Best Hospitals 2012-2013

U.S. News & World Report’s annual publication of the Best Hospitals was just released several days ago, and it includes the Honor Roll of 17 hospitals that are considered the best of the best for 2012-2013. Massachusetts General Hospital (MGH) has displaced Johns Hopkins from the top spot, where it had reigned for 21 years. I have never visited Johns Hopkins, but I used to volunteer as a recreational therapist at MGH in the early 1990s, and it was a top-notch facility. I’ll never forget what I experienced there. Volunteers had to wear bright pink jackets, and all the men felt silly wearing them.

However I might have looked in those pink jackets, my duties as a recreational therapist took me all over the hospital to see the many different units, from patients waiting for organ transplants, orthopedics, and the oncology ward. I made friends with a young model that had lost her hair, and I'd visit her at the Harvard Cyclotron located on campus near the Science Center where she was treated with radiation. Not only did MGH have the latest technology provided by the brightest medical doctors around, they also had an excellent volunteer staff.

MGH is located near many acclaimed medical schools, and this is important for being judged for the U.S. News list of best hospitals. In order to make the Honor Roll, a hospital must be a teaching hospital. This could limit other high performing hospitals from inclusion, but the article clearly states that the purpose of the list is not for regular care. "Best Hospitals' central mission remains unchanged: to help those who need an unusual degree of skilled inpatient care decides where to get it, especially when there's time to make a choice (Comarow, 2012)."

Only 17 hospitals performed well enough to score at the top or near the top in six specialties out of a total of sixteen total specialties. Factors utilized in the scoring include objective data that usually come from the government and includes bed sizes and death rates, and professional opinions from specialists are surveyed for their opinions. "The four basic elements for scoring are reputation, patient survival, patient safety, and care-related factors such as nursing and patient services (Comarow, 2012."

The interesting thing to me is to see this article come out yearly with the same big hospitals on the list. It is not that different than books that publish college rankings. Near the top, not much changes. Sometimes there is a battle between Harvard, Princeton, MIT, and Yale for number one. So, I see this last report more as a marketing strategy to draw in more medical tourism from people that live in other states and countries that are seeking the best care possible, and they can afford it.

One important distinction I immediately noticed was that few of the 17 Honor Roll hospitals were in the top list of Most Connected Hospitals that were recognized for their outstanding achievements in adopting information technology. It makes one wonder how important electronic medical records are to providing quality care. It would be more informative to see if those Most Connected Hospitals have positively correlated outcomes that result from the cost and commitment to the new technology.

References:

Camarow, A. (2012, July 16). Best hospitals 2012-2013: how they were 

     ranked. U.S. News & World Rport. Retrieved from

     http://health.usnews.com/health-news/best-

     hospitals/articles/2012/07/16/best-hospitals-2012-13-how-they-were-
     ranked

Refere
Camarow, A. (2012, July 16). Best hospitals 2012-2013: how they were ranked. U.S. News &
World Rport. Retrieved from http://health.usnews.com/health-news/best-
hospitals/articles/2012/07/16/best-hospitals-2012-13-how-they-were-ranked
nces:

In your own words, explain why or why not the perspective of the patient is the most important determinant as to whether an adverse event has occurred.

      I do not believe that the perspective of the patient is the most important determinant as to whether an adverse event has occurred.  Basing patient safety strictly by adverse events that occur deemphasizes any errors that occur that do not lead to harm.  Such errors, especially of the "near miss" category where the errors would most certainly have led to serious harm if they hadn't have been caught beforehand and prevented are never reported to the patient, yet it is vital to determine the root causes behind these errors.  In other cases, errors actually happen that do not lead to harm, such as giving the wrong dose of the right medication or a dose of a harmless, yet incorrect medication such as acetaminophen (Ransom, 2008, p. 244).
     The very definition of "adverse event" includes a great number of actual medical treatments simply because some form of harm or injury occurs to the patient.  No errors at all occur in the delivery of care.  There is just risk involved.  "Some argue that such events are not adverse and should not be considered as harm; instead, they see such events as known complications or risks of certain procedures and interventions (Ransom, 2008, p. 244)."
     The very nature of practicing medicine entails risk, much of which is not within the control of the medical providers.  I am referring to patient compliance, which is not only an issue pertinent to this topic of reporting adverse advents, but also to the adoption of Accountable Care Organizations that will hold physicians responsible for outcomes despite patients themselves having a large responsibility for their own health.  Patients often choose to not follow doctors' orders correctly and engage in self-destructive practices, further balancing the scales toward adverse events occuring beyond where they exist already due to natural complications due to things such as post surgical infection or medication intolerance. 
     Americans want Rolls Royce medical care for the price of a Honda, if not for free.  Despite signing legal forms acknowledging the risks involved with medical and surgical interventions, many expect miracles and are willing to find an attorney willing to gamble on a settlement offer when not satisfied with the outcomes. 
     I do not believe that patients, as lay people, are qualified to determine the occurrence of adverse events.  Epidemiologists or others professionally trained in collecting such data are better qualified.  Ideally, a group of professionals that is impartial to the process could be inserted into the process that could also address the problems of underreporting that occurs in medical institutions of errors and adverse advents.

