Would evidence-based regulation improve the practice and management of patient care?

The use of evidence to achieve sound medical diagnoses and optimal treatment plans is considered a standard of practice for healthcare providers. Indeed, failure to do so is prima facie evidence of malpractice. Health and medical care managers have begun espousing a similar philosophy: to make decisions that are data-driven rather than based on logic, intuition, personal preference, or last experience. Unfortunately, regulatory policies and practices in patient care are not always founded upon strong evidence. As a result, unintended consequences often surface after the passage of legislation or the adoption of policies by nongovernmental entities. These dysfunctions might be avoided if policymakers embraced evidence-based protocols commonly found throughout medicine and its management. This paper reviews the dilemmas that unfold when policy is formed without giving sufficient attention, in advance, to "hard" evidence.

Strategic planning to reduce medical errors: Part II--therapy.

In Part I of this series, medical errors were analyzed from a systems dynamics viewpoint. It was noted that despite extensive dialogue and a continuing stream of proposed medical practice revisions, medical errors and adverse impacts persist. Connectivity of vital elements is often underestimated or not fully understood. In Part II, our analysis suggests that the most fruitful strategies for dissolving medical errors include facilitating physician learning, educating patients about appropriate expectations surrounding treatment regimens, and creating "systematic" patient protections rather than depending on (nonexistent) perfect providers.

Strategic planning to reduce medical errors: Part I--diagnosis.

Despite extensive dialogue and a continuing stream of proposed medical practice revisions, medical errors and adverse impacts persist. Connectivity of vital elements is often underestimated or not fully understood. This paper analyzes medical errors from a systems dynamics viewpoint (Part I). Our analysis suggests in Part II that the most fruitful strategies for dissolving medical errors include facilitating physician learning, educating patients about appropriate expectations surrounding treatment regimens, and creating "systematic" patient protections rather than depending on (nonexistent) perfect providers.

The shocking cost of turnover in health care.

Review of turnover costs at a major medical center helps health care managers gain insights about the magnitude and determinants of this managerial challenge and assess the implications for organizational effectiveness. Here, turnover includes hiring, training, and productivity loss costs. Minimum cost of turnover represented a loss of >5 percent of the total annual operating budget. Editor's Note: This article is being reprinted with permission from Health Care Management Review 29(1), 2-7.

Overlapping spectra of SMAD4 mutations in juvenile polyposis (JP) and JP-HHT syndrome.

Juvenile polyposis (JP) and hereditary hemorrhagic telangiectasia (HHT) are clinically distinct diseases caused by mutations in SMAD4 and BMPR1A (for JP) and endoglin and ALK1 (for HHT). Recently, a combined syndrome of JP-HHT was described that is also caused by mutations in SMAD4. Although both JP and JP-HHT are caused by SMAD4 mutations, a possible genotype:phenotype correlation was noted as all of the SMAD4 mutations in the JP-HHT patients were clustered in the COOH-terminal MH2 domain of the protein. If valid, this correlation would provide a molecular explanation for the phenotypic differences, as well as a pre-symptomatic diagnostic test to distinguish patients at risk for the overlapping but different clinical features of the disorders. In this study, we collected 19 new JP-HHT patients from which we identified 15 additional SMAD4 mutations. We also reviewed the literature for other reports of JP patients with HHT symptoms with confirmed SMAD4 mutations. Our combined results show that although the SMAD4 mutations in JP-HHT patients do show a tendency to cluster in the MH2 domain, mutations in other parts of the gene also cause the combined syndrome. Thus, any mutation in SMAD4 can cause JP-HHT. Any JP patient with a SMAD4 mutation is, therefore, at risk for the visceral manifestations of HHT and any HHT patient with SMAD4 mutation is at risk for early onset gastrointestinal cancer. In conclusion, a patient who tests positive for any SMAD4 mutation must be considered at risk for the combined syndrome of JP-HHT and monitored accordingly.

Retention of chairs in obstetrics and gynecology: a comparison with other clinical departments.

OBJECTIVE: To compare the retention of chairs in academic obstetrics and gynecology with other core clinical departments. METHODS: Ongoing data were collected from each medical school for the Association of American Medical Colleges Faculty Roster between 1979 and 2007. Primary outcome measures included 5-year and 10-year retention rates and survival curves of first-time chairs. Comparisons were made between first-time chairs in obstetrics and gynecology and other core clinical departments: internal medicine, family medicine, pediatrics, psychiatry, and surgery. RESULTS: Five-year retention rates of obstetrics and gynecology chairs declined from 80% for those who began in 1979-1982 to 53% for those who began in 1998-2002. Ten-year retention in obstetrics and gynecology declined from 54% for those beginning in 1979-1982 to 26% for those beginning in 1993-1997. Other clinical departments experienced more stable 5-year and 10-year retention rates. Although substantially longer than other clinical departments in the 1979-1982 cohort, the median tenure of obstetrics and gynecology chairs who began in 1993-1997 was comparable with or less than that of other clinical departments. Discrete-time survival analysis revealed this decline in obstetrics and gynecology chair retention to be significant (P<.001) and more consistent than in other departments. CONCLUSION: Compared with other core clinical departments, retention of first-time chairs in obstetrics and gynecology declined more consistently from the highest to among the lowest. Chairs were inclined to not remain in office for a prolonged period. LEVEL OF EVIDENCE: II.

Learning - the only way to improve health-care outcomes.

Attempts to improve health care have generally failed. Systems analysis urges addressing processes, such as learning, rather than isolated parts of a system. We apply learning curve theory to health care and then explicate the process of learning. Specific recommendations involve how we learn (and unlearn), who should learn, and what should be learned.

