Nation's Hospitals Research Articles

Clostridium difficile: The evolving story.

In September 2007, the Public Health Agency of Canada (PHAC) announced its intention to develop a plan by January 2008 to reduce the number of infections occurring in the nation's hospitals (1). This comes at a time when the Safer Healthcare Now! campaign is exploring how it can build on efforts already underway in hospitals to decrease the transmission of antimicrobial-resistant organisms (S Paton, PHAC, personal communication). While methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci are the pathogens that usually come to mind when considering antimicrobial-resistant organisms, Clostridium difficile is also foremost in the minds of health care workers and patients when health care-acquired pathogens are mentioned. The concern over C difficile is supported by recurring stories in the public press of outbreaks of C difficile attributed to poor hygiene in hospitals (2,3), and scientific literature that suggests the emergence of a more contagious and virulent form of this pathogen in both hospital and community settings (4–6). It is instructive to consider how C difficile has evolved over the past 30 years, even since our last review of this topic in 2000 (7).

The Growth of Palliative Care Programs in United States Hospitals

Palliative care programs are becoming increasingly common in U.S. hospitals. To quantify the growth of hospital based palliative care programs from 2000-2003 and identify hospital characteristics associated with the development of a palliative care program. Data were obtained from the 2001-2004 American Hospital Association Annual Surveys which covered calendar years 2000-2003. We identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of a palliative care program in the 2003 survey data. Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased likelihood of having a palliative care program included greater numbers of hospital beds and critical care beds, geographic region, and being an academic medical center. Compared to notfor- profit hospitals, VA hospitals were significantly more likely to have a palliative care program and city, county or state and for-profit hospitals were significantly less likely to have a program. Hospitals operated by the Catholic Church, and hospitals that owned their own hospice program were significantly more likely to have a palliative care program than non- Catholic Church-operated hospitals and hospitals without hospice programs respectively. Our data suggest that although growth in palliative care programs has occurred throughout the nation's hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals are significantly more likely to develop a program compared to other hospitals.

Rethinking the Politics of the Family: Part IV

Recently, a PBS Frontline documentary called "The New Asylum" showed how our jails and prisons have become, by default, the nation's mental hospitals. This wasn't an exposé. The prison under examination didn't seem particularly bad. The staff seemed to be trying their best to deal with an impossible situation. But what, you might ask, has the topic of prisons to do with the culture war and family values, the subject of this series? First, it shows how the culture war, with its focus on hot-button issues like gay marriage, end-of-life decisions, and obscenity on television, to name the most recent examples, crowds out discussion of serious social problems. More than that, however, the documentary illustrates the reductio ad absurdum of America's current political culture: its rhetoric of faith and family values combined with its tax-and-services-slashing policies, its deference to corporate power and accompanying sink-or-swim economy, its tolerance of growing inequality, its bread and circuses media, and the unprecedented reliance of the current administration on a strategy of lies and denial. As a result of all this, prisons have become the social policy of last resort. No longer just the place to incarcerate violent offenders, the prison has become the final common repository of the social problems we are unwilling to prevent or remedy before they grow into crises. Only when these problems deteriorate into matters of crime and punishment can "government spending" be justified.

Overview of Acutely Decompensated Congestive Heart Failure (ADHF): A Report from the ADHERE Registry

Acute decompensated heart failure (ADHF) has emerged as a major public health problem, and HF has become the leading cause of hospitalization in persons over 65 years of age. It is estimated that there are 6.5 million hospital days attributed to ADHF each year. Patients hospitalized with ADHF face a substantial risk of readmission, as high as 50% by 6 months after discharge. Despite the large number of patients hospitalized and this substantial risk, data on these patients have been limited and there has been little effort to improve the quality of care for patients hospitalized with ADHF. The Acute Decompensated Heart Failure National Registry (ADHERE) was designed to bridge this gap in knowledge and care by prospectively studying the characteristics, management, and outcomes of a broad spectrum of patients hospitalized with ADHF. Participating community and university hospitals identified patients with a primary or secondary discharge diagnosis of HF and collected medical history, management, treatments, and health outcomes via secure Web browser technology. As of October 2004, more than 160,000 patients from 281 hospitals have been enrolled. These patients differ substantially from those typically enrolled in randomized clinical trials. Initial data from the ADHERE registry have provided important insights into the clinical characteristics, patterns of care, and outcomes of patients with ADHF. ADHERE has documented significant delays in diagnosis and initiation of ADHF therapies as well as a substantial under-use of evidenced-based, guideline-recommended chronic HF therapies at hospital discharge. As such, there are substantial opportunities to improve the quality of care for ADHF patients in the nation's hospitals.

Making Progress in Health Information Technology: More Realistic Leadership, Less Hype

THIS ISSUE OF Frontiers of Health Services Management presents two different but complementary perspectives on achieving what most would agree is a necessary step forward for the U.S. healthcare system-moving off paper and into the digital age. Michael Sachs presents a vision of what this transformed system might look like; Rosemarie Nelson lays out a practical step-by-step road map for getting there. While one might be tempted to conclude problem and uncritically climb on the healthcare information technology (IT) bandwagon, I would first offer a few words of caution. The vision for the optimal integration of health IT into clinical practice should certainly be bold, but it should not be uncritical or unrealistic. Similarly, the road map should lead to more than putting a computer on the physician's desktop, lest we simply end up with digitized dysfunction. IS THE VISION FOR HEALTHCARE IT POINTED IN THE RIGHT DIRECTION? Sachs's vision of the near-term future is certainly hopeful and bold (transformation of ...an information-enabled system without fragmentation is ...without question), but it is by no means certain. While one would like to think that within a decade our resuscitated healthcare system would have the latest bioscience wizardry virtually available to all, far more basic problems need to be solved first. Health IT will hopefully be part of that solution. The current system is fraught with dysfunction, fragmentation, and, in some areas, is itself on life support. Almost 50 million Americans are uninsured or underinsured. Almost half of our nation's hospitals are operating at a loss. Many emergency departments are so overcrowded that the average wait time is longer than a cross-country flight. Moving our sights from the hospital to the physician office does not present a better picture. The one-two punch of declining reimbursement and increasing practice hassles has led to widespread physician dissatisfaction, particularly in the primary care fields of internal medicine and family medicine. These physicians are retiring in mid-career or leaving practice for other non-patient care opportunities. Nor can we count on the next generation of doctors to fill in the gap. Each year fewer and fewer U.S. medical students chose careers in these primary care fields, and if it weren't for the international medical students accepting these training positions, the United States would already be feeling the effects of the impending shortage. If these challenges weren't enough, the population is aging; in spite of the dire IOM pronouncements of iatrogenic deaths (44,000-88,000/year) (Kohn et al. 2000), more people are surviving for longer periods of time with multiple chronic (and expensive) conditions. The implications of this demographic time bomb for Medicare are staggering (Rettenmaier and Saving 2004). Surfing the Web from the ICU Sachs's vision of patients biding their time in the ICU looking at their results and medical information is far-fetched and, if actualized, would lead to further waste of scarce resources. One of the reasons emergency departments have 6 to 8 hour waits is lack of bed availability in the critical care units. In the real world, when critically ill patients recover enough to sit up and focus on a computer screen (for medical reference reading or to download games), that patient is well enough to leave the ICU. How about the same vision, but for patients in a regular hospital bed? This might be a reasonable vision, assuming that the hospital really wanted to divert limited bandwidth from projects that involve, for example, mobilizing data and images for clinicians, but again, in the real world, patients aren't hospitalized except when severely ill. When patients are hospitalized for elective surgery, they are typically discharged once conscious and stable. Although there is nothing inherently wrong with extending ubiquitous Internet access to hospitalized patients, at a time when there is legitimate concern about just having sufficient hospital beds for our population, this seems at best frivolous. …

