Author: Truthsabout Healthcare

Clinical Quality, the #4 priority in health care.

If you refer to the front page of this website, you’ll see that I am placing Clinical Quality #4 on the list. This is referring to the quality of the care that is being delivered to you, the patient. In a series of upcoming posts, you will see why this is #4.

The Institute of Medicine (IOM) defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

My definition is simpler: The right thing happens at the right time, in the right place and without defects.

Do you notice how relatively ambiguous the IOM definition is? Sort of sounds like political gobbledy-gook, doesn’t it? Yup, that’s how the medical community and industry talk about quality.

Before delving into the details, it’s helpful to know some of the history.

Before 1965, there were no organized quality programs in medicine anywhere. Nope, not even in hospitals. The quality of care was dependent on the culture of a health care entity, like The Mayo Clinic. At the same time, no one was measuring anything, so, clinical quality was mainly based on anecdotes (“ my local doctors weren’t making me better so I went to The Mayo Clinic and I’m better now”).

So, let’s go way back.

There were some historical events that improved clinical quality which were based on one really smart clinician figuring something out and aggressively championing an improvement. It wasn’t generally a group activity or promoted by “the administration” or the “medical community”. Here are two examples:

In 1850, Ignaz Semmelweis noticed that post partum women cared for by obstetricians were dying of infections. He noticed that the incidence of these infections was a lot lower in the wards attended by midwives. The difference he noted was, the doctors were tending to other ill patients and doing autopsies, and the midwives only delivered babies. The physicians would come to the labor and delivery rooms or the post-partum wards immediately after working on the ill or dead patients without washing their hands. He theorized that there was something on their hands that was spreading the infections. He didn’t know what that was. (Louis Pasteur figured that out later.) Semmelwies tested his theory by having physicians wash their hands with a chlorinated lime solution. The infection rate plummeted dramatically.

Here’s a sentence you’ll see again…His ideas were rejected by the medical community.

Florence Nightingale noticed that soldiers did worse in facilities where the conditions were poor and unsanitary. She championed making things as clean as possible, improving hygiene and improving working conditions for caregivers. The death rates plummeted. She also created and promoted standards of care for nurses. Interestingly, she was criticized.

Semmelweis and Nightingale were what some people call “heroic” leaders. They worked tirelessly to maintain the improvements they believed were critical to good patient care despite resistance from the medical community. A lot of what Nightingale proposed became ingrained in nursing. Interestingly, except for surgery and OB, Semmelweis’ hand washing went by the wayside. Doctors and nurses and other staff went from room to room without washing hands. I was never trained to wash hands in between patients unless you touched something obviously contaminated or infected. No one wore gloves unless you were doing a sterile procedure. It wasn’t until 1995 that the CDC officially proposed that clinical staff wash hands before entering and upon leaving hospital rooms and outpatient exam rooms. To this day, getting everyone to consistently wash his/her hands is an issue, despite a national call to action about it. Yes, centuries after Semmelweis figured that out, medical staff still don’t consistently wash their hands.

These notable heroic leaders pretty much promoted or dictated tasks. Wash your hands, sanitize hospital wards, etc. They didn’t really look at the process of care longitudinally. It was more insert a task or change a task. The task-oriented culture is the Achilles heel of the medical industry. We’ll get to that later.

Anyway, with heroic leaders, when they leave, things mostly fall apart unless someone equally passionate about the subject stays behind to sustain it. What is really needed is a “non-heroic” leader.

Ever heard the sentence, “Give a man a fish and he will eat for the day, teach him how to fish and he will never be hungry”? How about “some people tell time and some people are clock builders”?

A non-heroic leader teaches people to fish, and they build clocks so when they leave, people won’t go hungry and they have a way to tell time.

The first real non-heroic-type leader in medicine was Ernest Codman. He was the first to propose measuring things and setting up systems to mitigate errors. This is different than promoting tasks. Codman was a Harvard trained surgeon who was one of the founding fathers the Society of Surgeons, a precursor to the American College of Surgeons. He was practicing successfully at Massachusetts General Hospital when he came up with the idea of what he called “The End Result”. In Codman’s words, The End Result was, “The common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ with a view to preventing similar failures in the future”. This was the first known suggestion that the process of taking care of people should be examined and improved. Codman started keeping ledgers of all of the surgeries performed at Mass General. The other surgeons didn’t like this. The idea was met with a lot of resistance. He was actually hated by other doctors. Codman presented his End Result idea at a Surgeon’s Society meeting where he portrayed surgeons as greedy surgeons grasping for wealthy people’s money. (See, even back then, it seems, it was all about the money). The medical community at Mass General went ballistic. He was asked to resign and was ostracized. Some stories about his leaving Mass General say the other doctors burned his surgery ledgers. Codman opened his own hospital and applied his End Result idea. He wrote books about it including case reports. But, the medical community of the time never adopted his approach. He also was a champion of hospital efficiency, and actually wrote a book about that. But for a long, long time, his ideas were rejected by the medical community.

