Tuesday, November 29, 2016

Lean methodology and patient safety

A recent story in U.S. News & World Report described how a Seattle hospital is taking a systems approach in improving healthcare quality and cutting costs. It said, "Virginia Mason Health System...has looked to adopt many of the much-admired and often-emulated business philosophies from Toyota."

The best-known of those philosophies is the so-called "lean methodology" which is based on eliminating waste and focusing on things that add value.

Attempts to incorporate lean into healthcare have met with varying degrees of success. I blogged about this six years ago and pointed out that a literature review done back then found "significant gaps in the [lean and six sigma] health care quality improvement literature and very weak evidence that [lean and six sigma] improve health care quality."

Randomized prospective trials of lean in medicine are lacking. A recent paper from the Journal of the American College of Radiology found only seven studies on the use of lean in radiology and they showed "high rates of systematic bias and imprecision." The authors concluded there was "a pressing need to conduct high quality studies in order to realize the true potential of these quality improvement methodologies [lean and six sigma] in healthcare and radiology."

In addition to the debatable evidence that lean actually works and the cost and time to develop and implement lean measures, the use of Toyota as a model for quality is also highly questionable.

In 2010, Toyota had recalled more than 9 million vehicles for various defects. Nothing has improved. So far this year Toyota has recalled over 11,654,000 vehicles. The problems included exploding airbags, brake failure, fuel tank defects, and minivan doors opening while cars were in motion.

Having adopted lean methodology in 2002, Virginia Mason is not really a new story. How is it doing?

About as well as Toyota.

In May of this year, the Joint Commission paid a surprise visit to Virginia Mason Medical Center and found 29 instances where the hospital was out of compliance with standards. The Seattle Times wrote that among the problems were not having an adequate infection prevention and control plan, failure to store medication safely, and failure to provide a "care, treatment, services and an environment that pose[d] no risk of an immediate threat to health or safety."

On September 17, Virginia Mason regained full Joint Commission accreditation status, and 6 weeks later the hospital announced that it received an "A" grade for patient safety from the Leapfrog Group.

A hospital that failed a Joint Commission site visit because of multiple safety issues gets an "A" for patient safety in the same year? I discussed problems with the Leapfrog patient safety rankings in a previous post.

And if lean works so well in healthcare, can anyone tell me how does a hospital that has been practicing lean methodology for 14 years achieve 29 Joint Commission citations?

Thursday, November 17, 2016

Why is medical school tuition so high?

A couple of weeks ago, BoingBoing posted a picture of a tuition and fee schedule for San Diego State University in 1959. Tuition was free for California residents but they still had to pay $33 for materials and services and $8 for student activities. Nonresident tuition for a full-time student was an additional $127.50. These charges were apparently all per semester.

Using this handy inflation calculator, the total per semester cost for a California resident of $41 equates to $340.16 in 2016 dollars, an inflation rate of 729.6%. Free tuition ended in 1970. Current tuition and fees at San Diego State for the year are now $7084 or $3542 per semester—compared to $340.16 that’s a 941% increase.

Just for fun I decided to run the numbers for my medical school tuition. In 1967, my first year, the total tuition for the year was $1200 or $8674.06 in 2016 dollars. The current tuition for the private medical school I attended is $52,000, a 499% increase.

Wednesday, November 9, 2016

Do postoperative adhesions cause abdominal pain?

A reader asks whether I think adhesions cause postoperative abdominal pain and if so, how should they be treated?

I have always been skeptical (no surprise) about blaming adhesions for pain.

If adhesions cause abdominal or pelvic pain, what is the mechanism? We know that the intestine can be handled, cut, and cauterized without causing pain. What about tugging or pulling on the bowel? Would that cause pain? I doubt it. How much tugging or pulling can take place within the confines of the peritoneal cavity anyway? A literature search did not turn up any studies on  the mechanism of adhesions causing pain.

UpToDate, the online medical textbook, has a section on this topic. It doesn't address how adhesions cause pain but does discuss the evidence that reoperating on patients with adhesions is not worthwhile.

Friday, November 4, 2016

A medical oncologist weighs in on the treatment of appendicitis

It was an interesting fortnight for the debate about the treatment of appendicitis.

On November 1, David Agus, a medical oncologist and Director of the University Of Southern California's Center for Applied Molecular Medicine, had some thoughts about how appendicitis should be treated. He cited the Finnish randomized trial of antibiotics vs. surgery and said a 70% cure rate was good enough.

In a brief article on the Fortune magazine website, Agus wondered why appendectomy "continues to reign supreme." He said it was "because 24/7 we’re taught you have to take it out if there’s appendicitis” and that the healthcare community is "stubborn and pigheaded" [pigheaded means stubborn] and that we focus on treatment instead of prevention.

Friday, October 21, 2016

The moon and hospital admissions

A few days ago we had a full moon. A lengthy discussion about the effect of a full moon on hospital admissions took place on Twitter.

Many papers say admissions increase and odd things happen, and many others have found there is no relationship between the phases of the moon and anything that goes on in hospitals.

Someone sent me a link to a paper that a lot of devotees of astrology like to quote. It's called "The influence of the full moon on the number of admissions related to gastrointestinal bleeding," and it appeared in the International Journal of Nursing Practice in 2004.

Wednesday, October 12, 2016

A brief tale of an 18th century Irish surgeon's demise

On my recent trip, I had the pleasure of visiting the Royal College of Surgeons in Ireland in Dublin. Its 200-year-old main building is steeped in history. During the 1916 uprising that led to Ireland's independence, the rebels used it as a billet. Pockmarks from British bullets are still visible on its front columns.

Today the RCSI houses a medical school with a diverse international student body. Thanks to my gracious host, vascular surgeon Sean Tierney, I was able to tour the college's modern classrooms. I also saw a well-equipped simulation laboratory and took part in some virtual reality exercises.

In one of the many beautifully appointed rooms is a statue of William Dease, a noted surgeon who was one of the founders of the RCSI in 1784 and its fifth president. He was also a member of the Society of United Irishmen which started the Irish Rebellion of 1798.

Although the circumstances surrounding Dease's death are somewhat unsettled, the most popular version of the story is that in June 1798 he learned he was about to be arrested because of his association with the United Irishmen and committed suicide by slicing open his femoral artery.

In 1886 his grandson donated a statue of Dease to the college. Some years later the statue developed a crack in a most unusual location. The photograph below shows why.

Monday, October 10, 2016

Incidence of speech recognition errors in the emergency department

Speech recognition errors occurred in 71% of emergency department notes and 21.1% of notes with errors were judged as critical with potential implications for patient care says a recent study in the International Journal of Medical Informatics.

Investigators looked at a random sample of 100 dictated notes and found 128 errors or 1.3 errors per note.

More than half of the errors were ascribed to speaker mispronunciation. Although when I use speech recognition software, it sometimes does not accurately discern what I am clearly saying.

Other errors involved deleted and added words, nonsense, and homonyms.

An example of a nonsense error was "patient up been admitted for stable gait."

Some of the critical errors (with possible interpretations) were as follows: