The New York Times published a recent story on
the secret recordings of doctors discussing concerns about poor surgical care. The
outcomes from surgeries were so bad the doctors questioned whether they should refer
patients for surgery if it meant in-house surgeons would perform the operation.
You can read the article here.
The popular podcast The Daily also published
a story on the topic. You can listen to the podcast here.
offering the poor care now refuses to release its mortality statistics. The Times is suing the hospital for the release
of the information. The information is called risk-adjusted mortality statistics.
The data details patient deaths at a specific hospital for heart and lung
surgeries. The data is adjusted to account for factors that may make some
procedures and/or patients riskier than others. Medical experts regard the data
as an excellent indicator of a hospital’s performance, including whether a hospital
is losing patients who should not die.
mortality statistics are published
on a website run by the Society of Thoracic Surgeons. The statistics are
searchable from hospital to hospital on a wide range of heart and chest surgeries.
Hospitals self-report the statistics to the website. There is no requirement
for hospitals to report such information.
be concerned about a hospital which refuses to report its mortality statistics.
As one of the doctors in the Times article states, “You should think twice about going to a [hospital] that doesn’t
publicly report. People don’t buy a car without knowing what the gas mileage
Searching through the website, the following hospitals in Southwest Virginia did not report their mortality statistics:
LewisGale Medical Center
Carilion Franklin Memorial Hospital
Carilion Giles Community Hospital
Carilion Tazewell Community Hospital
Carilion Stonewall Jackson Hospital
Carilion New River Valley Medical Center
Sovah Health Martinsville
Wythe County Community Hospital
LewisGale Hospital Pulaski
Russell County Hospital
Buchanan General Hospital
All Doctors Are Not Created Equal
May 15, 2019
Doctors are not gods. They are not infallible, all-knowing deities
picked by God Almighty to spread His wisdom to us mere plebes. Doctors receive a lot of training. Doctors work long hours and are well
compensated for their work. But
doctors are people just like you and me. Some doctors are better, or worse, than other
doctors. This makes sense as some teachers,
mechanics, barbers, chefs, lawyers, etc. are better than others.
I recently read a seminal article
on this topic called “The Health-Care Bell Curve” in New Yorker Magazine. The article was written in 2004, but the issue
remains as important today. People used
to assume the differences among doctors in a particular specialty were
insignificant. Today, we know that
assumption is wrong. If you plotted a
graph showing the results of doctors in a specific specialty, you would find a
bell curve: a handful of doctors with disturbingly bad outcomes, a handful with
remarkably good outcomes, and a great undistinguished middle.
The New Yorker article points to studies in a variety of fields to
illustrate the importance of the individual doctor on patient outcomes. In ordinary hernia operations, the chances of
recurrence are 1 in 10 for surgeons at the low end of the bell curve, 1 in 20
for those in the middle, and 1 in 500 for those at the very top. The 10 year survival rate for patients with
treatable colon cancer ranges from 63% to 20%, depending on the surgeon. For heart bypass surgery, risk-adjusted death
rates can vary from 5% to 1% depending on the surgeon, which is no small
difference when life or death is at stake.
The healthcare industry does not
like to acknowledge the common sense reality that all doctors are not created
equal. Patients, however, should always
be aware of this fact. Advocate for
yourself. Research all you can on the
best doctor and healthcare system for your procedure. We have written about this extensively in the
past: see articles here, here,
and here. It is often said that the most important
decision you make is the person you choose to marry. I would offer that a close second is the
doctor you choose to provide healthcare for yourself or a loved one.
 Gawande, Atul. The Health-Care Bell Curve. The New Yorker (Nov. 28, 2004), available at https://www.newyorker.com/magazine/2004/12/06/the-bell-curve.
Dental Errors Can Lead to Infectious Disease (HIV, Hepatitis, etc.)
