This week's
Newsweek has a really outstanding report on "Fixing America's Hospitals" that profiles several hospitals with innovative programs that are getting patients better care.
Join me below the fold to explore their articles covering such diverse topics as:
Facing up to Mistakes: disclosing errors and problems immediately leads to better patient outcomes, less stress for families and physicians, and fewer malpractice suits. And using the information openly to prevent future mistakes is a pretty nice benefit, too.
Real Food: Kaiser Permanente in Oakland added a farmer's market in the parking lot and is serving local produce to patients
Valuing Nurses: improving working conditions for nurses reduces staff turnover and saves lives. (Quel surprise!)
These are just three of the dozen or so stories in this week's issue - really interesting, definitely worth the cover price.
Facing up to Mistakes: Improving Quality Control
From Newsweek, an article called Perfect is Possible, by Donald M. Berwick, MD, and Lucian L. Leape, MD
When defects are common, they can feel normal -- inevitable. Instead of trying to fix them, people accept them. For a lot that is wrong with health care today, that is exactly the situation -- even though the Institute of Medicine reports that as many as 100,000 people die each year in hospitals from avoidable errors.
Recent experience - at first from just a handful of hospitals, but now from hundreds -- shows that this pessimism is unfounded. Many kinds of errors can be completely eliminated; "zero defects" is possible. Some hospitals are, for example, acheiving once impossible success at eliminating certain kinds of infections and medication errors. There is no reason these successes can't be widely replicated, perhaps everywhere.
The Robert Wood Johnson Foundation, along with the Institute for Healthcare Improvement, sponsored grants in 2000 to help hospitals "pursue perfection" - no patients dying unnecesarily. If car manufacturers can work for zero defects, can American medicine?
None of the test hospitals became perfect, but they all made dramatic improvements.
These projects are raising the bar for everyone. According to the Centers of Disease Control and Prevention, 2 million Americans get hospital infections each year. They do not need to. Rates in Norway and Sweden are nearly zero. Why should we accept as inevitable that patients have to die or suffer from hospital-acquired infections, wrong-site surgery, unreliable heart-attack treatment, medication errors -- and myriad other forms of error and unreliability in care -- when we can now name hospitals that have eliminated or drastically decreased each of these forms of harm?
I've tended to think that some American doctors are so enamored of antibiotics that they forget that these drugs have risks and don't always work, and so they get a bit casual about infection. I am thrilled to read this and very pleased about the prospect of dramatically lowering hospital-acquired infections.
But even with improvements, mistakes will still happen. The conventional wisdom is that medical professionals should never admit mistakes. It breaks down the barrier of all-knowing superhero and increases the likelihood of a malpractice suit. Right?
Disclosure, apology, and early financial compensation dramatically reduced the number of malpractice suits at the Department of Veterans Affairs hospitals in the 1990s, and more recently, in programs run by the physician insurers in Colorado (COPIC) and at the University of Michigan.
Hospitals are experimenting with different approaches, and finding them to be very successful. When mistakes happened in the past, physicians and nurses felt incredibly stressed about the deception; patients and their families knew something was wrong but couldn't get answers. Both sides felt not enough was being done to prevent future mistakes. Handling the problem openly resolved it faster and gave patients the sense that their injury or loss would not be in vain. In one example case, the family of a dead child settled and then donated a portion of the money back to the hospital to create a patient safety program in their daughter's name.
I hope this new attitude becomes prevalent. Coverups serve no one, not the doctor, not the patient, not the system, and not society.
Real Food: Bringing real, healthy food into hospitals.
Hospital food - an infelicitous term evoking gray peas, dry chicken, Jell-O -- is a near oxymoron. The connection between good food and good health is so obvious it's almost not worth mentioning. Yet from the first days of corporate health care, too many well-intentioned professionals have focused on the wrong thing -- food prepared days, even weeks, earlier; frozen, unpacked, zapped in a microwave -- food that serves the gods of efficiency, scalability and low cost. Institutional requirements have uncoupled food from the nurturing it does best, stripping it of its power to delight. The result is a missed chance to let the healing begin. Tracking day-to-day medical progress may be difficult for families, but you don't need a degree to read the meaning in "She didn't touch her tray."
