Medicare to Stop Paying for Rework


    Hospital-borne ailments face Medicare budget ax |

    Healthcare has LONG been a piecework industry. Caregivers and facilities are paid for WHAT they do and the services they provide. Doing more work gets you paid more, much the same way a piecework garment worker would get paid. There's a long history in medical piecework, as described in the book “Better” by Dr. Atul Gawande. One of the dysfunctions in healthcare is that the piecework pay also includes pay for rework (as well as unnecessary procedures, but that's a different story).

    Focusing on the rework…. if you read this blog often, you know I'm not big into blaming individuals, recognizing that most quality problems are systemic in nature. You also would know that I believe people generally want to do the right thing and that people definitely want to do quality work, this includes factory workers, as well as doctors and nurses. Nobody is TRYING to make mistakes so they can get paid for fixing them. I'm not implying that.

    But, that said, with highly skilled and highly trained people trying their hardest, medical mistakes occur at an alarming rate. I'm not talking diagnosis errors, but preventable procedural errors, such as leaving a surgical sponge inside a patient.

    The article I've linked to is about Medicare moving away from paying for rework. As the Lean definition goes (in part), something is “value added” only if it's done right the first time.

    Late next year Medicare plans to stop paying hospitals for costs incurred from some of the most common and preventable medical errors suffered by patients.

    It could be getting a bloodstream infection from a caretaker not thoroughly washing his or her hands. Or it could be developing a dangerous bed sore because a patient's skin was not inspected or cleaned as recommended.

    The problem is huge:

    Medical mistakes are deadly and expensive. Infections acquired in hospitals account for about 90,000 deaths and $4.5 billion in extra spending each year, according to the U.S. Centers for Disease Control and Prevention.

    But, hospitals are not helpless, they can work on avoiding and preventing these mistakes — not through trying harder, but through systemic quality improvement.

    Preventing such problems is an ongoing effort among hospitals, doctors and organizations focused on health-care quality.

    The Indiana Patient Safety Center was formed last year to help hospitals develop reliable systems to prevent harm to patients. Indiana also has a mandatory medical-error reporting system requiring that hospitals disclose certain mistakes, such as objects left inside a patient during surgery.

    “Developing reliable systems” is the key. Mandatory error reporting is a good way of sharing information so that future problems can be prevented, IF the reporting can be enforced and the reporting is done in a blame-free way.

    We sometimes find excuse makers in the healthcare world:

    The American Hospital Association, which represents almost 5,000 hospitals and other health-care providers, said it welcomes efforts by Medicare and others to reduce errors and improve health-care quality.

    “There's not a doctor or nurse who comes to work in the morning and wants to make a mistake,” said Carmela Coyle, the AHA's senior vice president of policy. “I don't see nonpayment as an incentive to try to do better.”

    She also said it is important to make sure that the conditions included in the Medicare policy change are indeed preventable and in control of the hospital.

    Again, I agree, nobody comes to work wanting to make a mistake. But, nonpayment is NOT an incentive?? It's incentive, but if we're relying on individuals “trying to do better,” we won't make much progress. The incentives need to drive systemic change, to prevent problems that are in the control of the hospital. What we don't need is people making excuses, you often hear “a certain number of infections are going to happen.” That can't be used as an excuse for not getting better. Trying harder is not the way to get better.

    Here's an article about a hospital that was able to reduce infections. It is possible.

    I applaud the steps Medicare is taking. The hope is that private insurers will follow and that the pressure will drive systemic change.

    Hat tip to Gemba Pantarei for seeing this first.

    Among the proposed conditions to be dropped are:

    1. Catheter-associated urinary tract infections.

    2. Bed sores.

    3. Objects left in after surgery.

    4. Air embolism, or bubbles, in bloodstream from injection.

    5. Patients given incompatible blood type.

    6. Bloodstream staph infection.

    7. Ventilator-associated pneumonia.

    8. Vascular-catheter-associated infection.

    9. Clostridium difficile-associated disease (gastrointestinal infections).

    10. Drug-resistant staph infection.

    11. Surgical site infections.

    12. Wrong surgery.

    13. Falls.

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.



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