Keywords: Quality, EMR.
Citation: deBronkart D. Who gets to define quality? J Participat Med. 2011 Mar 14; 3:e13.
Published: March 14, 2011.
Competing Interests: The author has declared that no competing interests exist.
After three years of looking at US health care, trying to figure out why it refuses to improve, I have a humble but impatient suggestion: When we talk about quality, we should only include measures that patients agree define quality. Talk about other metrics, but don’t call them quality, and don’t think that adjusting them is improving quality.
Why? Because we have a big, intractable safety problem in American health care — thousands of accidental killings a month — so improving quality is urgent; and because other industries have shown that successful process improvement starts with defining quality as “what the customer finds valuable.” In health care we don’t do that — we think customers (patients) don’t know enough. And I suspect that’s a root cause of why quality doesn’t improve.
Most readers will know that in November two disturbing, depressing studies were released, showing little or no progress in the more than 10 years of effort since the publication of “To Err Is Human”:
- The New England Journal of Medicine reported on North Carolina’s four years of trying to improve safety, and “found that harms remain common, with little evidence of widespread improvement.”
- The HHS Inspector General looked at a month of Medicare data and projected that we have 15,000 accidental deaths per month (500/day) and 134,000 cases of non-trivial harm (over 4000/day). And that’s only among Medicare patients — people over 65.
Is It Sane to Let Customers Define Quality in a Complex Profession?
It was true in the auto industry and it’s true in medicine: When highly trained, technically skilled people are told something new is more important than their opinions, egos can get in the way; who wants to give up being the most valuable opinion? Years ago Detroit’s best experts told Congress it wasn’t possible to build a safer, more efficient car: “We know what we’re talking about; this is our industry!” But Japan listened to consumers and did it anyway.
Changing the “quality compass” in no way diminishes the value of those skilled services. Our voyage can’t succeed without those skills – but they’re the ship’s engine, not its compass.
Mark Graban, author of Lean Hospitals, cites this example from Wisconsin health system ThedaCare, which implemented “lean thinking”: “When working on lean in the birthing suites, the staff and leaders thought it was about efficiency for staff. The mothers on the team said ‘hey, when you’re running in and out of the room constantly, it’s not a calm peaceful environment.’ So there was a far softer edge to the need to make sure the rooms were properly stocked and supplied. It wasn’t just about ‘avoid walking back and forth’ it became more about ‘create the right environment for the mother and baby.'”
That is customer centered/patient centered care … it’s not just the biological outcome but whether we feel well taken care of.
Let Us Scrutinize Every Definition of Quality
January’s Archives of Internal Medicine included a retrospective analysis of EMR data and found “no consistent association between EHRs and [clinical decision support systems] and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.” This article brought quality definitions to a head in a new way, which we discussed on e-patients.net.
What do they mean by care quality? To me, as a patient, it’s how well they took care of me and how well I “got better”. But this study only examined whether the doctors prescribed the right thing. I assert that as long as medicine defines quality as “not prescribing the wrong thing,” all our discussions about how to improve quality will be far from improving what patients want.
Yet reporters echoed the conclusions, from health IT vehicles such as FierceEMR (“EHRs and the Quality Conundrum”) to the mass media, such as CNN’s Sanjay Gupta’s “Electronic Health Records No Cure-All.” All gave the impression that if the goal of the stimulus bill was to improve the care people get, EMRs won’t do it.
(As a side note, other observers more knowledgeable than I have detailed numerous design problems with the study — not the least of which is a commentary appearing in the issue expressing suspicion that the EMRs in the study were not fully functioning, nor even covering the guidelines that the study targeted! Those posts are summarized in the e-patients.net post. How can an article with such major concerns get through peer review and be approved by editors, especially with that commentary alongside?)
Let us all, patients, clinicians, policy makers, and insurance companies look carefully when anyone cites quality statistics, and find out what they measured. And henceforth, let’s start by asking customers. Because if we don’t, I don’t see any reason to expect that safety and care in hospitals will be any better when your time comes to be treated.
When originally published, this article incorrectly stated that “The HHS Inspector General looked at a month of Medicare data and projected…400,000 cases of non-trivial harm (1300/day).” The actual figures from the cited report are 134,000 cases of non-trivial harm (over 4000/day). The correct figures now appear in the body of the article.
