Trust? What’s That? A Nurses Dilemma 9:48 AM

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I have been pouring over a lot of healthcare statistics lately, among them the costs of maintaining a hospital and what can be saved from their budgets. Of many of the topics I looked at are paperless script systems, EHR/HIT systems, bar-coding systems, and how insurance claims are allocated. Another topic I have gone over is the cost in medical errors, specifically medication errors. Nurses this time are most often charged with medication errors when they occur because they are most visible when they reach the patient. This then brought me to find ways to reduce those errors. On a rabbit track I headed off into the culture they have with there hospitals and their administration. I found that their is a reluctance to report errors because of a lack of support. If Nurses do not report self made errors whether it was systemic or not there is no real way to re-design a hospitals infrastructure to lower those error rates and save more lives and cut the costs of such disasters. I call this a social contract between nurses and their healthcare organizations. Social contracts have rules just like written contracts, although not quite apparent.

When a nurse enters into a contract to work in a healthcare agency such as a hospital, more often than not, what he or she assumed would be the working environment there does not exist. For a Nurse in such situations there must be emotional shock occurs because in many instances the employment conditions they have to work within are poor, just ask a nurse who has gone off shift. Hospital staff is continually under stress, having to deal with overcrowding of their ERs, having to use poorly designed outdated EHR/HIT systems, must bear with continual budget cuts, and they have to deal with lack of autonomy when deciding decisions about their own guilt or innocence- more often than non, the legal system does this for them. Hospitals have merged, closed and cut back on staffing when required. Many hospitals, especially inner-city facilities are lacking the necessary infrastructure repairs in order to keep up with federal and state regulations. Nurses are the largest workforce in a hospital and so bear the brunt of the labor that must be accomplished each day in a hospital. When a nurse is hired, they come to realize only after they are employed that the contract they step into when they began work has failed them. So after a while, I began to think of various ways to categorize hospital culture or even organization culture because I thought this might help pinpoint what needs to be altered. You cannot fix what you cannot understand. I thought there must be a type of ethics involved, it is healthcare right?

Deontology, Utilitarianism, Prudent Pragmatism, Feminism, Rawlins social justice theory, oh how-about-Hobbes social contract?

Well, Hobbes social contract offers other motives for not reporting a sharp error or an error made by oneself then that of contract failure as other papers view it, which would be as a legal breach and not as a social one- okay

Since Hobbes social contract aligns with both the organizational structure of a hospital and the act of system information modeling, how then does Hobbes ethical theory help with error reporting? Hobbes social contract identifies what key areas trust must be established and indicates the motives as of why medication error reporting has been so lax. It shows through theory not in a legal sense but in a societal form, we agree to be civil and follow law not because we are legally bound, but because we legally bind ourselves in order to escape social chaos. We can’t just go around doing anything we want right? We would trash the world and what good would doing what we want then be? We would live in a garbage dump and have short lives. So we make contracts with each other as societies that give us enough freedom but enough law so that we can do lots of things we want but not everything we want.

In health care constituents need to define what is considered a violation of their social contract, what needs to be changed for a decline in medication errors and for there to be an increase in reporting errors to occur. Unfortunately, nurses must agree to the current set of social rules that exist in their places of work because there is no other alternative at this time, unless they disenfranchise themselves from the healthcare system.

In addition, Hobbes points to the emotional more value centered person and how his or her values and their rational mind can be over-ridden, replaced by the need for personal preservation. Hobbes social contract points out what rules must be established in a hospital setting, its clinical guidelines and how teamwork should be socially defined. Hobbes social contract points out what is required to maintain the social contract between the enforcement side and the acceptance side. Hobbes social contract also dictates when social contracts become unattainable and can be broken such as in your own self-preservation. Hobbes social contract defines a just culture of trust and fairness that can be extended into information system modeling, error reporting and into health care organizations themselves.

