Wachter's World

Is it “Macaca” Time in Healthcare?

Bob Wachter — Tue, 19 Aug 2008 07:00:00 GMT

August 11th was the 2nd anniversary of the epic implosion of George Allen's presidential campaign, the first defeat at the hands of YouTube. Two recent videos of unattended patients dying in ER waiting rooms leave me wondering whether healthcare has also entered the YouTube era. Remember the George Allen fiasco? A 20-year-old Indian-American named S.R. Sidarth, working for Allen’s opponent Jim Webb, was filming an Allen campaign stop in Breaks, Virginia. Twice, Allen pointed to him and called him...(read more)

Post-Vacation Potpourri: Items Interesting, International, and Ineffably Sad

Bob Wachter — Thu, 14 Aug 2008 02:07:00 GMT

Just returning from a work-acation, including a talk in Buenos Aires. Today I’ll briefly cover a few items: Medicare’s final “no pay” list; patient safety in Argentina; a great post on hospital finances; and one of the saddest things I’ve ever experienced. First, the final “no pay” list. I’m not sure if this was CMS’s intent, but their trial balloon of possible additions to the “no pay” list included so many ludicrous items that the final list seems nearly rational. You’ll recall the proposed list;...(read more)

Is “Patient-Centeredness” a Healthcare MacGuffin?

Bob Wachter — Mon, 04 Aug 2008 03:16:00 GMT

Last week’s ABIM Foundation Summer Forum focused on patient-centered care… and who could be against that? But is patient-centered care just a healthcare MacGuffin? What’s a MacGuffin, you ask? In a spectacular talk at the Forum, Michael Richardson of Chicago’s Hines VA reminded us that the MacGuffin was one of Alfred Hitchcock’s favorite directorial strategies. Hitchcock defined the term this way: MacGuffin: a plot device that motivates the characters or advances the story, but the details of which...(read more)

Will Knols and Blogs Upend the Cozy World of Medical Publishing?

Bob Wachter — Fri, 25 Jul 2008 05:03:00 GMT

Yesterday, Google launched Knol, immediately branded as Google’s answer to Wikipedia. As healthcare advisor to the project, I’ll say a few words about Knol, but focus on how it – and other forms of electronic self-publishing – may signal the end of medical publishing as we have known it. First, a word about Knol (the name is short for “a unit of knowledge”). Google’s vision is that providing a tool for people to write about “things that they know” will make the world a better place. Unlike Wikipedia’s...(read more)

The Long Awaited Crisis in Primary Care: It’s Heeere!

Bob Wachter — Sun, 20 Jul 2008 18:36:00 GMT

I recently heard from a UCSF physician who was flabbergasted when he sought an appointment in our general medicine practice and was told it was “closed.” Turns out we’re not alone: there are also no new PCP slots available at Mass General. The primary care crisis has truly arrived.I’ve written about the roots of the problem previously, and won’t restate the sad tale of woe. But I hope you’ll take the time to listen to two very powerful NPR reports on the topic – the first, a WBUR special by healthcare...(read more)

Another Case of Wrong Site Surgery: Are We Averting Our Eyes From Some of the Root Causes?

Bob Wachter — Wed, 09 Jul 2008 06:52:00 GMT

Yet another case of wrong-side surgery, this one at Boston’s Beth-Israel Deaconess Hospital. Though CEO Paul Levy does a nice job discussing the case on his blog, I’ll focus on two aspects Paul neglects: the role of production pressures in errors, and the tension between “no blame” and accountability. First, I hope you’ll read Paul’s piece (on his always-interesting blog), which includes a courageous memo he and BI-D’s chief of quality Kenneth Sands sent to the entire community describing the case...(read more)

Door to Antibiotics Time in Pneumonia: Lessons from a Flawed Quality Measure

Bob Wachter — Wed, 02 Jul 2008 07:09:00 GMT

In today’s Annals of Internal Medicine, my colleagues and I describe the saga of the four-hour measure of door-to-antibiotics time for pneumonia – the first truly dangerous measure in the era of public quality reporting. It is an important cautionary tale.As I’ve discussed previously, the biggest surprise of the last decade in the quality field has been this: public reporting alone (even without pay-for-performance) leads to huge changes in the behavior of providers and healthcare organizations…...(read more)

The New (CMO) Math: Passion + Power = Progress

Bob Wachter — Wed, 25 Jun 2008 07:36:00 GMT

In his five years on the job, Dr. Ernie Ring taught me why the Chief Medical Officer role is crucial, and how to do it right. Since Ernie is retiring at week’s end, it seems like an opportune time to share what I’ve learned.A bit of background. UCSF Medical Center didn’t have a Chief Medical Officer until about 8 years ago; indeed, even today many U.S. hospitals lack a senior physician who is compensated by and works for the hospital. It is easy to understand why.Through several accidents of nature...(read more)

The Best and Worst of Times For “Infection Preventionists”