- To Err is Human: Building A Safer Health System. Institute of Medicine of the National Academies; 1999. Available at: http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx. Accessed March 4, 2011. ↩
- Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek., PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010; 363:2124-2134. Available at: http://www.nejm.org/doi/full/10.1056/NEJMsa1004404. Accessed March 4, 2011. ↩
- Adverse events in hospitals: National incidence among medicare beneficiaries. United States Department of Health and Human Services Office of Inspector General; 2010. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf. Accessed March 4, 2011. ↩
- Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York: Productivity Press; 2008. ↩
- McDonald C, Abhyankar S. Electronic health records and clinical decision support systems: impact on national ambulatory care quality . Arch Intern Med. 2011 Jan 24 [Epub ahead of print]. Available at: http://archinte.ama-assn.org/cgi/content/abstract/archinternmed.2010.527v1. Accessed March 4, 2011. ↩
- EHRs and the quality conundrum. FierceEMR; 2011. Available at: http://www.fierceemr.com/story/ehrs-and-quality-conundrum/2011-01-27. Accessed March 4, 2011. ↩
- Electronic health records no cure-all. CNN Health; 2011. Available at: http://pagingdrgupta.blogs.cnn.com/2011/01/24/electronic-health-records-no-cure-all. Accessed March 4, 2011.
Copyright: © 2011 Dave deBronkart. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author(s), with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.
This is helpful, and I want to add, for the times when people in the profession/industry will say, “but they (patients and family) will ask for the wrong things,” it will be very important to ask “why?”
And the answer might be, “because we didn’t share the information we have about what works.”
As they say, when two people have the same information, they are likely to come to the same conclusion….
> the answer might be, “because we didn’t share the
> information we have about what works.”
That’s a brilliant answer. Thanks so much!
DeBronkart cuts to the chase: quality needs to be defined by the users rather than practitioners of healthcare. Our studies show that use of consumer feedback regarding the process and outcome of services as much as triples the effectiveness while decreasing drop out and deterioration. Right now, thousands of behavioral health professionals are learning, connecting and sharing their experiences of using ongoing feedback on the International Center for Clinical Excellence web based community. While the larger professional community is slow to respond, I’m inspired by the dedication and pioneering spirit of this group. Thanks for this brilliant and succinct reminder that without consumers there is no healthcare.
Hi Scott –
> Our studies show that use of consumer feedback regarding
> the process and outcome of services
> as much as triples the effectiveness
> while decreasing drop out and deterioration.
Links please! And how about you write it up and submit it for publication here!
Please excuse the delay. Currently traveling in Europe teaching practitioners and healthcare systems about what we call, “Client-directed, Feedback-Informed Treatment” or FIT for short. In your reply to my first post, you asked for links to the research we’ve completing documenting the impact that client-feedback regarding the process and outcome of care improves effectiveness and reduces drop out and deterioration. To begin, I post regularly regarding such data on my “Top Performance Blog” which can be found at: http://www.scottdmiller.com/?q=blog/1. I used the search terms to highlight a number of posts summarizing the data. Each posts contains links to various articles and summaries: http://www.scottdmiller.com/?q=taxonomy/term/56. Finally, in 2000 and 2004, together with colleagues, I published a book on the subject entitled, no less, “The Heroic Client.” In it we not only review the research but make a passionate argument for reforming healthcare by placing the consumer (their goals, motivations, and evaluation of services) at the center of service delivery. Hope you find these links helpful. I’m finishing up an article for another journal at the moment. As soon as I’m finished, I’ll put something together for JoPM. Thanks again Dave for such a fine article.
Here is the link to the HHS report referenced in Dave’s excellent piece: http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf.
This report is focused on various types of errors and their frequency among hospitalized Medicare patients. It lends credence to the admonition one should have an advocate with you whenever you are hospitalized.
“Preventable events were most commonly linked to medication error, substandard treatment and inadequate patient monitoring or assessment.” At times more than one type of error contributed to a preventable event.
The book “Managing the Unexpected,” by K. Weick and K Sutcliffe, focuses on what are termed highly reliable organizations or HRO’s. HRO’s create “mindful infrastructures” that “track small failures, resist oversimplification, remain sensitive to operations, maintain capabilities for resilience” and perhaps most importantly with respect to our recent discussion, “take advantage of shifting locations of expertise.”
The ingrained culture and hierarchy in many hospitals put them at the opposite end of organizational behavior from the “highly reliable organization.”
We have the technologies and understandings to help people do their job well (attention and distraction theory, the importance of work place ergonomics, amazing computer capabilities, feedback loops, event analysis, health informatics etc.). These elements need to be incorporated into any approach to improving care. Every member of the organization has to be involved.