April 19, 2019
disease from improperly cleaned instruments is an all-too-common occurrence in our
healthcare system. Every year in the U.S., an estimated 648,000 people develop
infections during a hospital stay, and about 75,000 die. Many of these infections are completely preventable through, for example, proper
cleaning of medical instruments.
process for medical instruments is relatively straightforward process. There
are two main steps. The first step is removing
contaminating debris and scrubbing the instruments with a disinfectant. The
second step involves steam cleaning the instruments with hot, pressurized air. Both
steps are vital to ensuring instruments are safe to use on future patients.
many dentists’ offices fail to properly clean their instruments. Unclean
instruments can lead to the spread of potentially deadly infections to patients
such as HIV, hepatitis, MRSA, etc. Several studies are highly critical of the sterilization
process for dental instruments, particularly the second step of steam cleaning. Recently,
a Vermont dental clinic notified over 60 patients they may have been exposed to
infectious disease because the dental instruments were not steam cleaned. The
U.S. Department of Veterans Affairs investigated two incidences where 500
patients tested positive for bloodborne pathogens and 7,000 patients in
Oklahoma were at risk for HIV and hepatitis.
advise clients to be informed as the best way to ensure better healthcare
outcomes. The failure to clean dental instruments is unfortunately something patients
have little information about or often no way of knowing. If a dentist’s office
informs you that you may have been exposed to infectious disease due to
improperly cleaned equipment, we advise contacting our office.
In 2019, Medicare penalized 800 U.S.
hospitals for the high number of injuries and infections suffered by their
patients. The penalties were enacted through a program in the Affordable Care
Act where the federal government cuts Medicare reimbursements for hospitals with
high rates of patient infections and injuries. The idea being that if hospitals
suffer financially for poor outcomes, hospitals might improve the quality of
care they provide.
Hospital patients suffered an avoidable
injury in 9 out of every 100 hospital stays in 2016, or about 2.7 million
times, according to a June report from the federal Agency for Healthcare
Research and Quality. Such
injuries include adverse medication reaction, injury from a procedure, falls,
Sadly, our hospitals do not seem to be
getting the message. Medicare has punished over 1,500 hospitals at least once. In
2019, 110 hospitals were punished for a fifth straight time. The 800 hospitals penalized
in 2019 was the highest number since the since the program was created.
Virginia hospitals fared especially
poorly. Medicare punished 18 Virginia hospitals in 2019, listed below with Southwest Virginia hospitals in bold:
Medical Center in Harrisonburg
Virginia Medical Center in Charlottesville
Carilion Roanoke Memorial Hospital in Roanoke
VCU Health System
Novant Health UVA
Prince William Medical Center in Manassas
Regional Medical Center in Petersburg
Bedford Memorial Hospital in Bedford
Carilion Franklin Memorial Hospital in Rocky Mount
Inova Fair Oaks
Hospital in Fairfax
Medical Center in Petersburg
Johnston-Willis hospitals in Richmond
Lewisgale Hospital in Pulaski
Carilion Tazewell Community Hospital in Tazewell
Many of the Virginia hospitals punished
in 2019 have been punished by Medicare in the past. The best thing patients can do is to thoroughly research hospitals where they
are considering receiving care. In times of an emergency, patients may not be
able to choose their hospital. But for non-emergency situations, patients have more
Publicly available information is
becoming more and more accessible. A great starting point is this database maintained
by the Kaiser Family Foundation on which hospitals have been penalized by
Medicare for poor outcomes.
New, Facility Specific Data on Virginia Nursing Homes
December 17, 2018
Inadequate staffing is a widespread and persistent problem in nursing homes in Virginia. We have written extensively about how there are no minimum staffing requirements for Virginia nursing homes. Despite the failure to ensure staffing at the state level, the federal Centers for Medicare & Medicaid Services (CMS) asserts “nurse staffing is directly related to the quality of care that residents experience.”
The federal government recently indicated serious concerns about inadequate staffing, particularly on nights and weekends. A November 30th, 2018 letter from CMS warned about inadequate staffing at nursing homes. A New York Times analysis found 11% fewer nurses providing direct care and 8% fewer aids on weekends as opposed to weekdays. Nursing home residents and their families often tell us of the difficulty in getting basic help, such as assistance going to the bathroom, on weekends. The federal government is so concerned about inadequate staffing at nursing homes it recently ordered states to conduct more weekend inspections.