As a matter of fact, the exact opposite of what Codman championed occurred. Medicine became veiled in secrecy and no one wanted to talk about anything that didn’t go well. Unless a doctor did something so egregious that it was criminal or near criminal, doctors were pretty much left alone. Believe it or not, there is still a large component of this going on today. People only knew about medical “misadventures” when someone filed a medical malpractice lawsuit. State Medical Boards were pretty impotent, acting more like the “good old boy” system. I commonly heard, “We can’t really do something about this because this could have been me.”

It wasn’t until 1965 that some sort of organized quality program began, and only in hospitals. And it was only because of when the Medicare and Medicaid laws were passed. The laws called for certain standards to be met to ensure beneficiaries were getting appropriate care. Medicare called this Conditions of Participation. It was mostly utilization review, not quality improvement. There weren’t a lot of prescribed details. There weren’t any significant improvements. So Medicare mandated quality programs and started PSRO’s (these were committees of physicians and largely failed to make any impact) and QIO’s (these exist today). In the beginning, the hospitals, searching for something structured on which to base quality programs, chose the malpractice insurance companies’ risk triggers, like, unexpected transfer to an ICU, unexpected death, return to the ER within 2 weeks of discharge, etc. So, the hospitals essentially built their quality programs on events, and did reviews of cases that met the trigger events. This was the bulk of what quality programs did, case reviews. The result was a headhunting culture. The reviews look for who did the wrong thing or the things that resulted in the trigger event occurring. It was a culture of fear, so, clinicians and staff were always trying to hide their involvement in these events. People would be fired, embarrassed, admonished, etc.

What was really needed was an analysis of the processes of care within a culture that didn’t start with finger-pointing.

It wasn’t until about 1990 that people started to realize that 1. Human beings are error prone and 2. Processes can promote or mitigate errors.

This was due to two things, 1. A book called Human Error by James Reason and 2. The emergence of an awareness in the medical community of Statistical Process Control (SPC is based on the premise that 80% of defects and inefficiencies are due to the process, only 20% is due to individuals’ actions).

The event that seemed to spur more interest in the above was the beginning of the Patient Safety Movement, which occurred in 1998. Really, it wasn’t until 1998 that the medical community thought you ought to be kept safe from harm from medical “institutions”! As a matter of fact, before WW II hospitals were referred to “pest houses” because you were more likely to die in the hospital from something that happened in the hospital than the disease you had if you had stayed home!

Here’s a real story about this.

It was 1998. (two years before the IOM’s treatise: To Err is Human) I was the Chief Medical Officer (CMO) of a medium-size regional Managed Care Organization/Health Maintenance Organization (MCO/HMO). (I’ll use MCO from now on for these insurance companies) Once a year, just about all of the MCO’s in the country descended on Washington, DC for a large weeklong conference. There were tracks for different “positions” in MCO’s. There was a CMO track, a CEO track, a CFO track, an Employer CEO track, etc. Near the end of the week, there was a combined MCO CMO-Employer CEO 2 hour session. There had never been a track session like that before.

We were ushered into a large conference room with just about equal parts Health Plan CMO’s and Employer CEO’s. It seemed an odd combination for us CMO’s. We were wondering why it wasn’t MCO CEO and Employer CEO.

There was a long low stage set up with about 8 “panelists” sitting at a long table. The moderator said the subject of the session was Patient Safety. None of us really knew what that meant, having never heard that term before. I’m sure the Employer CEOs were thinking the same.

The moderator said the first thing they were going to do is play a video for us.

The video was about a ~11 year old boy. It was December; Christmas was approaching. The child had a “growth” on his ear that the surgeon had recommended to be removed. It was a procedure to be done under local in a same day surgery suite at the hospital. The parents were waiting in the waiting room. Suddenly the surgeon came out and told the parents that the surgery went wrong, there was a complication and the child did not survive the event. The Quality Nurse conducted an investigation and determined that the local anesthetic that was used had 10 times the amount of epinephrine than it should have, and that the anesthesiologist had given the operating surgeon the wrong bottle.

The video was stopped and four individuals gave accounts of the events including how they felt about what happened: The mother, the surgeon, the anesthesiologist and the Quality Nurse. It was extremely emotional, the mother obviously still grieving, the surgeon and anesthesiologist guilt ridden, the Quality Nurse compassionate.

The bottom line reached by the panelists was, the process, or lack of it, was the cause of this boy’s death. The participants in the process were well-trained and doing what they thought was right. The moderator went through statistics from studies from 1990-1995 about harms and deaths from “medical adverse events”. The moderator then opened the dialogue to those of us in the audience. Of course, we were all stunned.