Okay: Here is the laundry list then:

The board of directors must uphold the social contract for which clinicians have entered into, namely to be employed in a safe and adequately staffed facility. The board must provide adequate resources in order for the hospital in order for it to function at safe and efficient levels. Within health care organizations the board of directors must place patient safety above all other goals. They must keep the CEO on target with the reductions of malpractice incidents always in focus.The CEO must guarantee or attempt to limit short-term gains for the long-term stability of her hospital. The CEO/CFO should attempt to balance hospital finances, limit ER overcrowding, limit the potential for their hospital to close and limit their hospital’s number of mergers unless they are critical to the continued function or efficiency of their hospital. Vice presidents should be visible and approachable by staff, as social contract theory demands such, that representatives who have appointed power over others be available so the social contract cannot be manipulated from above or below that level in the social contract. Vice presidents should provide an atmosphere that medication safety is everyone’s responsibility to the staff supervisor and that safety is a core value throughout the chain of command. Clinical supervisors on a continual basis should inform nurses and doctors that safety decisions are made at all levels, not just at the staff level. Supervisors should instill a value system of family-centeredness and one of empathy not fear. Finally, staff should accept a “just-cause culture” and not a system of blame. However, nurses or other clinicians can only expect just-treatment when reporting errors, if they believe they will get just treatment from reporting it and they will only believe it themselves when they see just-treatment exercised over time.

This “just-culture” will only exist if enforced organization wide. Hobbes social contract highlights the fact that the lack of error reporting is a personal decision based on morality and this morality is contract based. This contract-based morality extends not only to the staff of the hospital but to its administrators and those who develop EHR systems for them to utilize. Staff enter into contracts by agreeing to work in health care agencies and that these contracts are failing them, both written and socially unwritten ones. So if these contracts are failing them after-the-fact and errors are being produced whether by nurses or by the systems they work for, why would they report them if given a chance not to? It is not to lie but to defend oneself against a broken in hospital healthcare organizational contract that forces much burdens upon them yet little freedom to express why there errors are occurring or even if it was their fault- it could have been the poorly written script, a technician error, a bed change, improper dispensary filling, or other such behind the senses mistake. Once fair and just treatment is occurring often enough, in enough hospitals nation-wide, then error reports will increase, infrastructure will be adjusted to lower the number or errors system-wide and costs per hospital will decline for those errors, lives will be saved and we will save money too.

A social contract is as every bit as binding as a legal one, in this authors opinion.

The Elements of Moral Philosophy by James Rachels

AACN Position Statement

Healthcare At the Crossroads

Medical Errors: The Scope of the problem

Sentinal Events

Debt for Cash-The Grinch Returns! 11:09 PM

We have made it through another rough year folks, now the season turns cold with a little snow on the horizon. This Christmas we can be thankful for all we have, our families, our wives and husbands, our children, our health and freedom- but I think we can be a little Grinchy about the costs we have paid in cash, jobs and homes for the spending of a few well placed influential's. This holiday season, we should reflect on our losses and how to prevent them in the future, our kids will thank us if we set them upon the rock instead of on the sand.

The past is no predictor of the future- but since we must live through the future and the past has already been done, we need to look back, we should not make the same mistakes twice, or three times. It is uncomfortable but once we do it we can move on to create the world we all wish to live in and pass on to our grand-kids.

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We have hear various figures on this one most often 11 trillion dollars, but we have to factor in all our public held debt, contractual requirements, Social Security and Medicare. This total figure of what needs to be paid sooner or later is about 56.4 trillion. Sound like a lot- it is. For a further explanation just click on this link from the Peter G. Peterson Foundation

If you feel your more of the traditional type regarding our national debt numbers you can head over to our National Debt Clock which as I type is now at 12.06 trillion- of course it rises so fast that by the time I finish this sentence its gone up a few million dollars. The clock is flash based so you can see the numbers jump in real time. A few interesting points about the clock is our debt held by foreign countries which is at 3 trillion and each persons held liabilities which is about 345 thousand- our estimated personal assets are only 242 thousand. Yes- there is the trade deficit too .

Of course we as individuals have much to blame on ourselves, in 2007 we actually out spent the amount of our gross domestic product, all funded by credit- we know how that story ended. The chart below was excerpted from NPRs Planet Money

Figure © 2009 NPR-

NPR does not promotes or endorse any third party's causes, ideas, web sites, products or services.

In terms of where we rank with the debt each person holds we are ranked 14th on a complied list of 188 above Australia and below Finland, the UK ranks 3rd with debt per capita held. For the complete chart click here- NationMaster.com

Today a bachelors degree does not command as much income anymore, the odds of a person who has a bachelors makes is in 25 to 35 are making less than the poverty level are 1 in almost 24- this according to the Book of Odds

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The world has much so much poverty we need to take a look at how this is related to health and life expectancy. This chart was created from the World Bank. Pay particular attention to the blue spheres, those countries have the poorest population with the shortest live expectancy. Poverty is related to life expectancy worldwide including at home in America- more on that in another blog article.