It is a great challenge. And to Dave’s point about the importance of patients in measuring quality–patients anchor one of the “locations of expertise” and are needed as part of the solution.
Paul, I want to spotlight by repeating (in list form) what you said about “HRO’s”:
…track small failures,
remain sensitive to operations,
maintain capabilities for resilience
…and perhaps most importantly with respect to our recent discussion, “take advantage of shifting locations of expertise.”
And the opposite:
The ingrained culture and hierarchy in many hospitals put them at the opposite end of organizational behavior
Are you in a position to write a short or long review (or essay or what have you) about that book, from a participatory medicine perspective, for this journal? Sounds HIGHLY relevant, and I know the editors would welcome it.
Your reference to the auto industry takes me back to one of my earliest encounters with the idea of patient empowerment – Love, Medicine & Miracles, by Bernie Siegel (1986) – in which he devotes a part of one chapter to “The Mechanic and The Healer”. He also recommended that all doctors be required to spend time as inpatients during their residency to experience first-hand the “care” that patients receive.
I agree that defining quality is important, and believe doing so in a measurable way is also important.
I thought I’d read somewhere about NIH requiring some kind of Quality of Life metrics for all future funded studies … but I must have been dreaming. In the futile search, however, I did uncover some other potentially relevant and/or interesting resources:
From Research to Practice: Quality of Life Assessment in Medical Oncology [PDF], Commentary by Betty Ferrell in the Journal of Supportive Oncology, Vol 6, No 6, May/June 2008.
The Quality of Life Instrument (Cancer Patient/Cancer Survivor version) [PDF] by Betty Ferrell and Marcia Grant.
I don’t know how applicable these would be outside of the oncological support context, but they may point the way toward measurable quality of life indicators that could serve a broader population of patients.
Quality measures do not exist in a vacuum. Quality measures without patient input and cost consideration = major issues with translating research into primary care reality. An interesting article that deals with the difference between “quality” and “value” can be found at http://bit.ly/ezSTIu. Quality chronic disease management is difficult if the cost is unaffordable or if patients don’t understand why the cost is beneficial for them (as Dr. Eytan pointed out above).
> translating research into primary care reality
Well said, Dr. Yanga.
I want to make clear that in writing this I wasn’t disagreeing with the importance of physicians’ skills. My point is that quality of care is a separate axis from what’s visible under the microscope.
On the Nature blog yesterday there was a post about CFS, in which the patient community (reportedly) wants much greater research into a particular issue. I don’t know a thing about CFS, but my commented ended with this:
“If the microscope is happy but the patient’s not, has care been achieved?”
And I submit that a whole lot of things will start to work out better if everyone involved in healthcare starts with asking “How do the customers [patients] like this?”
Thank you for using as an example of perceptions, rethinking birthing suite routines (staff efficiency doesn’t have to be at odds with improved patient satisfaction) As an activated and engaged patient (and person) with 15 years’ experience with one-on-one interviews with hospitalized patients and their families — each with their own set of illnesses, upsets, hopes and fears — there emerged five or six common themes. Very little to do with actual medical care (opinions of which ranged, as to be expected).
Important to these patients was to feel respected, and dignified. At the end of this comment, I’ve summed up themes, trying to do so with a sense of context. There’s supporting evidence for most.
Should it be of interest, see “Medication Safety,” a video produced with the Hospital for Special Surgery (NY) specifically to promote patient involvement with medication safety — and modeling mutually respectful communication. Disrespectful or patronizing tone of voice is one of the most regularly cited injustices. Another understanding of “quality” from the patient’s perspective.
Although filled to the brim with patients, hospitals were created to support doctors, not us patients. Historically, their organizational structure focused on doctors’ needs and doctors’ requirements. The concept of centering hospital care on patient needs and requirements is a relatively recent development.
How can a hospital switch from being provider centered to patient centered? Shifting such a complicated and cumbersome behemoth a full 180 degrees is a huge undertaking.
I believe many things can be done. I’ve put much thought into this and feel my five steps are doable and (relatively) easy to implement without interfering with the changes already in evidence organizationally and technologically. My five steps were born of an epiphany: Without us patients there would be no hospitals. Without us patients, there’d be no place for:
Patients are hospitals’ raison d’être. Here’s how you can make us feel more like the VIPs we are.
