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Dare to Reach into the Darkness
“Dare to reach into the darkness, to pull someone into the light. Remember strong people not only stand up for themselves, they stand up for others too.” – unknown
WHAT’S YOUR LEADERSHIP TILT?
We’ve surveyed hundreds of leaders about their greatest leader, the most important natural behaviors beyond character and hard worker were Results and Relationships.
Where do you tilt on the results and relationships scale?
Check out this free infographic, and please tell others about it!
Should Hospitals Limit the Number of Patients Nurses Can Help?
The medical community is divided over a November ballot measure that would make Massachusetts only the second state with such staffing requirements.
Voters this fall could make Massachusetts only the second state in the country to limit the number of patients that hospital nurses can help at one time.
Question 1 would create legal ratios based on the type of patients that nurses are dealing with. Nurses aiding women during birth and up to two hours after, for instance, would be limited to one patient. If they’re working with children, they could see four patients at once. In the psychiatric ward, nurses could help up to five patients.
While nurses unions and progressive political groups back the ballot measure, most medical groups — including the Massachusetts chapter of the American Nurses Association and the state’s Health and Hospital Association — oppose it.
The ballot measure’s supporters argue that not regulating this negatively impacts patient care and overall health outcomes.
“There is overwhelming evidence when you look at studies and talk to nurses that when there are limits, there are better health outcomes,” says Kate Norton, campaign spokewoman for the Committee to Ensure Safe Patient Care, which is the official campaign for the ballot measure.
A 2011 study in the journal Health Affairs found that nurse-patient ratios in California resulted in decreased mortality rates after surgery and an additional half-hour of care for patients overall.
Seven states have laws that require hospitals to have committees that address staffing issues, but California is the only state with a cap on the number of patients a nurse can see during one shift. Advocates have struggled to gain support for ratio laws elsewhere, in part because the hospital industry doesn’t believe there’s enough evidence to support them.
California’s regulations were drafted by the state’s department of health and have been in effect since 2004. There was some fear at the time that hospitals would be forced to hire more nurses with less education in order to comply with the ratios. But according to the 2011 study, that didn’t happen.
Opponents of Massachusetts’ measure also worry that it would force hospitals “to make deep cuts to critical programs, such as opioid treatment and mental health services. Many community hospitals will not be able to absorb the added cost and will be forced to close.”
In California’s experience, those fears are likely overblown.
Research by the California Healthcare Foundation in 2009 shows that while “leaders reported difficulties in absorbing the costs of the ratios, and many had to reduce budgets, reduce services or employ other cost-saving measures,” the impact of the ratios was not discernible on hospital finances.
Research further shows that hiring levels only increased slightly after the mandate. But California is expected to have a nursing shortage of more than 44,000 by 2030. It’s not clear how big a role, if any, the staffing ratios play in this shortage.
In Massachusetts, opponents of the measure argue that it would worsen the existing nurse shortage there. Right now the vacancy rate for registered nurses in Massachusetts hospitals is 6.4 percent.
“If it passes, the estimates are that hospitals will have to hire 6,000 more nurses [according to a study led by the opposition camp]. Where will they get them?” says Jake Krilovich, director of policy and public affairs for the Home Care Alliance of Massachusetts, which opposes the measure.
But according to data from the U.S. Department of Health and Human Services, the state is projected to have a surplus of nurses by 2030.
Although well-financed organizations like the Massachusetts Business Roundtable, Massachusetts Health and Hospital Association and 11 local chamber of commerces oppose the measure, the supporting campaign has much more cash on hand: $1 million to just over $11,000 in the opposition camp.
There hasn’t been any formal polling done on the measure.
THE SCENE OF THE CRIME: WHERE AND HOW HEALTHCARE FRAUD HAPPENS
https://www.healthleadersmedia.com/strategy/scene-crime-where-and-how-healthcare-fraud-happens
What does cyber fraud look like for a hospital or a healthcare group? Where does it happen, and how can organizations protect themselves? As you assess the security of your organization, here are top trends, emerging threats and things to consider.
1. Don’t forget the basics
As complicated as cyber fraud may seem, don’t forget the basics. The scariest headlines for healthcare executives are about fraudsters using ransomware to shut down a system, as happened to the UK’s National Health Service in 2017. But a breach doesn’t require sophistication. “A lot of cyber fraud continues to be perpetrated via good old-fashioned phishing techniques,” says Charles Alston, Market Executive at Bank of America Merrill Lynch. “Fraudsters send an email that gets them into an organization. Then employees, oftentimes even though thoroughly trained, can make an error in judgment by clicking on a link or responding to a fraudulent email. That one action ends up pulling a thread that creates a system wide problem.”
