutions such as homeless shelters, nursing homes and sometimes hospitals. Diagnosis may be delayed because scabies mimics other skin conditions and mites are difficult to see with the naked eye.

Its most characteristic symptom is itching at night so ferocious it can keep sufferers from getting any sleep. The mite burrows into the skin, laying eggs and producing toxins, causing an allergy that triggers the itching. Mites are attracted to warmth and human scent, and can live up to 24 hours on bedding.

Clark had the most severe form of scabies, called Norwegian or crusted scabies. In these cases, thousands of mites hide under skin, which becomes thickened, retarding penetration of topical medicines.

Treatment with topical medicines and, in severe cases, an anti-parasitic drug called ivermectin — Clark took both — is standard, and the residence of an infected person must be thoroughly cleaned and clothing washed in the hottest water possible. All members of a household must be treated, because the incubation period can be as long as eight weeks.

Luber, who diagnoses about six cases annually, recalled that Clark was “very surprised. I remember him saying that no one had mentioned scabies,” which would not show up on a biopsy.

Clark said that his wife turned out to have a milder case, as did the couple’s housekeeper. And as Luber predicted, Clark started to feel better within a day, although it took weeks before the itching subsided. He said he doesn’t know where he contracted the disease but suspects it might have been from a patient.

When Clark told some of the physicians who examined him what had happened, he said they were not sympathetic.

“Several told me I was an infectious disease specialist and I should have figured it out,” he recalled. “That was very unfair and made me angry. I was a basket case who couldn’t put two and two together.”