The first utterance was from an Employer CEO. His exact words were, “What are you health plan CMO’s doing all day long that you are allowing something like this to happen?”

Well, we thought, they actually had the wrong CMO’s in the room. They should have had the Health Care Delivery Systems’ CMO’s. How would we know what was going on day to day in hospitals? The Employer CEO’s said we should be holding the Health Care Delivery Systems accountable, sort of like the Patient Safety Police.

The start of the Patient Safety Movement was really a watershed event in medical quality. Although there were some (vast minority) health care systems that had started to adopt and train their staff in SPC (using The Improvement Model or FOCUS-PDCA), there was little evidence that anyone could do it well except for one or two institutions, like Intermountain Healthcare in Salt Lake City.

I recall being at a management meeting of a health care system that had hospitals, a medical group and a health plan in 1999 where I presented this emerging Patient Safety Movement. I was sitting next to the Chief Operating Officer of the hospitals. After some inquiry dialogue by the group, the COO said (exact words), “Well, we don’t have to do anything about this right away since this stuff has been going on for years.” Really? Seriously? See why your quality care is #4?

Sidebar: I actually took a year of the agendas for the highest management team meetings in an integrated health care system. 95% of the time spent by the most senior management team had nothing to do with patient care. It was mostly budgets, growth, HR issues, IT, marketing, etc. When I showed this to them the CEO said, “Well, we have Quality Committees that deal with that, we don’t need to go over that here.” Really? Want to know why Clinical Quality is #4?

Here’s another true story. Remember, I was the CMO of a health plan. I really took this Patient Safety Movement to heart, since, as a physician, this sentence was pounded into our brains, “First, do no harm.” It’s part of the Hippocratic Oath we all took. I started looking at whether a health plan and its processes could create a patient safety event. A case occurred that required a “root cause analysis” that confirmed my suspicion. Here’s a synopsis of that event.

A Medicaid member of our Medicaid Health Plan was admitted to a hospital with a ruptured appendix. She was a minor. She had the surgery and post-op was put on two antibiotics since ruptured appendices can cause an abdominal infection. The patient was discharged on the two antibiotics. One of them was not on the health plan formulary, so it required a “prior-authorization”. Error #1 – The hospital surgeon didn’t know which antibiotics were on the formulary (health plan based error).

The patient was discharged at 3:00 PM on a Friday. Her mother went to the drug store and handed in the prescriptions from the hospital. The Pharmacist told the mother that one of the antibiotics was not on the formulary and her primary care physician (PCP) would have to get an authorization from the health plan or the patient would have to pay out of pocket for the antibiotic, which cost more than $100. Since Medicaid folks can rarely afford $100 for a medicine, the mother left without the antibiotic, requesting the pharmacist notify the PCP. Error #2 – The Pharmacist didn’t access the health plan’s telephonic expedited authorization process. (health plan based and pharmacy based error). Error #3 – The Health Plan didn’t have an emergency Pharmacist driven prior-authorization override policy (health plan based error). The Pharmacist used the routine process to get the authorization…he faxed a request to the PCP office, assuming the PCP would send the authorization form to the health plan, who would then put an edit in the computer system to allow payment for the antibiotic. (Notice, none of the clinical folks talked to each other. This was a totally fax based communication system)

Well, it was about 4:00 before the fax was sent. Now, if you’ve ever been in a “modern” PCP office on Friday afternoon, you’d know that the PCP and staff were focused on getting out on time, which, nowadays is as close to 4:00 as possible. No one in the office checked the Fax stack that day. Error #4 – Inattention of the Office Staff to incoming notices. (PCP office based error) In fact, the office staff didn’t find the fax until Tuesday morning. The PCP sent the authorization request to the health plan at 2:00 PM that day. Error #5 – Delay in processing the authorization at the PCP office. (PCP office based error)

The big problem was, the Medicaid member had been re-admitted to the hospital with an abdominal infection at 9:00 AM Tuesday morning, five hours before the authorization request was sent to the health plan.

The root cause found by the quality staff was: the need for a prior –authorization for a critical medication for a patient being discharged from the hospital. We changed our policy to: anyone with a prescription coming from a hospital (inpatient, ER or Urgent Care) would have that prescription filled regardless of whether it needed a prior-authorization or not. Meanwhile we worked on figuring out how to make sure discharging physicians would be able to know whether a drug was on the formulary or not. Believe it or not, to this day, even with an Electronic Medical Record and a national system like Surescripts, knowing what is on a health plan’s formulary is very problematic.