The Difficult Realities of Healthcare in Our Country

EMILY FRIEDMAN AND Deborah Chollet raise important issues about the future of health insurance, the uninsured, and the underinsured; Friedman also focuses on possible consequences to our nation's hospitals. These two authors reflect my own view that the healthcare system in the United States is broken and that structural reforms are long overdue. The ultimate solution-universal healthcare coverage-is not currently a popular political choice. Even with bipartisan support, universal coverage would take time, intense effort, and unprecedented cooperation to accomplish. Still, it is the one solution that would ensure care for all, in the most appropriate settings, particularly for the most vulnerable among us. For now, however, we must deal with the difficult realities of healthcare in our country. I agree with many of the points that Friedman and Chollet make and would like to expand on some of them. HOSPITALS ARE THE SAFETY NET Friedman discusses a number of factors that contribute to continuing growth in uninsured and underinsured populations. She states that although it is not universally accepted, there is a widespread (and, in my opinion, correct) belief that hospitals serve as the safety net for the uninsured. Those of us who work in not-for-profit and faith-based hospitals can attest to the absolute correctness of this belief. Every day, Catholic Health Initiatives' emergency departments serve as a safety net for people who have no insurance, no primary care, and no knowledge of any other way to access the healthcare system. Sometimes, ours is the only emergency department in a community and, therefore, the only refuge for someone who needs care. Sometimes, we are one of several providers but our emergency department is still the provider of choice because our mission and faith-based tradition dictate that we help all of those in need, regardless of their ability to pay. As the uninsured population grows, our country continues to see significant and systematic constraints on public program funding. For many hospitals, this situation has precipitated a financial crisis that not only severely constrains their ability to provide care to the uninsured but also threatens their continued viability-the impending disaster to which Friedman refers. However, many individuals, including influential policy-makers, do not acknowledge this crisis. They know that more than 45 million uninsured people live in the United States, but they argue that those people need not go without healthcare; all they have to do is walk into a hospital emergency department. Policymakers must take this scenario to the next step: who will pay for the care? If there is little or no insurance or if federal or state health funding is lacking, the hospital must pay for the care. And with millions of uninsured people in communities throughout our country, that is too great a burden for hospitals to bear. In addition, not-for-profit hospitals in a community do not always share that burden equally. In some markets, I see a reduction in the quantity of care that city-, county-, and state-run facilities are providing to the poor. Faced with the same financial hardships as other not-for-profit providers, they are devising ways to reduce the number of uninsured and underinsured people they treat, thereby limiting their exposure in ways that would have been unthinkable just a few years ago. HIGH-COST EMERGENCY CARE Another essential issue that many policy-makers fail to recognize is that emergency care is a far more costly safety net than primary care. Regular primary care can identify and resolve health problems before they become serious and much more expensive to treat. I started my career in healthcare as an emergency department administrator, working at one of the busiest emergency departments in the country during the late 19703. The department had 130,000 patient visits per year, or roughly more than 350 patients a day. …

The Culture Factor

THE FEATURE ARTlCLES in this issue of Frontiers of Health Services Management, Patient Safety: What Is Really at Issue? by Bagian, and Patient Safety: Mindful, Meaningful, and Fulfilling, by Winokur and Beauregard, present two extremely important topics related to patient safety: the implementation of an effective patient safety program and the importance of creating culture of safety within your organization. Bagian is highly respected leader in the field of patient safety. Certainly many of the well-known safety initiatives that the Veterans Health Administration (VA) system has implemented, such as computerized physician order entry and safety simulation labs, are to be admired. Many of the patient safety initiatives at Winokur and Beauregard's institution have been implemented at Hackensack University Medical Center (HUMC) as well. What is striking about these articles is that the information that they provide should be basic to most healthcare organizations. Five years after the Institute of Medicine's (lOM's) report about the failure of our hospitals to do no harm, should we still be discussing implementing safety systems and creating safety cultures? In May 2005, HealthGrades Inc., national hospital quality consulting group, found that the nation's healthcare system is still far short of its goal of reducing deadly errors by 50 percent. In fact, the report states that while patient safety is improving at the nation's best hospitals-those hospitals in the top io percent have built what the authors called a culture of still lags at the worst hospitals, creating troublesome gap. Winokur and Beauregard ask the question, Does culture truly drive behavior, or is the reverse true? James Reason, an internationally recognized psychologist who has contributed greatly to the patient safety dialog, suggests the following definition of an organization's culture: shared values (what is important) and beliefs (how things work) that interact with the organizations' structures and control systems to produce behavioral norms (the way we do things around here) (Reason 1997, 223). A variety of culture types and their importance are discussed in the following sections. We would suggest that cultures drive behaviors only if healthcare organizations are functioning within each of the following culture types. A REPORTING CULTURE In reporting culture, staff is both encouraged to discuss and is comfortable discussing incidents so that they prevent errors from happening in the future. In this type of organization most staff could probably tell you that they are aware of the reporting system. However, recall key point made from the VA survey discussed by Bagian about patient safety-it was important but not their problem to correct. At HUMC, during our weekly administrative safety rounds and at educational programs, we reinforce the importance of reporting and the responsibility on the part of staff to report errors, including near-miss events. As healthcare leaders, we must ask ourselves, have any of our patient care units or departments not reported an event during the past 6 to 12 months, and why not? Of those that have reported events, how many of them have received any feedback about those incidents and what the plan is to correct those system failures? Workload may be limiting factor in the extent of incident reporting. What tools have we provided to staff to make sure that reporting is easy and to provide for more rapid investigation of the facts? Online reporting systems are key to quick analysis of the event so that facts are fresh to those involved immediately afterward and details are not lost on retrospective analysis done weeks or even month or more after the event. The online reporting system at HUMC includes staff narratives about the event that provide as many facts about the incident as possible. Similarly, the VA system solicits staff feedback concerning process improvement, which is highly commendable. …