Reference:

Ransom, R.R., Joshi, M.S., Nash, D.B., and Ransom, S.B. (2008).  The
     healthcare quality book, 2nd Ed., vision, strategy, and tools.  Chicago,
     IL:  Health Administration Press.

                I just got back from a trip to Durham, North Carolina.  It was a dual purpose visit.  On one hand, I was visiting my alma mater, Duke, which I hadn’t seen in many years.  I was able to revisit some old memories, and the timing couldn’t have been better for dropping by Cameron Indoor Stadium.  There was a basketball camp in progress hosted by Coach K, and I was able to see numerous alumni there, including Christian Laettner and current Magic players Chris Duhon and J.J. Redick.  The main purpose of the trip, though, was to accompany my mother to see her doctor for lymphoma treatment.  She has a local doctor, but the disease has reached a point where the current therapy is ineffective. 

                I used to work at Duke’s Comprehensive Cancer Center while a student, but it is now a huge new complex.  The labs are drawn on the first floor, and the clinics are on separate floors differentiated by specialty with a total of six floors.  I realize that I come with a personal bias, but I left with a reinforced impression of why Duke Hospital is synonymous with high quality.

                The building is spotless and designed with patient ease in mind.  There is excellent lighting with open windows showing the natural beauty of gothic buildings that surround the site.  Directions are clearly presented to main areas, and there are colored zones to differentiate separate clinical areas of the cancer center (ex. purple zone, orange zone).  Upon check-in, patients are given a buzzer similar to restaurants (Olive Garden or Outback Steakhouse), even though the waiting areas are so large and open with multiple televisions, magazines, and refreshments that it is unlikely that one would leave the waiting area.  There are even five large screen computers with internet access in the waiting areas to manage the wait times.

                The more intense the medical problem, the more important quality is to a patient.  Ultimately, we were there for the care of the specialist.  After looking at my mother’s labs, the doctor needed to perform a bone marrow biopsy.  The doctor and his nurse stayed until 7 p.m. to complete the job, and they couldn’t be nicer.  Follow-up care is coordinated with the doctor here in Orlando (who trained with the Duke doctor), and test results are available to my mother on the internet. 

                Although some things at Duke were the same, much had changed.  I certainly felt older as I saw my old dorm and the buildings that were now standing in the places of ones that were torn down.  In the case of the medical center, it is clear that the progress is for the better.

P.S.  As we left town, we stopped by Cameron Indoor Stadium, and here's a picture of my dad with Chris Duhon.

What does quality mean to me?  The word itself (“quality”) brings to mind an aspect that a person or thing exhibits.  For example, one of Ahab’s qualities was megalomania, or the one quality of that lampshade is that it is red.  So, it is helpful if the quality is observable and even better if it is measurable.  However, what value do those qualities have?  The answer could vary widely from person to person.

In the case of health care delivery, quality is not easily defined or uniformly measured.  The very nature of observing and measuring quality can affect the behavior of those being observed, too, if they are aware of the fact that they are being evaluated.  When considering the measurement of quality, arguably most think of a continuum ranging from poor to excellent such as a scale of zero to ten.  This is consistent with Donabedian’s concept of quality as a “balance of health benefits and harm” as “the essential core of a definition of quality (Ransom et al., 2008, p. 3).”

The six dimensions of quality offered by the Institute of Medicine are excellent guidelines for judging quality in the delivery of health care, judging it on the following criteria:  safe, effective, efficient, timely, patient centered, and equitable (Ransom et al., 2008, p. 5).  When I seek medical care, I personally judge its quality on those six factors, especially timeliness, patient centeredness, and efficiency.  The level of skill that the provider exhibits is important, especially if the nature of the medical problem is complex.  I prefer that a practitioner show a concern for economic matters, too, such as a willingness to prescribe cheaper alternatives to medications and provide multiple refills in order to prevent unnecessary office visits in the future.

Ultimately, quality is similar to beauty in that it is in the eye of the beholder.  What is important to me may not be important to you.  However, there is common ground of limited criteria that most can agree upon:  properly accredited and educated physicians to provide care, for example.  Obviously quality is an important idea to the American people.  Its role in cost-benefit analyses utilizing Quality Adjusted Life Years is evidence of how quality is paramount to not just the care we receive, but also what we expect health care to provide us.

 Scott

Reference:

Ransom, E.R., Joshi, M.S., Nash, D.B, & Ransom, S.B. (2008).  The  

     Healthcare Quality Book; 2^nd Ed. Chicago, IL:  Health Administration

     Press.

     In case anybody is wondering why I have a picture of a dog in place of my image, it is (1) because she is arguably better looking than me, and (2) because of the following video entitled "It's a Dog's World" comparing the health care of a person compared to the care his dog receives from the vet:  http://www.youtube.com/watch?v=FTaw8aTE-7g.

Scott