Here’s the kicker. I wrote up a proposal to start up a health plan based Patient Safety Committee that not only looked at patient safety cases from the delivery systems, but that also looked at and tried to mitigate health plan patient safety events. That had to go to the Board of Directors. They couldn’t understand how a health plan could cause patient safety events. I had to go back to the Board meeting two more times with case reviews like the above to convince them that we should have a Patient Safety Committee and that a health plan could cause patient safety events. As I went to conferences after this and talked about our Patient Safety Committee and that we were looking at cases where the health plan policies and actions caused adverse patient safety events, none of the other health plans would agree to or admit that a health plan could cause patient safety events. To them it was a delivery system problem, and the role of the health plan was to hold them accountable. My ideas were rejected by the medical community. To this day I don’t know of any other health plan that looks at or thinks they have an active hand in causing patient safety events and I’m pretty sure the health plan in the above story has abandoned their committee (I left there 8 years ago).

Anyway, if you noticed, it always takes an outside force to get the medical community to do something. First, Medicare, and then, the Patient Safety Movement in this story. Employers got in the act and created Leapfrog, which rates hospitals on safety, but, it’s voluntary and not all hospitals participate. Leapfrog gives non-participating hospitals a failing grade.

So, you’re getting some idea why Quality is #4. More to come.

The Swiss Cheese Model

In 1990, James Reason proposed a relatively simplistic model for understanding errors and defenses against errors resulting in defects.

Definitions: Errors = something went wrong. Defects = errors have an impact on the customer, in our case, the patient.

So, an error can be a mistake or mishap that is blocked by a “defense mechanism” so that the customer/patient never feels any impact (the defect). If the error in a process is blocked near the customer/patient it is called a “near miss”.

Example: A patient is in a same day surgery center and requires a medication. A nurse hands the doctor a syringe full of the medication. The doctor asks a verifying question about the dose amount. The nurse double checks the medication vial and says, “Oops, the syringe has 10 times the requested dose” and takes back the syringe. This is a blocked error (wrong dose) and a near miss (since the next step in the process would have been injecting the medication into the patient which would have caused a defect).

James Reason’s model assumes that every step in a process has inherent errors and is like a slice of Swiss cheese. The first trick is to have as few holes and the smallest holes in the cheese as possible. As the process steps line up, each step/slice of cheese has holes, but the next trick is to have none of the holes line up, so each step “blocks” the previous step’s “holes” (errors). Problems occur when holes line up in the slices of cheese creating an “error conduit” allowing an error effect to pass through the holes resulting in a defect event impacting the customer/patient. Often this defect event has catastrophic consequences. If you Google “Swiss Cheese Model” you will be able to see Reason’s drawings of the model.

In the example above, the holes might be: There is no training regarding call-back between nurse and doctor (where the doctor says “ten milligrams valium IV”, the nurse says “ten milligrams Valium IV”), maybe the bottle of Valium delivered by the pharmacy is 100mg per cc instead of 10mg per cc, the nurse didn’t read the bottle for concentration amount, etc. You get the point. All of these errors added up to the nurse giving the doctor a syringe with ten times the requested dose. If the doctor just took the syringe and injected it, the patient would have had a respiratory arrest. A catastrophic event.

Well, it turns out, health care processes have a lot of holes in the Swiss cheese and it isn’t uncommon for the holes to line up.

But, you don’t have to take my word for it. Here is an excerpt from a study of Medicare beneficiaries. An “adverse event” is a “defect”.

Department of Health and Human Services

OFFICE OF INSPECTOR GENERAL 

ADVERSE EVENTS IN HOSPITALS:

NATIONAL INCIDENCE AMONG MEDICARE BENEFICIARIES

FINDINGS

“An estimated 13.5 percent of hospitalized Medicare beneficiaries experienced adverse events during their hospital stays. Of the nearly 1 million Medicare beneficiaries discharged from hospitals in October 2008, about 1 in 7 experienced an adverse event that met at least 1 of our criteria (13.5 percent). This rate projects to an estimated 134,000 Medicare beneficiaries experiencing at least 1 adverse event in hospitals during the 1-month study period. We calculated incidence rates for adverse events that met our three criteria: 0.6 percent of beneficiaries had an NQF Serious Reportable Event, 1.0 percent had a Medicare HAC event, and 13.1 percent experienced an adverse event resulting in the four most serious categories of patient harm. An estimated 1.5 percent of Medicare beneficiaries experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.

An additional 13.5 percent of Medicare beneficiaries experienced events during their hospital stays that resulted in temporary harm.

Temporary harm events are those that require intervention but do not cause lasting harm. Although many cases represent fairly minor occurrences, such as hypoglycemia, others were classified as temporary harm only because the patients were in the hospital for lengthy periods as a result of other, more serious, diagnoses, allowing hospitals enough time to address the harm prior to discharge. Additionally, 28 percent of beneficiaries who experienced adverse events also had temporary harm events during the same stay.

Physician reviewers determined that 44 percent of adverse and temporary harm events were clearly or likely preventable.