American Surgical Association Blue Ribbon Committee Report on Surgical Education: 2004

Debas, Haile T. MD; Bass, Barbara L. MD, FACS; Brennan, Murray F. MD, FACS; Flynn, Timothy C. MD, FACS; Folse, J Roland MD, FACS; Freischlag, Julie A. MD, FACS; Friedmann, Paul MD, FACS; Greenfield, Lazar J. MD, FACS; Jones, R Scott MD, FACS; Lewis, Frank R. Jr. MD, FACS; Malangoni, Mark A. MD, FACS; Pellegrini, Carlos A. MD, FACS; Rose, Eric A. MD, FACS; Sachdeva, Ajit K. MD, FRCSC, FACS; Sheldon, George F. MD, FACS; Turner, Patricia L. MD; Warshaw, Andrew L. MD, FACS; Welling, Richard E. MD, FACS; Zinner, Michael J. MD, FACS Author Information

Doing Away with Uncompensated Care of the Uninsured

As more people lose their health insurance, an increasing volume of uncompensated care is absorbing billions of dollars of limited resources of the nation's hospitals, health systems, and other provider organizations. As yet, no provider organization has developed a comprehensive management approach to address this growing problem. Currently, the money spent on uncompensated care is viewed as a drain on institutional bottom lines rather than as a fund dedicated to improving the health of uninsured patients and prospective patients. If an accountable executive were made responsible for managing this problem by paying for all of this care on a case-by-case basis as third parties do, uncompensated care could be eliminated. Payment for each case would come from the institutional resources no longer required for uncompensated care. There is reason to hypothesize that with effective management, a significant amount of the resources currently absorbed by uncompensated care could be shifted from excessive inpatient care to more productive, innovative community initiatives. This paper outlines a six-point management program designed to increase the income and decrease the expense currently associated with uncompensated care, while improving quality, patient satisfaction, and outcomes. The program can be carried out by an individual provider organization, or as a collaborative program involving two or more organizations. Recommended are demonstration projects to test the feasibility and net cost or cost savings of such an approach, preferably starting in one-hospital towns.

Attention to 'details': etiquette and the pharmaceutical salesman in postwar American.

This paper provides a sketch of the emerging role of the pharmaceutical salesman, or 'detail man', in the growth years of the American post-World War II pharmaceutical industry. Using training manuals, trade literature, in-house company newsletters, memoirs, and a variety of other published sources, the paper follows the delicate tactics employed by salesmen and their managers in their attempts to recast drug salesmanship as a 'professional service' fulfilling vital functions within medical education. As they worked to legitimate their presence in the nation's hospitals and clinics, particular emphasis was given to precise management of the etiquette of doctor-salesman interaction. Ultimately, the techniques employed by mid-century salesmen and their managers were to prove successful in generating a widespread acceptance of the industry representative within the clinical spaces of hospital and clinic. Indeed, many of the practices of market research and market strategy employed across the pharmaceutical industry today have their origins in the practices of the individual detail man. Exploration of the postwar pharmaceutical salesman as an overlooked historical 'type' provides significant insights into the intersection of medicine and the consumer marketplace during the later 20th century.