5 Steps to a Patient-Centered Hospital
1. Be Quiet.
Quiet. Shhhh. We need a library environment. I don’t want to hear staff shrieking to one another down halls and across nursing stations. You have other options. You can get up and walk over to the person you are addressing or send a text (SMS, IM etc.), a Twitter message or an email. Silence the doors, drawers, cabinets, carts. No more slamming, ramming or bashing. We VIPs have sensitive ears and nerves. I know this quiet can be done. On hospital office floors for example, it’s dead quiet.
Hospital colors are depressing. We need something comforting and peaceful, colors that create a warm and welcoming atmosphere. Color can also help us VIPs find our way in the hallway labyrinths. Mazes befuddle and confuse.
3. Change the linens.
Hospital bedding is just awful. Please learn from hotels. They also grapple with high volumes of laundry and infection-control requirements. Yet, their sheets have a thread count of more than 100.
4. Turn curtains into art.
The privacy curtains. Honestly! They’re utterly useless. Privacy’s a joke and the color makes us VIPs feel we’re already dead. Instead, use them as a canvas and showcase local art. Use the same industrial strength material as scrubs.
5. Let us dress with dignity.
Even if you can’t do the first four steps right away, there’s one I hope you’ll consider changing — the hospital gown! The hospital gown is the single most important thing that demoralizes even the most understanding VIP. They’re embarrassing for all. They dehumanize, demean, and really make us VIPs feel like we’re an afterthought — and a tiresome one at that. Please change the design of the hospital gowns. Grownups need grownup gowns.
Bonus: Change the floors.
Changing the floors may be too expensive. But wouldn’t it be great for every foot that ever walked on a hospital floor to have a nicer surface like bamboo or cork, providing they met with infection prevention and other necessary codes.
Perhaps, compared to the issues of patient safety, medication errors and technology inequities, what I propose may seem frivolous: nice to have, rather than need to have. But ask any one of us VIPs. For us, it’s often the common sense, meeting-human-needs components that gives meaning to the term “patient centered.”
Kathy, I just LOVE those five suggestions! How non-biological! How human!
Here they are again, everyone:
1. Be Quiet.
3. Change the linens.
4. Turn curtains into art.
5. Let us dress with dignity.
I agree that the patient needs to have a voice in defining what it is that makes an encounter with the medical-industrial complex, or a relationship with a health care provider, good. However, I think that the patient-defined piece of the puzzle is a subset of “quality,” and not the entirety of “quality.” Patient/consumer demands can improve quality (as in your auto industry example), but I can’t tell a good carburetor from a bad one (does my car even have one any more? I don’t even know, and I don’t care), and I can’t tell a good gallbladder removal from a bad one (I assume they would leave the same tiny laparoscopy scars). There’s a whole lot of stuff that goes on to ensure automotive and medical safety that the typical engaged patient/consumer cannot evaluate. So — maybe I’m caught up in semantics, but I think that patient experience is a big part of what you’re including in quality (e.g., the labor and delivery example), and that is an important part. There are a good number of measures of patient experience (HCAHPS, others). There are just a whole lot of other things that I (and others) would include in the quality bucket.
One of the reasons health care is such an intransigent problem is the imbalance: expert knowledge imbalance (providers have some, patients have some), financial incentive imbalance (payor-provider-patient mess). I don’t think that the solution is to give the patient the keys to the old jalopy, so to speak. This needs to be a joint effort, a co-pilot arrangement. As a patient, I get to ask the hard questions. But I need someone across the table from me who can answer those questions.
I agree with Dave that patients must be part of the quality discussion and that we are the best judges of whether we feel cared for. We want to feel that things are being done for us, not to us.
But I also agree with David that we are only part of the answer to the quality debate. Patients know better than anyone what’s going on with our bodies but we don’t know why. Doctors know why (medical mysteries aside) but not what.
The one thing I would add to David’s remarks is that in addition to getting to ask the hard questions, patients must ultimately make the treatment decisions. And as David said with his gallbladder example, that’s hardly a DIY endeavor. I have told people you will never hear this on a plane: “We have a medical emergency. Could someone who has researched their condition online please press the call button?”
This is a great discussion! Thanks, Dave!
> Patients know better than anyone what’s going on with our bodies but we don’t know why.
Clap clap clap!
I’d insert a “may,” though – “patients MAY know better…” In my own case, I had no idea I was sick, much less what to do about it; I’d be dead if I’d gone to out-of-date doctors or a hospital that was quiet & pretty but poorly trained.
My point, as I said above, is that the patient’s experience of care is the compass – “true north,” as it’s called in Lean. Without a compass the most highly skilled hard work will not achieve what it could.