Physicians determined that 44 percent of all events were preventable and 51 percent were not preventable. (For the remaining 5 percent of events, physicians were unable to make determinations.) Events related to surgery or procedures were less likely to be preventable than other types of events, such as hospital-acquired infections. Preventable events were linked most commonly to medical errors, substandard care, and lack of patient monitoring and assessment. Physician reviewers assessed events as not preventable when they occurred despite proper assessment and care or when the patients were highly susceptible to the events due to health status. Nearly all events on the NQF and Medicare lists were assessed as preventable, a key criterion of both lists.”

One thing is, the VAST majority of studies on medical adverse events is in hospitals, which are relatively controlled environments. Some experts estimate that outpatient adverse events are at least 20 times higher than hospital events, but, up to the date of this post, I don’t know of any well-designed study that quantifies outpatient adverse events. I proposed doing this when I was a Medical Director of a large integrated delivery system (IDS) (Hospitals, Ancillaries, Health Plan and Physician Group) and they wouldn’t fund or allow the activity. We could have done it because we had huge amounts of outpatient data, including non-IDS-physician group providers and pharmacies. We could have made a positive impact with the information. The main problems with getting the activity funded were: 1. Since the prevalence and types of adverse events weren’t known, a financial return on investment (ROI) estimate couldn’t be made (remember, it’s all about the money) and, 2. Fixing things would have meant applying the IDS’s resources to address things outside of the “four walls” of the IDS, i.e., it would cost the IDS money to improve these non-IDS systems. This was tantamount to heresy by the Finance Department, I mean, spend the IDS money on non-IDS providers and processes that would result in better and safer patient care? Yeah, right, that would never happen.

I’m going to get more into preventing errors and defects in future posts. There are ways to do it. Unfortunately, the US health care system doesn’t have the will to implement and maintain the ways to do it. Even Don Berwick is skeptical about the will of the health care industry to improve things. (Berwick, D., Vital Directions and National Will, JAMA, March 21, 2017)

So, here are three personal examples of outpatient errors. They didn’t result in a defect only because of my and my wife’s persistence. These are the stories of three consecutive prescription refill requests. I’m convinced that, if a person not as knowledgeable in health care systems as I am had these experiences, these would have been adverse events.

Here are my tales:

Twenty-first Century Medical Office

So, here’s an example of how a “next-generation” medical office system works. The issues were shared between the pharmacy and the physician office, but predominantly there were physician office systems errors.

My primary care physician (PCP) of 16 years is in a 650 “provider” (Physicians, Advance Practice Clinicians, Pharmacist Clinicians) multispecialty group. In August 2016, I had a periodic health check-up. My primary care told me he was moving to a government corporate position in October and I should call on October first and get a new PCP.

On October 1, I called the customer service department. They had no knowledge of the PCP leaving the medical group. I asked how they determine how the PCPs patients are re-distributed. They don’t know. I ask if there is any system or process involved that tries to match a patient’s conditions with an appropriate provider and… they don’t know. They tell me I’ll get a letter in the mail about it, but they don’t know when. I had to file a complaint to get the information about the available PCPs, their training, and any areas of clinical interest or enhanced training, etc.

I agreed on a PCP at the same clinic. Since I had just had my annual check up, there was no need for an appointment.

I moved from one side of town to the other side of town. Now my new PCP was about 12 miles away. The medical group opened a new clinic 3 miles from my new home. I called to transfer to the new site. I got a call from the medical group explaining that the new site was a new model, you weren’t signing up for a PCP, but a primary care site that was manned by one physician and five Advanced Practice Clinicians. I said that was OK with me as I supported that model. I also had transferred all of my prescriptions to a new pharmacy (same chain) near my home.

Two months later, I needed a prescription refill. I’d been on this medication for more than 10 years. I used the Pharmacy chain’s online refill request system. I had refilled the prescription 60 days before, and was, at the time, a little perplexed that they gave me 60 because the usual amount was 90. Here’s the 24-hour chain of events:

March 12: Submitted refill request online.

March 13, 9:00 AM: I get a text message from the Pharmacy saying my prescription was delayed. The message said click on the link to see details. I clicked on the link and it brought me to a page that said, in order for me to see my prescription status, input your birthdate into the field below. I used their calendar function to input my birthdate. The birthdate showed up but it was grayed out and when I clicked “continue”, it reverted to an empty field and said it was a required field and I hadn’t filled it out. I tried to input the date 3 more times, got the same cycle back to an empty field with the same message and finally gave up on it.

March 13, 11:11 AM: I call the pharmacy asking what is the cause of the delay. The answer was, I have no more refills, that the reason I only got 60 the last time was there were no refills on the prescription the last time I requested a refill. This seemed odd as the process should have been requesting the refills from the PCP at that time and I should have gotten 90. [ERROR #1, not following standard process] – A prescription with no refills was refilled instead of the pharmacy requesting refills from the PCP. [ERROR #2, not following standard process] – The pharmacy never notified me that there were no refills.