William Bosworth Castle: pioneer of haematological clinical investigation.

William Bosworth Castle (1897-1990) spent his entire haematological career at the Harvard Medical Unit and Thorndike Memorial Laboratory at Boston City Hospital during the golden age of haematology. Castle's experiments in solving the puzzle of pernicious anaemia by identifying the intrinsic factor are models of clinical investigation and marked a new era in haematology. Castle's insatiable curiosity about the mechanisms of disease, his ability to design and conduct simple experiments to test hypotheses, and his ability to attract clinical investigators to the Thorndike Laboratory, and inspire them and make them feel like intellectual equals, fuelled the dramatic output of seminal work on nutritional anaemias, haemolysis, splenic function, haemoglobin physiology and coagulation. Indeed it was Castle's breadth of scientific achievements in haematology and his leadership of the Thorndike Memorial Laboratory that contributed to the notion that modern haematology was born in Boston but nurtured at the Thorndike Memorial Laboratory.

Special Supplement: Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times

Hospitals are complex and imposing institutions. They are vital to the communities they serve and to society as a whole. They are places of joy and sorrow, rescue and loss, recovery and death. They command enormous capital investment, expensive high technology, and often the largest payrolls of any organization in their community. They are monuments to governmental and philanthropic largess. Most are now integrated health systems offering multiple health services and countless activities under the headings of counseling, education, health promotion, and community service. They employ and support the practice of some of the most highly trained, intelligent, and capable professionals in the nation; their hallways are thick with titles, academic honors, and advanced degrees. Over half of the nation's hospitals today are not-for-profit organizations, traditionally called voluntary because, while they are managed by specialized professionals, they are governed and supported by volunteers--philanthropists, community leaders, business people, clergy, and others with a civic orientation of service. These are not-for-profit hospital trustees, men and women who serve without pay and who are entrusted with the oversight, mission, and strategic operations of these expensive and vital institutions. (1) It is important to all of us that not-for-profit hospitals be governed well and trustees do their job well. Hospitals deal with the most fundamental matters of human well-being; their services are not just another commodity in the marketplace. By providing health care services of high quality, a hospital is an important community resource. Those who run not-for-profit organizations owe a fiduciary duty to the founders, benefactors, and donors who support the institution with an expectation that their money will be used in certain ways and for certain purposes. Not-for-profit hospitals also enjoy tax exempt status in return for fulfilling certain public purposes, and thus those who govern these institutions have a responsibility to all citizens and taxpayers to ensure that these public purposes are realized. There is much with which trustees have been entrusted. These public and private fiduciary promises, implicit in each trustee's acceptance of appointment to the board, lay the foundation for a set of more specific ethical and legal duties that not-for-profit hospital trustees assume. This report is a discussion of the roles and responsibilities of those who serve on not-for-profit hospital boards. It is about the ethics of being a trustee. (2) It is about how ethics can be used to assist, facilitate, and enable already virtuous people to make hard choices. It is not about one right answer but about striving to do the right thing for the right reasons. In a legal sense, not-for-profit trustees are not as highly regulated or as accountable as the directors of for-profit corporations, who are formally accountable to the shareholders who elect them. State attorneys general oversee the conduct of not-for-profit trustees, and they rarely use their regulatory power to interfere with board actions, except in cases of the most blatant misconduct and abuse of trust. (3) The law trusts trustees and provides a set of general guidelines for conscientious service. The legal obligations of hospital trustees can be summarized as a duty of care, a duty of obedience, and a duty of loyalty. (4) The trustee must attend meetings and become informed enough to make reasonable, prudent decisions. A trustee must adhere to the mission of the hospital. A trustee must pursue the best interest of the hospital and not misuse his or her position to advance personal interests. The trustee must avoid conflicts of interest, engage in open decisionmaking, and act with an independent mind and in a fiduciary spirit. This emphasis in the law of trusts and trusteeship on personal, conscientious goodwill and ethical motivation comports well with the perspective of ethics. …

Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals.