An amazing and well written piece. Thank you so much for articulating so clearly how we are missing an important voice in healthcare – the voice of the patient. In many other industries companies and organizations have adopted “Voice of the Customer” practices. I’ve found this brief VoC guide from Bain & Co. very useful http://www.bain.com/management_tools/tools_voice_customer_innovation.asp?groupcode=2
I hope that more healthcare providers begin to adopt a variant of this best practice. Only by giving patients a voice will healthcare be truly transformed.
Your thoughts articulated mine very well as I read the article and the subsequent posts. Unfortunately, patients “don’t know what they don’t know” and may not be able to recognize when their care is substandard. I recount my encounter with a diagnostic mammogram in my blog posts at http://tw0.us/Rjy that I feel was substandard. I only know this because of my background and knowledge of medicine.
Most patients would not have known the exam should have been more thorough – both breasts instead of just the upper right quadrant of one breast. The staff at the facility was very warm, friendly & caring. The large sign by the elevator advertised they are striving for excellence in service, quality, etc. The patient “experience” couldn’t have been better. On a scale of 1-10 with 10 excellent, I would rate them a 10 and they would have felt they are top notch.
BUT, the real thing that counts is a proper exam and proper diagnosis. I felt the guidelines they follow (after an hour long discussion with one of the radiologists) are seriously lacking. I wonder how many women have left that facility without a proper exam or correct diagnosis. The thing that was so disconcerting was the fact that for an hour the radiologist kept talking about 80% of regular patients without considering the fact they already knew I had a problem and needed a more thorough exam.
The system is broken in very deep places patients don’t usually see or understand. They think the diagnosis is made by the doctor and somehow the tests procedures are infallible with black & white answers.
Yes, patients definitely need a seat at the table, but they must be patients who understand the system well enough and have insight into what can and does happen in order to have a meaningful contribution. Input is needed in all aspects of care not just the hospital, but the doctor’s office, test facilities of every kind, the insurance companies and who is allowed to own what (ex. doctors with ownership in test facilities or surgical suites). Money drives the whole system – patients need a voice in it all.
Kathy Kastner’s comment about hospital environments being designed for doctors (also read staff) and not patients is insightful. There are times when high acuity requires the high tech setting, but so often staff convenience means patient discomfort, embarrassment and risk. Patients are expected to share cramped rooms, be disturbed throughout sleep, treated as asexual (e.g. the gown issue), be woken early for the physician’s benefit, and sometimes be subjected to the most stressful environment when exactly the opposite is needed. And all of this happens at thousands of dollars a day!
HHS has a web site – Hospital Compare that allows you to compare hospitals on quality metrics of process, outcome and patient satisfaction, http://www.hospitalcompare.hhs.gov/
Paul your comments are especially insightful.
For example – One of the hospitals that is setting national benchmarks for lean and quality – Virginia Mason Medical Center in Seattle also ranks very low on patient satisfaction scores. Only 34% of patients say that “the area around my room was always quite at night”. http://www.hospitalcompare.hhs.gov/hospital-compare.aspx?hid=500005,500025,500008&stype=GENERAL&&Tab=3&lat=47.6062095&lng=-122.3320708&stateSearched=WA
One other challenge is that hospitals with a strong “brand” (examples in Boston and Seattle) are often able to demand a premium for their services but they don’t always provide higher quality or more effective care. Insurance companies are now forcing patients to carry a higher cost if they use these systems but it is the provider who determines where the patient will go.
It seems “we”, who are part of the health care professions, keep trying to make “them”, the patients, change. Why not design a system that supports and helps people where they are and where they want to be, vs. where we want them to be? Our work through the Healthy Memphis Common Table’s Aligning Forces for Quality project is challenging us to rethink the usual approaches and processes.
Great example came up the other evening at a consumer meeting: why are we working so hard to get people to stop using the emergency room when there are a myriad of reasons they WANT to use the emergency room? Why not consider designing an “emergency room”-type of place that people would want to use and that meets the system’s desire for continuity of comprehensive care and cost efficiencies? Might this approach work better than “making” “them” get a traditional primary care physician?
It’s hard work to change the perspective to the person from the system. We are just starting that work and I hope we will continue on that journey. It opens up so many more solutions!
Cristie, please say more about the difference between the ER of today and the kind you’re talking about.
The obvious thing to me is simply the ability to get care without an appointment – basically walk-in. What else?