Then they tell me they sent the refill request to the old PCPs office for the refill request. However, my new PCP is not in that practice since I moved to the new site. They suggest I call the old PCP office to make sure it would be refilled, since I wasn’t technically their patient anymore.

March 13, 11:18 AM: I call my old PCP office. The woman there tells me the prescription refill should come from the providers at my new site. She takes down all of the information and says she is sending a note to the new site to have it renewed.

March 13, 11:37 AM: I get a voicemail call from my new PCP site saying the prescription was renewed on March 1 at my old pharmacy 15 miles away and I should call my new pharmacy and have the refill transferred to my new pharmacy.

March 13, 11:44 AM: I call my new pharmacy and tell them what the last caller told me. The woman there searched their system and said there were no active requests for this medication for me in their system.

I started thinking, the March 1 date may have been incorrect and the last caller may have misstated the date. Maybe my old PCP site had sent it in and now there was also a request from the new site and there could be two requests going in at the same time.

March 13, 12:31 PM: I call back the old PCP site and voice my concerns that there could be two requests, and I request that they make my new pharmacy the default pharmacy in their Electronic Medical Record. The woman there said the default pharmacy was changed previously but there is no evidence of a prescription being sent in.

March 13, 1:05 PM: I call my new PCP site and inform them that there apparently is no refill request issued by them, because they think there was one called in on March 1, and my old PCP’s site hadn’t sent one in. I told the woman there that there was no evidence of a request in the pharmacy’s system, either. She said she would go over all of the info in the Electronic Medical Record (EMR) and put me on hold. She came back on and said she would get back to me.

March 13, 3:29 PM: I get a call back from a different woman from my new PCP site who tells me they misread the EMR and the March 1 refill was one year old, in 2016! [ERROR #3, inattention] – Misreading the EMR led to a potential gap in my having my medication (a “near miss” because of my persistence). She tells me that my new PCP may not refill the prescription because she has never seen me, that she would ask the “provider of the day” to renew it if the PCP wouldn’t but if he also declined, they would send the request to the old PCP’s site because they should be responsible for renewals until I can be seen by the new PCP. This is the exact opposite from what the first woman told me at my old PCP’s site. Also, this didn’t make sense because no provider at either site has seen me and they both have the same medical record to refer to since they are in the same group. [ERROR #4, lack of standardization or lack of adequate training] – Inconsistent staff information led to delay and bouncing accountability back and forth within the same medical group. [ERROR #5, lack of standardization] – A provider in the same medical group, seemingly the same medical practice, being unwilling to refill a continuous medication because they had never seen that person, but was willing to defer that to another provider who had never seen me and would never see me.

March 13, 3:47 PM: I get a call back from the new PCP office. The woman tells me that the new PCP will refill the prescription but wouldn’t approve any more refills until I was seen. I asked for an appointment and she gave me an appointment for 6 weeks hence.

When I got to the pharmacy, I only got a 30 day supply phoned into the pharmacy, two weeks less than needed to get to my appointment! [Error #6, inattention]

Does anyone think this is patient friendly?

Retail Pharmcy – this was mainly a pharmacy set of issues

I had a medication that needed to be refilled. With Big W Pharmacy, you can create an account and manage your medications online and with a smartphone app. So, I went online on my computer, signed in and went to the “Refill Prescriptions” page in the dropdown menu.

In the Refill Prescription page, all of your prescribed medications are listed. You can click on a button that activates automatic refill if you want. My medication is one that runs out variably so I didn’t activate that function for this particular medication. To the right of the auto-refill button is a check box that you check to refill a prescription. I checked the box next to the medication I wanted refilled. There is a button at the lower right that says “Request Refill”. I click on that button and I get a page that says my medication refill request is sent to my Big W Pharmacy, including the pharmacy’s address and telephone number.

Now I wait. The process should be, the request is sent to my pharmacy and the pharmacy either refills the prescription or, if all of the refills have been used, the pharmacy faxes a refill request to the doctor’s office. The doctor’s office is expected to review the faxes daily and send a doctor’s decision (refill or not refill) back to the pharmacy. If the doctor orders a refill, the pharmacy notifies the patient one of three ways: 1. A robo-phone call, 2. An email, 3. A text message.

Seven days later, I’m suspicious that something went wrong. I went into the online account and clicked on “Prescription status”. It’s an empty page. I called the doctor office, they hadn’t gotten a fax from the pharmacy. I called the pharmacy. They said they never got a notification from the online system. [Error #1, IT system malfunction] The woman who answered the phone said , “This happens all the time.” I asked, “Who do I talk to, to file a complaint?” She said I have to call corporate, the local pharmacies have nothing to do with the IT stuff. The woman entered my refill request into the system for me and said they would send a fax to the doctor’s office.

I called the corporate office and filed a complaint. They told me they would call me within 48 hours to tell me why the system didn’t work.