Bob Wachter — Mon, 23 Jun 2008 04:51:00 GMT

As I mentioned in my last post, these should be the best of times for "Infection Preventionists" (formerly known as Infection Control Officers). After years of trying to get someone – anyone – to pay attention to their work, their day in the sun has finally arrived. But they are far from a joyful bunch. Why? In my talk to 4,000 members of the Association for Professionals in Infection Control (APIC) last week, I riffed on this question. After being prepped like a pre-debate presidential candidate...(read more)

How Infection Prevention Came to Dominate the Patient Safety Movement

Bob Wachter — Sun, 22 Jun 2008 00:10:00 GMT

The Joint Commission just released its 2009 National Patient Safety Goals, and – no surprise – they focus on infection prevention. While this seems natural today, it wasn’t always so. In fact, the conflation of infection control and patient safety is one of the most surprising twists of the patient safety revolution.The inclusion – make that dominance – of infection prevention in the safety field was anything but preordained. The IOM Report on medical errors, which sparked the modern patient safety...(read more)

Announcing our Hospitalist CME Course, and a New Hospitalist Mini-College

Bob Wachter — Sun, 15 Jun 2008 18:51:00 GMT

A quick heads-up for those of you thinking about attending this year’s Management of the Hospitalized Patient (MHP) conference, October 23-25 in SF… we’re adding a hands-on, small group “Hospitalist Mini-College” pre-course. I think it will be tremendous. This will be our 12th Annual MHP conference (co-sponsored by the Society of Hospital Medicine). It is a clinical CME course, blending lectures on key topics in hospital medicine (I hand-pick the faculty for their lecturing skill) with nearly 20...(read more)

Could Intensivists Be Harmful to ICU Patients’ Health?

Bob Wachter — Wed, 04 Jun 2008 06:34:00 GMT

Of all the structural (how care is organized) “evidence-based markers of high quality care,” perhaps the most ironclad has been the involvement of critical care physicians in the care of ICU patients. That is, until now. In a sophisticated study in today’s Annals of Internal Medicine, Levy and colleagues mine a decade-old, 100-hospital, 123-ICU database containing detailed clinical data on more than 100,000 patients to examine the association between ICU staffing models and hospital mortality. The...(read more)

Why Diagnostic Errors Don’t Get Any Respect… And What Can Be Done About It

Bob Wachter — Mon, 02 Jun 2008 03:20:00 GMT

I gave a keynote yesterday to the first-ever meeting on “Diagnostic Error in Medicine.” I hope the confab helps put diagnostic errors on the safety map. But, as Ricky Ricardo would say, the experts and advocates in the audience have some ‘splainin’ to do. I date the origin of the patient safety field to the publication of the IOM report on medical errors (To Err is Human) – it is the field’s equivalent of the Birth of Christ (as in, there was before, and there is after). But from the get-go, diagnostic...(read more)

The Funniest Satire on Interoperability You've Ever Seen (Trust Me)

Bob Wachter — Thu, 29 May 2008 07:54:00 GMT

There is nothing better than a good satire to capture certain (uncomfortable) truths – just ask any of the presidential candidates after an episode of Saturday Night Live. So check out this hilarious spoof on information technology interoperability. As Captain Kirk said to Bones, “have you lost your mind?” Hilarious? Interoperability? But really, check it out. It is very funny. Now for those deep truths. When my friend David Brailer became the first federal IT czar, I think most people expected him...(read more)

Google Health: A View From the Inside

Bob Wachter — Thu, 22 May 2008 15:24:00 GMT

Google Health launched on Monday, which sent the world’s Google-watchers into a tizzy. I serve on Google Health's Advisory Council – which met all day Tuesday – and so here’s a bit of inside dish, along with my impressions of the site and the company. FYI, my work on the Council is covered by a Non-Disclosure Agreement, so I won’t reveal anything that isn’t publicly known regarding Google’s products or intentions. Also, in the interest of full disclosure, you should know that I am compensated for...(read more)

The “Technology Hype Cycle”: Why Bad Things Happen to Good Technologies

Bob Wachter — Tue, 13 May 2008 00:50:00 GMT

Fresh on the heels of my recent bar coding epiphany comes another “unintended consequences” article. It turns out that the whipsawing that accompanies the adoption of new technologies is completely foreseeable, the “why doesn’t this thing work right?” phase as predictable as the seasons. Thanks to Dr. Mark Wheeler, Director of Clinical Informatics of PeaceHealth, for introducing me last week to the “Technology Hype Cycle” concept. The Cycle, originally described by the IT consulting firm Gartner,...(read more)

Oprah, Obama, Putin, Springsteen… and Pronovost

Bob Wachter — Sun, 11 May 2008 06:28:00 GMT

Last week, Time Magazine named the 100 most influential people in the world. Among the luminaries was Dr. Peter Pronovost of Johns Hopkins. I thought it was an inspired choice. The modern patient safety field has been blessed with a number of important leaders and visionaries. A few examples: Lucian Leape, the Harvard surgeon who introduced the idea of systems thinking to mainstream medicine; Don Berwick, whose passion found form in the Institute for Healthcare Improvement, which has helped thousands...(read more)