Figure © 2009 World Bank Group -

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You buy a cup of coffee and a bagel before you go to work do you ever think about how much that costs, maybe 2.00 to 3.00 dollars? What can you do with 3 bucks? According to the World Bank and included in an article at the site Globalissues.org half the world lives on 2.50 dollars a day. Consider this as well: We spend more on cosmetics in the US that the world does on achieving basic education its poorest, 8 billion US dollars on cosmetics vs. 6 billion for basic education in developing nations- also taken from Globalissues.org

According to the Food and Agriculture Organization of the United Nations, currently there are more than 1 billion people in the world who are hungry every day.

Figure © FAO, 2009- Hyperlinks to non- FAO Internet sites does not imply any official endorsement of or responsibility for the opinions, ideas, data or products presented at these locations.

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Current bank right-down estimates for 2007 through 2010 as a result from our so called toxic assets (remember we live in these toxic asset houses and raise families but…) in an article by Reuters is estimated to be 1 trillion for the US and 1.6 trillion for the EU .

According to CNN’s Money and Main Street we lost approximately 1.3 trillion worth of wealth right from our pockets due to the depress- I mean recession.

According to Bread.org 16,000 children each day in the world die from hunger related illnesses. That sobering statistic also from Bread.org originates from a journal article written for the theLancet.com

In an article by Unicef there are more than 140 million children from the ages of 6 to 11 in the world that do not go to school and school of course is one way to escape poverty. It would take 6 billion a year to put keep these children in school which according to Unicef in 1997 is less than 1% of the money the world spends on weapons.

In another Unicef report over 2 million children die each year due to poor water quality and lack of sanitation. For that article click here as well.

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Average level of debt a US student graduates college with 21,000 dollars- taken from moneycentral from msn.

Average level of medical debt for those who filed for bankruptcy is 12,000 dollars- taken from fixourhealthcare.ca.gov

Average level of consumer credit card debt 5,612 dollars, but that is down some from last quarter- taken from prnewswire.com

So how did the world get this way- we over spent on everything, priorities and non-priorities. In a world of limited resources we (the world) not just America, borrowed from the wealthy, billions of people owe trillions to millions. Those who lent money and resources also borrowed to lend more than they could otherwise from those with still more resources. At some point the cycle becomes unmanageable, which is what we are beginning to see. What is different about today’s recession that did not occur during the great depression, many more people in the world and a greater ability to do more harm to them or more good for them. How do we reduce this debt? Simple, we learn live within our means, with moderation and return to the values of sharing.

Remember during this holiday season it is always easier to share than to have it taken out as taxes.

What about the few who hold all this debt: Careful of those who rule in high places, the last thing we should do is spend our way out of this recession- look at the messengers, isn’t that how we put the chains on in the first place?

Squeezing Money from a Health Care Stone 10:21 PM

Ambitious global attempts have been undertaken to analyze many countries' healthcare systems to document what has facilitated positive change and what has not. Everyone then armed with the data sit and pour over the stacks of paper to figure out how to better our healthcare system and suggest policy. Once it gets to the sub-committee though it dies a slow death to be transformed into some would say pork or other type of species the public would rather not look at.

One such an attempt to dig into the world health care systems is the World Health Report of 2000 which used weights to create an index of quality care. Using a composite of the twelve most industrialized nations they tabulated results and ranked them. Based on how well their health system works Greece ranked 14 with universal access and national healthcare services, the United States ranked 37 with variable access and supplemental insurance and Brazil ranked 125th with universal rights but contracted and national services. The US had a rank of 7th out of 12 that encompass a national system of healthcare, but those of higher ranking invariably provide universal healthcare while the US does not.

Statistical infant mortalities also have been used as a measure of healthcare effectiveness in a country as well. Infant mortalities in studies have been measured comparatively while in other studies within countries. In Australia, it was found that the lowest two classes set above the bottom class had 23% of the total infant deaths. These were the semi-skilled and skilled working class, and not the poorest unskilled. If you think about it his has implications for the US because these classes of people, who are also within the United States, are unlikely to be poor enough for US social insurance policies but not rich enough to afford healthcare. By implication if we have a very high infant mortality and 45 million are uninsured then infant mortality is a very good indicator of those who were poorer and uninsured, but employed with an income great enough to not be eligible for state run insurance.