The next day, I got a text message that says my refill has been delayed and I should click on a link to see the status of my request. I clicked on the link and it took me to a page that said I must enter my date of birth in the field in order to access my prescription status. Since I’m on my smartphone, I poke at the field. It is totally dead. I try this 10 times, and it won’t work. The check box next to “I agree with the terms and conditions” works, but the birthdate field doesn’t. This was actually the second time in a row this happened. [Error #2, IT System malfunction]

I called the Big W Pharmacy’s corporate office again and filed another complaint. I get the same answer that someone will call me within 48 hours with what went wrong, but, I should use the online or smartphone app as they will be accurate. I told the person on the phone that I didn’t believe that those would be accurate since nothing I’ve used so far had been accurate.

I called the doctor’s office and got a voice mail. I left a message saying that Big W Pharmacy’s system has been problematic in getting a refill request to them and could they check their fax pile and see if something has come in. The voice mail says I will hear from them within 24 hours.

30 hours later, I’d heard nothing from either the pharmacy or the doctor’s office. [Error #3 Physician Office process delay] My wife checked the prescription status and it said Big W Pharmacy had sent the request twice to the doctor’s office.

At that point my wife called and left a long angry message. Now, it is nine days trying to get the refill and I’m out of the medication. Two hours later I get a call from the doctor’s office that they sent in the refill request. Fifty minutes later I got a Big W Pharmacy text saying my refill was ready. I got in the car and drove to the pharmacy drive-through window. There was a sign on the window saying the staff was on lunch from 1:30-2:00 and the pharmacy was closed. It was 1:35. [Error #4, Delay due to wait time]

I had to go home, and then drive back to the pharmacy after 2:30. [Error #5, customer required to over process]

I’ve never gotten a call from Big W Pharmacy IT people.

Does anyone think this is patient friendly?

Mail Order Pharmacy

My health plan has a contract with RxMO Pharmacy for mail order prescriptions. I had a visit with my Primary Care Physician (PCP) and asked her to send a prescription for a 90 day supply to the mail order pharmacy after I notified her through the patient portal that I was registered for mail order (I had never gotten mail order medications before).

I went to the health plan website and looked up how to get mail order prescriptions. What they had was a brochure .pdf from RxMO Pharmacy. The brochure had thee options: 1. Online registration, 2. Telephonic registration, and, 3. Paper registration through snail mail. I chose the online method.

I went to the URL on the brochure and clicked on “create new account”. I filled out all of the required fields and clicked “submit”. I got a page that said check my email to activate my account. I went to my email and there was the RxMO Pharmacy email. I opened the email and clicked on the activation link provided. That brought me to a page with a box that said, “click to activate”. I clicked on that box and it changed to “Your account has been activated.” Below that there was a button that said, “continue”. I clicked on continue and it brought me back to my health plan member pharmacy portal page, where I had started. I went to the RxMO Pharmacy website and signed in. It brought me back to my health plan member pharmacy portal page. [Error #1, IT malfunction]

So, I called the health plan member services telephone number. The customer service rep listened to my tale and then said, “I have to transfer you to someone who knows more about this.” She transferred me and I got another woman who told me the IT link between the health plan and RxMO Pharmacy wasn’t working and they were trying to fix it. She gave me the telephone number for the telephonic registration. [Error #2, re-processing]

I called the number and got a nice woman who looked in the system and said that the only two fields that had “taken” were my name and date of birth. I had to go through all of the fields again with her verbally. I also arranged for payment to be made by credit card. She said that all that needed to be done now was for my PCP to send them the prescription and they would process it, send it and charge my credit card. She said I would get a call within two days of their getting the prescription from my PCP notifying me when the package would arrive.

I messaged my PCP to send the prescription.

Two days later I got a message from the PCP office that they had sent in the prescription.

The next day, my phone rang with an 866 number. When I answered it, it was a robo-call fromRxMO Pharmacy. It said before they could send me the prescription they needed to verify that I was the person they should be sending it to. They asked me to input my date of birth. While I was doing that, my phone double struck one of the numbers and my phone doesn’t have a delete function for this, so, now I was stuck with a wrong date of birth. The robo-caller finally said it couldn’t understand my date of birth and it was transferring me to a live person. The phone rang twice and I got another robo-caller asking for my date of birth. I put it in correctly. Then it asked for my zip code. I put that in correctly. Then it asked for my phone number. I put that in correctly. Then it asked for my prescription number, also saying if I didn’t have the bottle with me, it would hold until I found the bottle.