Should Hospitals Install Bar Coding or CPOE First? Why I’ve Changed My Tune

Bob Wachter — Fri, 02 May 2008 20:00:00 GMT

This is one of the most commonly asked questions in IT World, and my answer has always been “CPOE first” – largely because that has always been David Bates’s (the world’s leading IT/safety researcher) answer. But I’ve changed my mind. Here’s why. Before I start, I promised that I’d let you know if I ever blogged on a topic in which I have a financial conflict of interest. On this, I do: I serve as a paid member of the Scientific Advisory Board of IntelliDOT, a company that makes a stand-alone bar...(read more)

Message to Medicare: Whoa, Nellie!

Bob Wachter — Mon, 28 Apr 2008 06:37:00 GMT

Last week, Medicare proposed nine additional “do not pay” conditions, several months before implementing the first eight. I like the concept of not paying for preventable adverse events, but this new list is a case of too far, too fast. In my previous review of the new policy (here and in this article), I described four conditions that should be met for an adverse event (AE) to be included on the “do not pay” list: Evidence demonstrates that the AE in question can largely be prevented by widespread...(read more)

Snooping At Britney’s Chart: Why Should Docs and Nurses Have Different Rules?

Bob Wachter — Sun, 20 Apr 2008 19:53:00 GMT

Should doctors and nurses be subject to different penalties for precisely the same infraction? Of course not. Are they? Sure. Just ask Britney Spears. Britney was hospitalized at UCLA at least twice in the past few years – once when she gave birth to her first son in 2005, and again in early 2008 for psychiatric care. Both times, dozens of UCLA staff members peeked at her medical records, despite having no clinical reason to do so. This voyeurism, of course, is hard wired into our DNA, and we aren’t...(read more)

Should Patient Satisfaction Scores Be Adjusted for Where Patients Shop?

Bob Wachter — Sun, 13 Apr 2008 03:03:00 GMT

Last week, Medicare added patient satisfaction data to its hospital reporting website. This is progress, but it raises an interesting question: should patient satisfaction scores be case-mix adjusted? The motivation to include patient satisfaction data comes from the Institute of Medicine’s inclusion of “patient-centeredness” as one key component of quality. And what could be simpler than asking patients a few questions, as the Center for Medicare & Medicaid Services (CMS) survey does. (A pdf...(read more)

A Quick Thanks for a Very Nice Honor

Bob Wachter — Tue, 08 Apr 2008 04:35:00 GMT

Today, Modern Healthcare released its yearly list of the 50 most influential physician-execs in the U.S. I have to believe that you, my readers, are at least partly responsible (along with my parents and their pals in Boca) for my #19 position, the highest rank of any full-time faculty physician. As nice as this is, I must admit that seeing myself on this list of movers and shakers is a bit odd. At number 19, I'm sandwiched between people like the leaders of the Mayo Clinic and HCA, and the heads...(read more)

Notes from the Society of Hospital Medicine's Annual Meeting

Bob Wachter — Sat, 05 Apr 2008 06:39:00 GMT

A few random observations from the Society of Hospital Medicine’s annual meeting in San Diego: There are about 1600 people here, most of whom I don’t know. How did this happen? People still seem pretty jazzed about their jobs and lives. The meeting has not lost its soul, nor its sense of wonderment or of family. That’s a very good thing, since these intangibles can be easily lost with time and size. Certain issues seem to bubble up in every hallway conversation: Are you co-managing surgical patients...(read more)

Average Time of Discharge: Why a Hospital is Not a Hilton

Bob Wachter — Wed, 26 Mar 2008 07:05:00 GMT

Do you get as annoyed as I do about being pressured on your “Time of Discharge?” I just received my monthly report, and we’re in The Doghouse again: our average TOD – 3:28 pm – is hours after “check-out time.” But when did we turn into the Holiday Inn? Let’s start by appreciating where this comes from. Many hospitals, including mine, tend to run full – given the huge fixed costs of operating a modern hospital, being full is probably the only way you can be profitable, just like the airlines. Queuing...(read more)

The Great Quality Debate: Berwick’s Plea for Action vs. Evidence-Based Medicine

Bob Wachter — Mon, 17 Mar 2008 23:59:00 GMT

In this week’s JAMA, Dr. Don Berwick, CEO of the Institute for Healthcare Improvement, argues that evidence-based standards should be relaxed for quality improvement practices. Ironically, a few pages away, a Swiss study finds than an IHI-endorsed MRSA prevention strategy doesn't work.What’s a person or hospital to do?A little background on both issues, beginning with the Berwick piece. Don, as everybody knows, is the world’s leading figure in safety and quality – much of today’s quality movement...(read more)