Clipping 4, 1985 Problems with Quality Assurance Program and Infection Control

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Another clipping from - the VA Office of the Inspector General report, 1985, is the earliest internal documentation I found on the escalating cyclical threat of horrible outcomes at some facilities.  The cycle shows that policies were in place to guide processes that help radiate consistently good outcomes throughout all facilities.  Here is an excerpt mentioning one of those policies.

     “Infection control review determines the trend and extent of hospital-related infections, proposes corrective actions, when appropriate, and should ensure that exposure to such infection is minimized.” Chapter 2 page 6

Yet, the inspectors noted that no data, trends, or standards were developed in some facilities.  This included monitoring problems with surgeries.  A chart on the 24^th page (pdf) of the Inspector General Report shows that 8 of the 13 hospitals inspected complied with the infection control QA program. 

There are plenty of direct statements by inspectors that show different interpretations and complete misinterpretations of policy by VA Medical Center Directors.   Weaknesses in consistent oversight exacerbated the problem.  In the case of infection control programs, one can see how different interpretations developed.  It is downright hard to see how the policy could have been misinterpreted as not requiring any activity whatsoever. 

The implications of having no program are:

- Even if an infection occurred in the patient, it may have gone unreported.

- The process was meant to drive down infection rates but in some cases there was no process in place to determine the actual infection rate.  If infection rates are neither monitored nor driven down, they probably rise. 

- Leap forward to 2010.  This gives a quick look at how horrible this situation may have been in 1985.  In 2010, the VA announced that it may have infected over a thousand patients with infectious diseases.  As awful as it was, the VA centered on the causes, tracked the cases, and responded.  The 1985 report certainly points to the possibility of even more dangerous incidents may have occurred.  And it could have happened without even so much as the ability to become aware of it.    

Back to the report:

    Infection control review determines the trend and extent of hospital-related infections proposes corrective actions when appropriate – This was not tracked. There was no corrective action because no need could be identified.

    And should ensure that exposure to such infection is minimized.  - No clue of the infection rate exited.  There was no adherence to the policy or process.  Nothing was minimized.  The infection rates probably rose.

The repetitiveness of this blog post is purposeful.  Then so is the entire matter… repetitive… new leader, same problems.  Final words for this blog post, in 2 questions.

-  What would you do if you had been treated at a hospital that had no clue of whether it infected customers and were not doing anything to find out?

-  What kind of culture has to develop to perpetuate this type of failure?    

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Part 2, THE GLOBAL SICKCARE SYSTEM

In part 1, we met Dr. Arlen Meyers, President and CEO at the Society of Physician Entrepreneurs and Director, University of Colorado CITI Digital Health Consortium.  He is a practicing surgeon and otolaryngologist, professor, and entrepreneur.   We met over social media as a result of reading his comments on physicians’ use of Electronic Medical Records.  He wrote “1.  Show up for the patient appointment on time.  2.  Sit down and talk to the patient.   3. Avoid using the EMR as much as possible.”

He believes that healthcare incentives should be directed more toward the consumer and understands why admission to hospital can be seen as a failure of the healthcare system.

We left off part 1 with a look into the future of healthcare devices,  including a machine diagnosis.  “As technology helps us get smarter in making more predictive diagnoses, the computer can connect the dots better than I can.  So, what is there left for me to do when it comes to diagnoses?”

Start Part 2, The Global Sickcare System

It is a bit scary when coming out of a care model (Dr. Meyers would say sickcare model) where the doctor looks you in the eyes and declares, It’s gas.  We discussed a case like hypertension.  If a watch tracks and trends blood pressure, a contact lens tracks a blood panel, add screening questions with a mobile app similar to those from one of my previous post, where does the doctor fall into making the diagnosis?  Will charges for tests be acceptable when a medical lab device returns the same results and with the same accuracy as a wearable device?  Am I comfortable with that?  Will device manufacturers start buying up wearable device companies?

Dr. Meyers, Society of Physician Entrepreneurs at Tie Rockies,

with Permission of SOPE, http://youtu.be/0FzV-pwl1z8

Remember, that’s really not the prime use for the data.  Dr. Meyers says that a prime use of the information is for the consumer to do something to prevent the condition or early detection and receive a monetary reward for doing so.  In this new ecosystem, depending on how it shakes out, I may be able to live with that cash rebate.