Change your metrics: if you get what you measure, then measure what you want--retention.

What we want is retention, not turnover, of our workforce. We should measure what we want-net retention-which is a fundamentally different metric from turnover (not its inverse). Net retention is a highly useful managerial tool, especially for fiscal and strategic planning. Retention enables learning and therefore can facilitate improved medical and organizational outcomes. To retain our workforce and achieve superior results, we must clarify priorities; change our metrics, particularly to long-term outcomes; use evidence-based medicine and evidence-based management; apply the "internal customer" concept; and utilize systems thinking.

Healthcare CEOs and physicians: reaching common ground.

A survey of 670 hospital and health system CEOs was conducted to understand why they chose a career path to CEO, what characteristics typify their career paths, and what major concerns they have about the future. Respondents expressed very strong altruistic reasons for becoming CEO, a finding that is consistent with the rationale many physicians express for entering medical practice. Early CEO career paths were diverse but typically led respondents to a senior managerial position before becoming CEO. Nine percent started as direct providers of healthcare. The respondents' most frequently expressed concerns for the future centered on reimbursement/financing issues and staffing shortages. Physicians may be surprised to learn that healthcare CEOs share their core values, experience similar frustrations, and have identical fears about the future of healthcare. Rather than emphasizing the differences between CEOs and doctors as a stumbling block to alliance, we urge the establishment of a common ground based on similar core values and purposes that will lead to improved communication and the powerful combination of talents derived from collegial collaboration.

Improving medical practice outcomes by retaining clinicians.

Turnover of medical care providers has become so commonplace that callous disregard or weary resignation are prevailing sentiments among remaining staff members when a colleague leaves. This article analyzes reasons for turnover of caregivers and the consequences. Turnover is particularly detrimental in medical practice because it undermines learning, as well as acquisition of judgment and adaptability. Medical practice managers may be unaware of the magnitude of the hidden costs-financial, strategic, and quality-associated with turnover. Strategies are proposed to assist medical care organizations in retaining clinicians and thereby improving healthcare effectiveness and efficiency.

Creating a favorable practice environment for nurses.

Chronic nurse turnover and attendant personnel shortages threaten patient care. Inadequate pay and benefits are primary factors leading to nurses' job dissatisfaction and, subsequently, to turnover. However, recent meta-analyses suggest that a favorable practice setting can improve nurses' satisfaction and minimize turnover. The practice environment's potential to positively influence nurses' job satisfaction is analyzed in a large academic medical center. Nurse supervisors, job characteristics, management style, and service quality emphasis--not just money and benefits--surface as key factors associated with a positive practice milieu. Implications for raising nurses' job satisfaction, reducing turnover, and improving care delivery are discussed.

The shocking cost of turnover in health care.

Review of turnover costs at a major medical center helps health care managers gain insights about the magnitude and determinants of this managerial challenge and assess the implications for organizational effectiveness. Here, turnover includes hiring, training, and productivity loss costs. Minimum cost of turnover represented a loss of >5 percent of the total annual operating budget.

Corporate culture: the missing piece of the healthcare puzzle.

The U.S. healthcare system requires radical, not incremental, change. Management issues in healthcare delivery are fundamentally different from those in the business world. Systems thinking forces a focus on corporate culture, about which there is little hard data. The use of cost/benefit analysis suffers from the lack of any accepted measure of long-term "benefit." The authors make four observations: (1) corporate culture is both part of the cause and part of the cure for healthcare; (2) long-term financial and functional measures are necessary to make evidence-based decisions; (3) valid, nationwide data must be developed regarding the corporate culture of medicine; and (4) direct (unmodified) application of management theory or practices will not achieve sustainable improvements.

Learning curves in health care.

This article explores the uses of learning curve theory in medicine. Though effective application of learning curve theory in health care can result in higher quality and lower cost, it is seldom methodically applied in clinical practice. Fundamental changes are necessary in the corporate culture of medicine in order to capitalize maximally on the benefits of learning.

Inhaled Nitric Oxide as a Preoperative Test (INOP Test I): the INOP Test Study Group.

BACKGROUND: This study was performed to determine whether a preoperative hemodynamic evaluation with oxygen and inhaled nitric oxide identifies patients with pulmonary hypertension who are appropriate candidates for corrective cardiac surgery or transplantation more accurately than an evaluation with oxygen alone. METHODS AND RESULTS: At 10 institutions, 124 patients with heart disease and severe pulmonary hypertension underwent cardiac catheterization to determine operability. The ratio of pulmonary and systemic vascular resistance (Rp:Rs) was determined at baseline while breathing approximately 21% to 30% oxygen, and in approximately 100% oxygen and approximately 100% oxygen with 10 to 80 parts per million nitric oxide to evaluate pulmonary vascular reactivity. Surgery was performed in 74 patients. Twelve patients died or developed right heart failure secondary to pulmonary hypertension following surgery. Rp:Rs<0.33 and a 20% decrease in Rp:Rs from baseline were chosen as 2 criteria for operability to determine, in retrospect, the efficacy of preoperative testing in patient selection. In comparison to an evaluation with oxygen alone, sensitivity (64% versus 97%) and accuracy (68% versus 90%) were increased by an evaluation with oxygen and nitric oxide when Rp:Rs<0.33 was used as the criterion for operability. Specificity was only 8% when a 20% decrease in Rp:Rs from baseline was used as the criterion for operability. CONCLUSION: By using a combination of oxygen and inhaled nitric oxide, a greater number of appropriate candidates for corrective cardiac surgery or transplantation can be identified during preoperative testing when a specific value of Rp:Rs is used as a criterion for operability.