Dave, in terms of Cristie’s post, I think that’s about it. People go to the ED because they can get in, period. They may not have a regular doctor to call, or if they do, they’re busy. They may not be able to go at any time, since they may rely on public (or borrowed) transportation.
I think this is a great way to frame the problem, stop trying to change people’s unchangeable habits, just give them what they need as an alternative.
And now I’m going to go suggest this at work.
Christie Travis’s insights are valuable. I have worked in both ER and UC settings for about 30 years – and both settings take good care of patients.
The UC setting where I work sees close to 250,000 people/year at six different sites. It is designed to handle moderately high acuity as well as common conditions. Surveys have demonstrated that 40-50% of patients prefer episodic care. Even those who do prefer having an established provider often note that for acute injuries or “sudden onset” problems waiting for an appointment isnt a first choice.
There are good reasons why patients might prefer accessing care in this fashion. Changing demographics within the work force means many parents/patients can only access care in the evening. In the areas surrounding many cities there is a 10-15% turnover in population per year. Thus patients are not tied to one clinic or provider the same way. Additionally people change jobs at a high rate and different employers often means different health plans. Finally, people want instant access.
Some problems clearly need a different setting. But many issues can be effectively managed well outside of primary or specialty care. The notion this is more costly care or necessarily results in over utilization of imaging etc. is arguable.
Patients vote with their feet – unless someone is having them run along narrow tracks.
Dave, I don’t have the answers to your question at this point. But, one of the reasons we have heard people prefer the ER is not just getting care without an appointment, but that they get access to all they need at one place and one time..all the lab tests, all the radiology, the treatments, etc. They feel that if they are at a hospital ER they can get it all done at once and feel that they are getting comprehensive care. A quality, comprehensive one-stop shop.
There may be other reasons, but this is one we have heard.
Fascinating – and how common-sense, customer-oriented.
I had a “run-in” (not really) yesterday with my hospital’s billing people. Every time I go there THEY have to ask ME how much I owe for a co-pay. (I’m not making this up.) Sometimes I get it wrong, and I end up with a balance due. This has happened 3x in the past year, and they end up sending me bills, which annoy me so I block them out.
Well, yesterday I finally called, and it turns out THEY have a separate ACCOUNT NUMBER for each of the bills, because each was with a different department, each of which has its own billing accounts, and no, they DON’T consider it their problem to give me a single bill; they are nothing more than a mall that houses the different “shops.”
That explains why each time I visited one of them, not only were they not connected to my insurance, they had no idea that I owe somebody else in the “mall” $10. Because I could have paid it right then. Instead, they kept mailing out more letters.
And we wonder why US healthcare is inefficient and costly. If these people can’t even get efficient about collecting money, is there hope they’ll get efficient about other things?
Not to mention that it’s not customer-centered.
Well, I came to see another reason why integrated systems (where the docs are employees) are the only sensible approach. I wonder if other hospitals who are actually “malls” of individual doctors have nonetheless managed to present a common front for billing purposes, shielding the consumer from the behind-the-scenes craziness.:)
btw, are you at liberty to say who “we” is?
Why is the discussion about ‘us’ and ‘them’, whichever side you are on? The topic of healthcare quality and patient empowerment is for everyone, we are all patients, even if we work in the healthcare field. So, why do we think of patients as ‘them’s?
As a retired clinical RN for 25+ years, who has been severely and permanently disabled, with multiple disabling conditions and declining health, for the past 5+ years, I can easily see both sides of the issue raised here. The realities on both sides, are SO complex, it’s too overwhelming for me to even begin to tackle in a short reply.
However, I would like to know why basic, patient AND RN-friendly mechanical devices, such as the Japanese-developed “washelets” or “bidet-toilet” devices, are not mandated in every hospital toileting area. These are appliances that replace regular toilet seats, can be operated via remote controls, and can completely clean & blow-dry the genital area (after all forms of elimination), with the user privately getting their hygiene needs met, without RNs & CNAs having to strain their backs & other body parts, to clean patients’ genitals, after toileting.
They are available on multiple American plumbing websites, yet I’ve never seen or heard of a single hospital using them, anywhere. The most deluxe ones usually only cost about $500.00 USD and, this device has been critical in allowing me to maintain my toilet hygiene and personal dignity, since I live alone with multiple disabling conditions. NO ONE likes to have others clean them after toileting. So why aren’t devices, like this, that can maintain patients’ dignity, long-since in use in health care facilities?
I’ve never heard of this either, but I think it’s great to know about. And it’s a great example of patient-DEFINED priorities. I’ll try to spread the word.