In the December 2010 issue of The Hospitalist (p. 43), I started the discussion of “The Story of Us” by outlining three threats that could limit our effectiveness in realizing our vision of quality and patient safety. The story continues here, with four additional threats to the culture of quality that is our mutual dream.
Threat 4: Strategy Trumps Tactics and Execution
There is no shortage of “strategery” in the context of healthcare reform, and it is tempting to succumb to the idea that the correct strategy automatically translates into intended results. But anyone who has suffered through a high-school rendition of Hamlet knows that while Shakespeare’s words might be the same, it is hardly a Broadway performance. Put another way, what is written in the coach’s playbook is the first step; execution of the playbook is what wins or loses the game.
Chan et al’s article “Delayed Time to Defibrillation after In-Hospital Cardiac Arrest” makes this point.1 I doubt there is any physician who does not know that defibrillation is indicated in a cardiac arrest, but as the article illustrates, it took more than two minutes for 30% of patients with in-hospital cardiac arrest to be defibrillated. The upshot: If you have a cardiac arrest, you might be safer in a casino than you are in a hospital.
Healthcare reform and the expanding literature in patient safety and quality bring us closer to having the strategy we need, but what lags is execution of that strategy. Tactics, not strategy, is our greatest deficiency now. And while strategy can be designed for virtually all hospitals, tactics rest with each individual hospital, as each individual hospital system is unique.
Enter again the importance of the hospitalist: the physician intimately aware of the intricacies of their hospital system. There are reasons that defibrillation might be delayed in an individual hospital; perhaps it’s the location of the code cart, perhaps it is how patients are determined to need telemetry monitoring, perhaps it is the line of communication between telemetry and the responsible physician. But whatever the reason, it is not likely to be the same for all hospitals.
And here is the new challenge for the hospitalist: Discover the unique systems deficits in your hospital that prevent the perfect strategy from translating into perfect results.
Threat 5: Focus on One Component at a Time
The essence of systems-level change is simple: In a system, changing one component has effects (good or bad) on other components of the system. Unfortunately, our healthcare systems continue to exist in silos, with few people in leadership positions who are empowered with a perspective of the system as a whole.
Case in point: the yin-yang of length of stay (LOS) and hospital readmissions. I doubt there is a hospitalist who has not heard the words “discharge by 11 a.m.,” in large part because of the hospital truism “every medicine bed is a wasted ortho bed.” Patients who leave by 11 a.m. open up more beds for patients coming out of the operating rooms, and that translates into more surgical procedures. But discharge by 11 a.m. is not as simple as it appears. A sound discharge decision that does not result in readmissions is predicated upon multiple components of the system: results from diagnostic testing have to be obtainable early, the physician must not be dual-tasked during the early hours (e.g. receiving patients from the ED or ICU, performing procedures, etc.), and communication with the family and PCP has to be established early.