2. Watch for wire fraud
In addition to straightforward check and ACH fraud, “Healthcare is just as susceptible as any other business to wirefraud,” Alston says. In a wirefraud, the fraudster sends an email to a treasury employee that appears to be from a top-level executive in the organization; often it will be sophisticated enough to mimic the executive’s writing style, or arrive when the exec is at a conference or on vacation, and hard to reach. The message asks the recipient to wire funds to an account—again, presenting it as an emergency or time-sensitive situation. The recipient is reluctant to turn down the request, since it’s coming from management. “People ask, ‘Why would a controller or treasury employee respond to an email like that?’” Alston says. “Well, it appears legitimate, and it’s a rare event; no one has likely seen something like that before.
And once that transfer is executed, the money is gone, because employees hadn’t been trained, or regularly reminded about such types of fraud, and there wasn’t a process in place to handle such situations. These are the situations that training can help avoid.”
3. Monitor for ransomware
Criminals’ use of ransomware is a threat that organizations should consider carefully, and will handle best if well prepared. One of the most effective preparation tools is a tabletop exercise that can walk the organization through a simulated ransomware event.
Doing a simulation can help answer the key questions: Would we be able to identify a situation and stop it? Would we be able to trace where it came from? Do we have all the right disciplines at the table? What kind of communications do we need to let people know what’s happening? Can we get the system back up? Many executives may be tempted to invest in cryptocurrency like Bitcoin, so they’re able to quickly pay in the event of a ransom demand, but should carefully consider whether paying a ransom is the best solution. Lynn Wiatrowski, National Treasury Executive at Bank of America Merrill Lynch suggests that healthcare providers, who often train for emergency medical events and natural disasters, can apply those learnings to handle a cyber fraud event.
4. Tighten provider-insurer connections
The connections between healthcare providers and insurance companies can create cracks where cyber fraud can flourish. “The structure of health insurance involves a lot of transactions and a slow process, a complicated architecture. And there is a lot of money fueling the system,” says Roger Boucher, Market Executive at Bank of America Merrill Lynch. “The process of reimbursement creates a back and forth interaction that the patient never sees; it can be weeks or months of submission, denial, resubmission, correction, denial (again), before the bills are processed. That lag creates a vulnerability. With so much data traveling back and forth, and such delays in payment, crooks find a way to insert themselves in the gap.” He says healthcare providers need to assess, and continually re-assess, the reimbursement process to double check that insurance companies are sending payments to the correct entity
5. Protect patient data
Patient data needs to be protected in as many ways as possible. Not only do healthcare providers need to be cognizant of patient privacy and HIPAA rules, they need to continually remind themselves that patient data is currency for criminals. As patient records are migrated from paper to digital forms, organizations need to be vigilant in keeping track of older records and how they are handled, stored or disposed of. Policies need to be in place to ensure safety, for instance, when employees handle patient data while working at home. Similarly, to keep records safe and up to date, providers need to regularly back up the data contained in their computer systems. Organizations will complain that backing up the database for the entire system is too time-consuming, or creates too much downtime. A solution is to break the data into smaller pieces, backing up a department or a piece at a time.
6. Keep tabs on third-parties
Whether it’s insurance companies, labs, doctors’ offices or other partners, an organization is only as protected as the third parties it works with and shares its computer connections and its data with. “A healthcare organization should be asking, ‘Where is all my data going, and who is keeping an eye on it?” Boucher says.
A strong vendor management program should include regularly checking the data protection policies and cybersecurity procedures of vendors, third-party services and strategic partners to make sure everyone is on the same page. “When contracts are reviewed, there should be an opportunity to build on a security element as well as outline liability of loss, if those items do not already exist,” Alston says.
7. Secure new equipment
The industry has been buzzing about how new products in the internet of things and medical devices are offering new entry points into a healthcare system. “When a hospital is introducing the newest, most sophisticated piece of medical equipment, thoughts are on the difference this new technology will make in patients’ lives, rather than considering that the new technology may also be introducing a cyberthreat,” Wiatrowski says. “It is not second nature to think about who is on the other end of those pieces of equipment, and what entry points may be introduced.”
8. Stay alert for new threats
Finally, remember that the threat environment will continue to evolve. Stay updated on the newest forms of cyberattacks by reading trade publications, attending conferences and webinars to share information with your peers, and comparing notes with your own strategic partners about what they are seeing. Says Alston, “There is a lot more ground to protect if you are in a healthcare organization, and a lot more opportunity for fraud to occur. And it’s hard to stop something if you have never seen it before. That’s why ongoing education and training are so important.”
It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.
It’s Hard for Doctors to Unlearn Things. That’s Costly for All of Us.
We know it can be hard to persuade physicians to do some things that have proven benefits, such as monitor blood pressure or keep patients on anticoagulants. But it might be even harder to get them to stop doing things.
In May, a systematic review in JAMA Pediatrics looked at the medical literature related to overuse in pediatric care published in 2016. The articles were ranked by the quality of methods; the magnitude of potential harm to patients from overuse; and the potential number of children that might be harmed.