Dr. Preston Maring, associate physician in chief of Kaiser Permanente's Oakland Medical Center, started wondering what he could do about it. An amateur chef, he enjoys farmer's markets and working with food, and has always felt it was important for good health. And, remarkably - a few conversations after his hairbrained question first came into his head - in spring 2003 the hospital had its own farmer's market. (I happen to have some marvellous vinegars that came from that market... mmmm!)
From the Oakland Business Review:
But if it's Friday at the Oakland Medical Center, you can find an array of organic greens, berries, peaches, and other delights from California farms, right outside the hospital door at 3801 Howe St. It's called Fresh Friday, and it's the brainchild of Preston Maring, MD. "I've been here for 32 years, and I've seen vendors selling a variety of things," he said. "If we're going to have leather purses and coats for sale, why can't we also sell things that are more in line with our mission?"
Dr. Maring was shopping at a local farmer's market last year when he happened to run across the director of the Pacific Coast Farmer's Market Association. They struck up a conversation about bringing a market to the medical facility, and earlier this month that conversation bore fruit.
The past two Friday markets have been a huge success, by all accounts. The buzz from physicians and employees has been extremely positive, said Dr. Maring, and patients and visitors have also had good things to say about it. "Lots of people have come up to me and told me how good this was for them," he said. "The basic concept of bringing the market to where people are is creating demand. People who work long hours don't get a chance to go to farmer's markets. This way, the market comes to them."
32 Kaiser hospitals in six states now have farmer's markets, thanks to Dr. Maring's inspiration and willingess to try out a kooky idea.
From another interview with Dr. Maring
So you prescribe fruits and vegetables to your patients?
As a primary care physician, I often talk to patients about their diets. I take my prescription pad and write out recipes, or I may tell someone that they have to cook one of my recipes at least once a month, just to get them interested in cooking at home.
What if you don't like vegetables?
I tell people how spectacularly tasty these things can be, and how easy it can be to [prepare them]. A lot of people say they don't mind vegetables, but they just don't like to cook. Showing them that cooking can be fun is half the battle.
What's an easy way to do that?
If you like listening to music or watching TV, put your stereo or your TV in the kitchen, and cook while you do something else you like to do. Building cooking at home into your life will be cheaper, and can be healthier for you. You can control what goes into your meals at home; if you don't want a big glop of cheese sauce, you don't have to add it. Eating healthy doesn't mean you can't eat a strip of bacon. You just have to pay attention and make good choices when you can.
And he didn't stop with the market in the parking lot.
"I kept thinking," Maring says, "we use 250 tons of fruits and vegetables in our northern California hospitals, 100 tons of it imported from around the world. And here are all these urban eaters; what can we possibly do to connect with a sustainably grown rural supply? I never knew how in-patient food services worked. I just knew that food showed up and people complained about it. I had never even met the director of National Nutrition Services."
Eight months ago, Maring sat down with that director, Jan Sanders, and light bulbs went off. Maring asked more "What if" questions. What if we no longer ordered grapes from Chile in December? What if we sourced the fruits and vegetables locally, from small, minority, sustainable farmers? Sanders' instant reply: "Why not?"
It took Sanders' endorsement from deep inside the corporate structure to send out the necessary signals. "We were lucky," she explains. "All our meals, some 5,000 to 6,000 a day, for 19 hospitals, are prepared at one central commissary in South San Francisco." Which is where Food Service Partners' Ralph Rico (whom Maring describes as a saint) came in. FSP had to agree to process from a less predictable flow of fruits and vegetables. To carry out their goal of sourcing from small, sustainable, minority farmers, Maring turned to Community Alliance with Family Farmers, asking CAFF's director, Anya Fernald, to take on a study of Kaiser's produce patterns and needs. "It's far easier to buy from a farmer who has 40,000 acres in carrots than a small farmer with nine acres of mixed crops," says Fernald. It's not about spending more money. It's about accepting a greater degree of inefficiency." On Aug 7, Kaiser launched the pilot program that tests the new farm-to-tray system with eight sustainably grown fruits and vegetables, such as cherry tomatoes, kiwis, cantelopes, mandarin oranges, even broccoli. Fruits such as the glorious red strawberries, sourced from farmers represented by CAFF, are delivered to FSP. Then, half a dozen of those strawberries, with their green hulls intact, are piled into a small cup and put on every patient's tray. They are so beautiful they make your heart beat with joy. Which is, of course, the point.
Is this awesome or what?
I wanted to write more about the nursing story, but my fingers are giving out. Maybe tomorrow, if no one else picks it up in the meantime.