Now, since this was totally new, I had no prescription number. The robo-caller finally said, if I didn’t input the prescription number, it couldn’t help me. [Error #3, Delay in process] I hit Zero on the phone. I got another robo-caller asking me if I was calling about Medicare Part D. I hit zero again and the robo-caller started talking again. I hit zero before I could even understand what it was saying. I hit zero five times and finally got a “transferring to a customer service representative. [Error #4, Over-processing]

A woman came on the phone and asked me the same questions the robo-caller did. [Error #5, Over processing] Then she said she had my account pulled up, why was I calling? I told her the above story, also adding that there should have been an opt out of the robo-caller (like, dial 0 at anytime to get to a live person) and asking me for a prescription number was really stupid for a first time prescription (yes, I used the term stupid!) and they should have had another opt out command, like, “if you don’t have a prescription number dial 0”.

She said, “I’m sorry, I can’t help you with filling a prescription. I’m going to live transfer you to the correct person” and put me on hold. I was on hold for almost 10 minutes. [Error #6, Delay on processing] The customer service rep came back on three times telling me she was still trying to transfer me. Finally, she said she had the person on the line and was now transferring me.

The person who received the transfer started with something like, “Hi, I hope I can help you but I may be the wrong person.”

WHAT?

So, I told her my story (again). [Error #7, Over-processing] She said she was the right person but didn’t know before I told her the story because the person who transferred me to her didn’t say why the transfer was occurring. [Error #8, inaccurate communication] She pulled up my account, verified the medication and asked if I wanted them to send me the drug (REALLY?!?). I said, yes. She verified the address and told me the medication would be arriving in eight days.

Does anyone think this is patient friendly?

You can see how these errors can line up like holes in Swiss cheese and result in a defect impacting a person. Luckily, my medications weren’t “life-saving” and I knew how to work the system. Not true for most people. And it could have been catastrophic for people on medications treating their cardiac disease or diabetes where their life is at stake. Read my Clinical Quality Part 1 post dated April 29, 2017 to see a more serious consequence of  Pharmacy/Health Plan/Physician Office processes creating a serious adverse event.

And these examples are only relating to getting a medication!

This has to be what the majority of patients go through on a daily basis. I can’t imagine that these stories are specific only to me. And this is only the tip of the iceberg. There are studies of patients who get re-admitted within 30 days of a hospital discharge that show that process issues like the above related to multiple health care service providers (doctors not responding, durable medical equipment companies not showing up, pharmacies’ processes causing delays or not filling prescriptions correctly, home health agencies arriving 3-5 days late, etc.) are significant contributing factors for those 30-day re-admissions, which are adverse events.

There are similar error prone experiences that patients are going through related to other health care systems. Tests that don’t get reported, test results that are never reviewed (cases like an imaging study shows a cancer but is never reviewed, the physician office policy is “if you don’t hear from us everything is normal” and 6-12 months later, the patient comes in for a re-check and now has an untreatable cancer…this actually happened…), etc.

Here’s another scarier true story.

I’m seeing same day patients at a primary care site. It’s Thursday afternoon. I see an elderly woman being treated for a cancer, undergoing chemotherapy. She presented to the ER four days earlier with fever and a bad sore throat with swelling on the left side of her face and neck. They do a bunch of tests. Her white blood cell count is low due to the chemotherapy. As a matter of fact, she says her chemo was delayed because her counts were so low. They do a CT scan of the face and neck. It shows a 0.5 cm stone obstructing the salivary gland duct and the salivary gland is very swollen. There is no mention of this in the ER physician’s notes. They give her a prescription for amoxicillin and advise her to follow-up with her PCP if she is not better, and the final diagnosis is pharyngitis.

Now, I have to assume they missed the salivary duct stone reported on the CT scan report. FYI, you can’t clear a salivary gland infection caused by a stone stuck in the duct without removing the stone. And, this patient was significantly immunocompromised and could have gone into full sepsis with the degree of  leukopenia (low white blood cell count) she had.

I call our medical group’s Ear, Nose and Throat (ENT) department, giving them the story and requesting an immediate appointment to have the stone removed before the patient became septic. They said they couldn’t see her until the next Tuesday. I told them this was unacceptable, she needed the procedure ASAP. They said, send her to the ER. Since that was where she had been and that hadn’t gone well, I wanted the specialist who could treat her to see her. They said sorry, Tuesday was the best they could do.

I hung up and called a non-medical group ENT, a physician in solo private practice. He advised me to change her antibiotics to cover more bugs, and he would see her first thing in the morning. She made it through the night and had her procedure in the morning and did fine, no thanks to the health care system she was in.

I bet you can relate a similar story. Most people can, either for themselves or someone they know. Sad! But true!

Now, the thing is, there are ways to make these systems more reliable and they are used by industries like the aviation and nuclear reactor industries. They are also used by companies like Toyota and Hyundai. These “ways” to make systems and processes more reliable and reduce errors and defects have been tried by some health care systems but most abandon them, spending their money on things like  building new shiny buildings. They like spending money on tangible things that you can touch rather than improving care processes that actually benefit the patient by improving outcomes or creating a safer environment.