In 2016 alone, studies were published that showed that we still recommend that children consume commercial rehydration drinks (like Pedialyte), which cost more, when their drink of choice would do. We give antidepressants to children too often. We induce deliveries too early, instead of waiting for labor to kick in naturally, which is associated with developmental issues in children born that way. We get X-rays of ankles looking for injuries we almost never find. And although there’s almost no evidence that hydrolyzed formulas do anything to prevent allergic or autoimmune disease, they’re still recommended in many guidelines.
Those researchers had reviewed the literature on overuse in children before, looking at all the studies from a year earlier. They modeled the work on a set of papers in JAMA Internal Medicine that looked at overuse in adults through a review of the literature published in 2015, 2014 and 2013.
Overuse is rampant. And it can harm patients.
By the end of the 20th century, for example, research seemed to indicate that we wanted to keep patients in the intensive care unit in a tight range of blood glucose levels. The evidence base for these recommendations came from observational studies that showed that patients with such tight control seemed less likely to develop adverse outcomes like infections or hyperglycemia, and they seemed more likely to survive.
Researchers tested this recommendation prospectively in a randomized controlled trial in a surgical intensive care unit. The results, published in 2001, appeared to confirm the prior findings, that tight glycemic control saved lives.
The study wasn’t perfect. It wasn’t blinded, for instance, and there were downsides to the recommendations. About 5 percent of those who received the intensive therapy had severe hypoglycemia at least once. The mortality in the control group was higher than what might be expected. Finally, this was a study of mostly post-cardiac surgery patients, and it wasn’t clear how widely the findings could be generalized.
Nevertheless, this was a huge benefit, and given the severity of the population being treated (intensive care patients are usually very, very ill), many experts called for changes in treatment while further research was done.
That larger work was published in 2009. The study randomly assigned more than 6,000 patients admitted to an intensive care unit for more than three days — to either tight or traditional glucose control. This time, there was a significantly higher rate of death in the tight control group (27.5 percent vs. 24.9 percent), as well as a much higher rate of severe hypoglycemia (6.8 percent vs. 0.5 percent). These findings applied to patients over all and to subgroups (like surgical versus medical patients).
In light of this, guidelines changed again. Physicians were asked to stop the widespread tight glycemic control.
In 2015, some enterprising researchers set out to look at how this knowledge changed physician behavior. Beginning in 2001, they looked at how physicians adopted the recommendations to use tight glycemic control in patients admitted to intensive care units. Starting in 2009, they looked at how physicians absorbed new information telling them to stop.
From 2001 through 2012, they analyzed data on more than 377,000 admissions to 113 intensive care units in 56 hospitals. Before the first trial was published, in 2001, 17 percent of admissions used tight glycemic control. Beginning in that year, however, there was a slow but steady increase in its use. About 1.7 percent more patients were being treated with recommended practice each quarter.
It’s hard to change behavior, but over time, physicians did. By 2009, the use of tight glycemic control had increased to about 23 percent. Many might have hoped for more, but at least there was progress.
Starting in 2009, however, the reverse was recommended. Doctors were asked to stop. Tight glycemic control was associated not only with higher mortality, but also with more adverse events.
That didn’t happen. From 2009 through 2012, there was no decrease in tight glycemic control. The authors argued that “there is an urgent need to understand and promote the de-adoption of ineffective clinical practices.”
That is, of course, an understatement.
Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, is entirely focused on the identification of care that physicians routinely recommend but shouldn’t. Almost 600 different tests, procedures or treatments, collected over the last six years, are currently listed on their website. Almost all the recommendations basically say “don’t do” them.
This overuse doesn’t provide a benefit. It can lead to harms. It can also cost a lot of money.
The public shares some culpability. Americans often seem to prefer more care than less. But a lot of it still comes from physicians, and from our inability to stop when the evidence tells us to. Professional organizations and others that issue such guidelines also seem better at telling physicians about new practices than about abandoning old ones.
I asked Daniel Niven, the lead author of the 2015 study, why it’s so hard to persuade doctors to discontinue certain practices. He said physicians have a hard time unlearning what they have learned, even when there’s newer and better science available. He said, “Even if the new contradictory science is accepted, providers often struggle applying this information in their daily clinical practice, not because they don’t want to, but rather, because they work within a system that doesn’t adapt well to changing evidence.”
He also said doctors might need to be more thoughtful about prevention: “We need to take a more cautious approach to technology adoption, and learn from mistakes of early adoption of health care technologies based on little or low-quality clinical evidence. This way we can prevent the need to ‘break up’ with the practice when the high-quality evidence shows that it is ineffective.”
Overuse represents a significant problem. As policymakers look for ways to save money without harming quality in the health care system, reducing overuse seems as if it should be a top option.
Cartoon – What I Lack in Experience
Cartoon – Content vs. Thought Leadership
Cartoon – Suddenly It’s My Fault for Caring About the Budget
Cartoon – A Leap of Faith
HENRY KOTULA 