In other words if similarities exist among certain countries and situations with their people then you can be certain that the statistics do not lie. You cannot fight statistics, except through misinformation and fear of change.

Unfortunately, the US links together voluntary insurance with private employer insurance and social insurance to provide healthcare coverage with the largest social insurance coverage administered through Medicare and Medicaid for a total of 17.3% of the US healthcare expenditures in 2000. Each country that has mixed coverage healthcare benefits have one common detriment in that all have issues ensuring quality on all the levels the mixture provides and in cost effective means, hence the current debate on universal healthcare and cost.

Everyone wishes for high quality healthcare but measuring the quality of care and improving it can be difficult to quantify. Continuous quality improvement, total quality improvement and the ever present process re-design are just a few of the many methods available to a healthcare systems management. But how can hospitals and other large clinical facilities find the money necessary to re-design ageing buildings, and retrofit older EHR/HIT systems, or throw them out and upgrade complexly? If we rank 37th in how our health system provides for its citizens but we spend the most per capita on health care where is all this money going? Hospitals are not receiving this money, their rates from Medicare, Medicaid and HMO insurance have been cut progressively over the years. In a few words: Follow the bread crumb trail of current health insurance commercials back to the source. While watching the news count how many health advocacy commercials and the words they use are for or against universal healthcare, note words such as experimental and government run are used.

A partial explanation of how costs are incurred by a hospital and how they are locked into a poor revenue stream is noted below:

In any organization, some aspects of the entity will drive costs and other parts will drive revenue. In a healthcare organization, cost centers generally do not have contact with clients and therefore are likely to induce costs without providing the corporate entity with income, that is the hospital. Most hospital expenses are fixed until a set point when new staff, equipment or even facilities are needed which creates a credible reason for strategic planning. Hospitals are constantly planning, why? They have very ridged streams of income but it is predictable so planning for new equipment, more staff or technology updates can be estimated for and monies can be allocated over time. There is little in the way of providing profitability to the organization except for fee services and perhaps donations. But, donations are down and fee for service has just about vanished into a relic.

A few ways hospitals are getting by with less is the electronic storage of documents and data; paper charts have to be stored while electronic charts can be expanded indefinitely and shared among facilities within the system. Electronic data has the capacity to be readily available and the details of the raw information can be adjusted for the specific treatment of each patient and return patients. One such very successful system was implemented by the U.S Military, AHLA which services 9 million patients through TRICARE.

Sadly, sometimes an economic loss cannot be contained with technology, restructuring or otherwise and divestment or a selling off of unprofitable components of the organization can occur.

1 stone = 6.35029318 kilograms

With efficient patient scheduling for appointments cost savings can result as well. There are many methods to schedule appointments, some being: standard, wave, resource-based, and open access scheduling. To facilitate payment to the physician or physician group, or reimbursement for services from insurer, CPT coding is used as well as statistical implications for payment on the insurer side such as usual, customary, and reasonable payment schedules, dictated by the data the insurer obtains over time in a geographical area. So this is being creative, squeezing money from the stone. So who are the people and organizations not being creative?

In 2000 we spent 4,499 dollars per person on health care but in 2001 as quoted from the book Health Care Administration: Planning, Implementing and Managing Organized Delivery Systems: 4th ed by Lawrence F. Wolper, 48 million Americans were without health insurance. In 2000 Medicaid accounted for 15.6 percent of all health care costs, while Medicare accounted for 17.3 percent of all health care costs for that year. In the year 2000 out of pocket health expenses comprised a total of 15.3 percent of total health care expenditures for that year. Ask yourself, “Where all the other health care expenditures came from, how were they paid and by what organizations?” and “Why were so many people uninsured then and are now?”

Why are hospitals doing without, our infant mortality so high. In 2004 our infant mortality rate slipped again to 23rd in the world. Why do we spend 10 to 20 percent of our personal income on our health care bills-the out of pocket costs and premiums? It should be noted that these costs are not associated with Medicare and Medicaid, they are from employer HMO sponsored plans. Why are 100 hospitals cutting more than 50 doctors and staff at a time when we spend so much? Hospitals are hurting, we are hurting, who or what organizations are not? What organizations have had enough cash to provide lots of health care commercials during your news hour? Again a link brought up on an early post that shows how hospitals are hurting in this recession. See the bottom link on going lean for other ways hospitals are getting creative or rather money from the stone: AMA Hospital Crisis

Hospitals Going Lean

Health Reform

APHA Infant Mortality