Dr. Meyers seeks to promote finding answers through with SOPE.  “To provide resources and advice for those who want to bring such innovations to the patient.... Our vision is to close global health disparities. Our mission is to help anyone interested in getting an idea to a patient by offering education, resources, and networks.

"SOPE was born out of anger because this needed to be done. In  my professional career, I had been involved in technology commercialization and got so frustrated with the lack of resources to do it properly that I decided with a couple of others to create something to do it myself.  Me and others created SOPE because no one else was doing it and it needed to be done.  It filled a gap.  Everyone had a good idea but no one knew what to do with it.  So we created a place.

"We are a not-for-profit global biomedical and healthcare innovation network.  You do not have to be a doctor to be a member of SOPE.  The thing that holds everything together is that everyone in the organization has an interest in getting an idea to a patient or helping someone get an idea to a patient.   We are everything from ideation to terminal deployment.  We do not do it.  We are a sandbox. We put everyone in the same place and let good things happen.  But we provide them with the education, resource, and networks.

"We are growing in dues paying members at a rate of 100 persons each month.  Our audience numbers in the tens of thousands. Our dues are only $50US per year.  We keep it ridiculously cheap to encourage people to participate.  We feel that we offer a fairly compelling value proposition.  We want to engage as many people as possible and yet sustain the organization.”

“So if a person has an idea, what should be the first thing to do?”

“Join SOPE at http://www.sopenet.org.”

“And what happens after that?"

“They have to go through a series of steps in the life science innovation roadmap. That involves fairly clear steps in getting an idea to market. Whether the idea is drugs, devices, diagnostics, digital health, care delivery innovation.  It depends on the idea.  It depends on following those steps to get to the next success factor before you can move on to the next.  Whether you need a mentor or to pay someone to commercialize your idea, you can do that.  SOPE is not the place where a person hands off an idea to just expect checks in the mail.  This is a very hands-on experience.”

Coming Up this week on Asset Management for Healthcare, Part 2 of the Global Sick Care System, an interview with Dr. Arlen Meyers President and CEO at the Society of Physician Entrepreneurs. Click here to Read Part 1.

Coming up 23 June, Clipping 4 from #NewSameProblem No Data, No Trends, No Standards Search #NewSameProblem to read preview blogs.

Clipping 3, From 1985 - VA has not fully implemented Its Healthcare Quality Assurance Program

Report GAO/HRD-85-57 was filed in response to requests made in 1983 and 1984 by the chairman and ranking minority members of the Committee on Veterans Affairs, US Senate. - GAO Reports to The Committee Veterans’ Affair United States Senate. “VA has not fully implemented Its Healthcare Quality Assurance Program, GAO/HRD-85-57, June 27, 1985.   This report surfaces problems with infection control some 25 years before some many veterans were infected with debilitating and life-threatening diseases. 

The cover letter in the report states:

“In response to the December 21, 1983, request from the previous Chairman and the September 6, 1984, request he made jointly with the Ranking Minority Member, we have reviewed the Veterans Administration's (VA's) systems and procedures for assuring the provision of quality health care.  This report discusses (1) the extent to which the VA medical centers we visited had implemented quality assurance programs and (2) the roles of and processes used by other VA organizations in assuring quality of care. We did not evaluate the effectiveness of VA's programs and therefore do not comment on the quality of health care provided.”

The review covered internal quality programs and VA oversight of those programs.  Infection control reviews were a part of continuous monitoring function, 1 of 5 mandatory functions.

“Infection control review determines the trend and extent of hospital-related infections, proposes corrective actions, when appropriate, and should ensure that exposure to such infection is minimized.” Chapter 2 page 6

The GAO visited 13 VA medical centers.  None fully met the requirements of the VA’s quality program.  Compliance issues were recorded as a misinterpretation of the requirements and the perceived low need for review and analysis. Chapter 2 page 10, None of the medical centers performed all five of the required functions of the quality assurance plans.  Continuous Monitoring was specifically noted.  Again, infection control fell under that function.

The report reflects issues with high-level VA oversight as well.  The projected number of reviews to “ascertain the quality of health care” and to actually assess the effectiveness of each medical center’s internal quality had fallen short since 1977.  The goal was 60 reviews, the annual average was 44. Page iv

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