The direct relationships and associations among clinical pharmacy services, pharmacist staffing, and medication errors in United States hospitals were evaluated. A database was constructed from the 1992 National Clinical Pharmacy Services database. Both simple and multiple regression analyses were employed to determine relationships and associations. A total of 429,827 medication errors were evaluated from 1081 hospitals (study population). Medication errors occurred in 5.22% of patients admitted to these hospitals each year. Hospitals experienced a medication error every 22.04 hours (every 19.13 admissions). These findings suggest that at minimum, 90,895 patients annually were harmed by medication errors in our nation's general medical-surgical hospitals. Factors associated with increased medication errors/occupied bed/year were drug-use evaluation (slope = 0.0023476, p=0.006), increased staffing of hospital pharmacy administrators/occupied bed (slope = 29.1972932, p<0.001), and increased staffing of dispensing pharmacists/occupied bed (slope = 19.3784148, p<0.001). Factors associated with decreased medication errors/occupied bed/year were presence of a drug information service (slope = -0.1279301, p<0.001), pharmacist-provided adverse drug reaction management (slope = -0.3409332, p<0.001), pharmacist-provided drug protocol management (slope = -0.3981472, p=0.013), pharmacist participation on medical rounds (slope = -0.6974303, p<0.001), pharmacist-provided admission histories (slope = -1.6021493, p<0.001), and increased staffing of clinical pharmacists/occupied bed (slope = -9.5483813, p<0.001). As staffing increased for clinical pharmacists/occupied bed from the 10th percentile to the 90th percentile, medication errors decreased from 700.98 +/- 601.42 to 245.09 +/- 197.38/hospital/year, a decrease of 286%. Specific increases or decreases in yearly medication errors associated with these clinical pharmacy services in the 1081 study hospitals were drug-use evaluation (21,372 more medication errors), drug information services (26,738 fewer medication errors), adverse drug reaction management (44,803 fewer medication errors), drug protocol management (90,019 fewer medication errors), medical round participation (42,859 fewer medication errors), and medication admission histories (17,638 fewer medication errors). Overall, clinical pharmacy services and hospital pharmacy staffing variables were associated with medication error rates. The results of this study should help hospitals reduce the number of medication errors that occur each year.

Nosocomial Infection among Immunosuppressed Patients in the Intensive Care Unit

Advances in technology and development of multidrug-resistant antibiotics have increased the number of immunosuppressed patients in need of crisis care and the incidence of nosocomial infection in the nation's hospitals. Nosocomial infections are proving particularly difficult to prevent in intensive care units (ICUs), where special care must be taken to avoid transmission of any infection. The authors present an overview of this problem in the ICU, outlining basic measures to be taken in preventing nosocomial infections and ensuring the safety of the patients.

Economic Grand Rounds: Trends in Managed Care, 2000 Edition

Economic Grand Rounds: Trends in Managed Care, 2000 Edition

Fatal Distraction: Finance vs Vigilance in Our Nation's Hospitals

Fatal Distraction: Finance vs Vigilance in Our Nation's Hospitals

US doctors are granted the right to form unions

For the first time, doctors in training in the United States have been granted the legal right to form workers' unions to negotiate salary and working conditions. The US National Labor Relations Board opened the door to the unionisation of medical residents at American teaching hospitals by giving house staff the right to bargain collectively. By ruling that residents at private hospitals have the right to unionise under federal labor protections, the National Labor Relations Board strengthened the hand of doctors in training, potentially shifting the economic underpinnings of the nation's teaching hospitals. The ruling by the US National Labor Relations Board changes a precedent of 23 years that has held that medical residents, interns, …

Globalized, Focused Healthcare?

