Monday, June 28, 2010

“Don’t get sick in July”

"Don't get sick in July" - It's an old adage in the medical community, most pronounced in academic medical centers, when the annual turnover of interns and residents occurs each summer. Each June and July, newly minted MDs, only weeks out of medical school, become interns. Popularized as the "July effect" or "July phenomenon," is when care at teaching hospitals is, according to myth, chaotic and disorganized as the cohorts of incoming interns fill the ranks of first-year residents.

    A recent study at UCLA set out to prove the July theory. Researchers analyzed 244,000 death certificates from between 1979 and 2006 at a medical center, and noticed a significant 'July spike' in fatal medication related errors. Another study conducted at a trauma center noticed a similar spike in non-fatal preventable medical complications.

    July effect or not – the truth is that hospitals are always at the brink of change – implementing changes to policies, rolling out new IT tools and systems, new equipment and so on. And there will always be the newbie's who didn't know better. Earlier this year, an article reported on a series of radiotherapy accidents across hospitals, resulting from radiation overdose from new linear accelerators. In a recent NYTimes interview with Dr. Peter Provonost, the man who spearheaded checklists in surgical ICU's at Hopkins, was quoted as saying that "in every hospital in America, patients die because of dysfunctional teamwork and hierarchy" and it has to do with the culture of hospitals and the way doctors are trained.

While the debate is still far from consensus, whether electronic health records will lower or raise costs, no amount of technological innovation can ever replace culture – the culture of transparency, teamwork, accountability and not shoving mistakes under the carpet. Just as medical students are afraid to talk back to their professors or raise safety issues, nurses are afraid to stand up to surgeons who won't take a mandatory "time out" to do safety checks before they commence surgery – these cultures ultimately cost patients their lives. Moreover, the logic is undeniable that safety and efficiency go together. Safer hospitals will achieve lower costs – by working inside out – first with the right culture and then with the technology.

How are innovative hospital's dealing with the culture issue – by being transparent about errors and near misses. AHRQ Innovations Exchange reports on how the University of Michigan Health System adopted a process of full disclosure of medical errors that involved multiple components including an online incident reporting system, open and honest communication with patients and families, with an apology offered when warranted; and quality improvement initiatives guided by reported errors. The program increased error reporting, significantly reduced malpractice claims and costs per claim, hastened the claims resolution process, and reduced insurance reserve requirements.

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