SUCCESS CAN BE a slippery thing. Sometimes it comes to organizations that focus on depth of offering (e.g., children's book sales, on a specific comer, on a certain side of town). Other times, it comes to superstores that focus on breadth of offering while providing discounts (high customer satisfaction) possible through economies of scale. Yet other times, success comes through enabling technologies like the Internet, which spawned high-tech, high-touch book sales from the convenience of the home. These technologies offer even deeper discounts and broader depth of product lines. So it seems our predictive models depend on which business sector we choose to analyze. Although Herzlinger's article on Dr. Denton Cooley at Texas Heart Institute, it was silent on the equally successful surgery program of Dr. Michael Debakey's heart team operating in a traditional full-service academic medical center, The Methodist Hospital, across Fannin Street in Houston. Dr. Herzlinger's prescription for the future is tantalizing to consider. No one has written or spoken as extensively on the subject of as she has. In its simplest form, focused healthcare is a system of seriously hospitals and neighborhood clinics for treating most major illnesses. Focus brings efficiency, productivity, and efficacy to the treatment of a single disease category. Nonetheless, chronic diseases often do not exist in isolation from other major diseases in the same individual. Chronic patients often present with complex, multiple diseases, such as the diabetic cancer patient. Our nation's hospitals stand ready to address multidisease states of individuals under a single organizational roof To take Herzlinger's argument to an extreme level, we would need to build ten new neighborhood clinics (one for each major disease) throughout town, plus hundreds of small hospitals to replace our current academic medical centers and community hospitals. Several problem areas are likely to arise if our nation universally goes down this pathway. The debt equity required to finance these new structures would be enormous, right at a time when the health provider sector is experiencing a crisis in lowered bond ratings and diminished ability to raise new capital. The example of diabetes brought forward in Dr. Herzlinger's article is worthy of careful scrutiny. According to her analysis, an average state would require $2 billion for a sufficient number of neighborhood clinics and hospitals just for the treatment of diabetes. One can easily compute the enormity of the task to fund such programs in all 50 states for treatment of a number of diverse diseases. Would the traditional practicing physicians and hospitals have to give up all these new revenues to startup firms? If so, a dislocation for physicians, nurses, and hospital workers would occur to a degree never before seen in history. The problem of getting consistent quality in our country is especially well documented by Herzlinger. Every physician leader, administrator, and board member can recite this litany. We are all aware of the problem, and can transform our current practices into the excellence Dr. Herzlinger calls us to, by building on the best practices already emerging in leading organizations around the United States. Focused may be one of the routes to such success, but it is doubtful that model will ever dominate medicine in the United States. The landscape of the future is likely to include large comprehensive medical centers as well as full-service, but less intensive, community and rural hospitals in cooperation with multispecialty physician practices. For me, the end game is efficient, high-quality care that is appropriate and leads to high customer satisfaction. Health systems like Mayo Clinic, Johns Hopkins, Northwestern Memorial, and Henry Ford do not have to be dismantled to get us there. A major tenet of Wanda Jones' paper is that none of us are operating our organizations the same way we did 35 years ago; thus, she concludes that none of us will be operating in the same way in the year 2025. …

Performance of the '100 top hospitals': what does the report card report?

We examine whether Medicare patients with acute myocardial infarction (AMI) admitted to one of HCIA-Mercer's "100 top hospitals" received better care or had better outcomes than patients treated in other hospitals. Among four hospital peer groups, the top 100 hospitals had similar thirty-day mortality and use of aspirin, beta-blockers, and reperfusion compared with their peers, but lower lengths-of-stay and in-hospital costs, with similar or lower readmission rates. Our findings suggest that the 100 Top Hospitals study may be better suited for identifying hospitals with higher performance on financial and operating measures than superior clinical performance in treating elderly AMI patients. However, there was no evidence that quality was sacrificed for increased financial efficiency among the top 100 hospitals.

Clinical pharmacy services and hospital mortality rates.

We evaluated the associations between clinical pharmacy services and mortality rates in 1029 United States hospitals. A data base was constructed from Medicare mortality rates from the Health Care Financing Administration and the National Clinical Pharmacy Services data base. A multivariate regression analysis, controlling for severity of illness, was employed to determine the associations. Four clinical pharmacy services were associated with lower mortality rates: clinical research (p<0.0001), drug information (p=0.043), drug admission histories (p=0.005), and participation on a cardiopulmonary resuscitation (CPR) team (p=0.039). The actual number of deaths (lower) associated with the presence of these four services were clinical research 21,125 deaths in 108 hospitals, drug information 10,463 deaths in 237 hospitals, drug admission histories 3843 deaths in 30 hospitals, and CPR team participation 5047 deaths in 282 hospitals. This is the first study to indicate that both centrally based and patient-specific clinical pharmacy services are associated with reduced hospital mortality rates. This suggests that these services save a significant number of lives in our nation's hospitals.