The ability to find out staffing levels at individual nursing homes is critical to ensuring quality care for your loved one. Until recently, it was difficult for family members to determine which facilities staffed appropriately. Now, there are easy-to-use resources available. On December 11, 2018, the Long Term Care Community Coalition, an advocacy group, announced it will publish staffing information for every nursing home in the country. Simply visit their website, www.nursinghome411.org, to download sortable spreadsheets for every state that include:
The facility’s direct care RN, LPN, and CNA staffing;
The ratios of care staff to residents;
Select non-nursing staff hours per day, including administrators, social workers, and activities staff; and
The extent to which the facility relies on contract staff to provide resident care.
You can download the Virginia data set for the second quarter of 2018 here. Every family member with a relative in a nursing home should review this data to see if the facility they use has been staffing appropriately.
The data are not encouraging. In the second quarter of 2018, Virginia nursing homes averaged 3.5 hours of total direct care per resident per day. A landmark 2001 federal study indicated at least 4.1 hours are needed to meet a typical resident’s needs. Virginia nursing homes also averaged 0.4 hours of RN staff time per resident per day, less than the 0.5 hours averaged nationally and significantly less than the 0.55-0.75 RN hours recommended by the same 2001 study.
Pregnancy Deaths – A Uniquely American Problem and What Expecting Mothers Can Do to Protect Themselves
November 19, 2018
In America, thousands of mothers suffer significant injuries or die during childbirth. Each year more than 50,000 American women suffer severe injuries from childbirth. About 700 American women die each year from childbirth. A recent study from the USA Today demonstrates half of the deaths and injuries can be prevented by implementing safety practices mostly ignored by hospitals today.
In the study, fewer than half of women received prompt treatment for dangerous blood pressure readings that put them at risk for stroke. At some hospitals, less than 15 percent of mothers in peril received recommended treatment. Many of the hospitals failed to take safety steps such as quantifying women’s blood loss or tracking whether moms with dangerously high blood pressure received medication timely.
Today, the United States is the most dangerous place to give birth in the developed world. From 1990 to 2015, maternal deaths in other developed nations flatted or declined significantly. Other countries reduced maternal deaths by monitoring care provided and implementing maternal safety practices.
Childbirth in America does not have to be so dangerous. Regulators and oversight groups could require hospitals to report data on childbirth complications and injuries. As opposed to the inaction in regulating births, regulators monitor elder care aggressively. For example, Medicare requires hospitals to disclose information on compilations for hip and knee surgeries. Unfortunately, there is little information available on maternal health. No national tracking system exists for childbirth complications.
Despite the lack of information, expecting mothers can take a variety of steps to protect themselves. Mothers should know common warning signs and proper safety responses. For example, mothers are at risk of stroke once their blood pressure hits 160/110 (or either of those numbers individually). If blood pressure reaches 160/110 (or either individually): 1) the healthcare provider should retake the mother’s blood pressure within 15 minutes to ensure the reading is accurate; and 2) if still in the danger zone, the healthcare provider should give blood pressure medication to the mother within an hour.
Women should ask if their hospital tracks patient outcome data the maternal care. The Alliance for Innovation on Maternal Health (AIM) contains many of the best maternal safety practices. Expecting mothers should familiarize themselves with the guidelines included in the AIM Program and ask whether their hospital is one of the 985 hospitals enrolled in the AIM Program.
It is regrettable the burden of receiving proper maternal care falls on patients. But, as is so often the case in the American medical system, patients must take an active role in their treatment to ensure the best possible care.
Choosing Your Doctor: The Importance of Procedure Volume at a Given Healthcare Facility
June 14, 2018
One of the most important decisions a person can make is which doctor to trust with his or her medical care. A recent blog post on our website discusses factors to consider when selecting your doctor, including the number of times a doctor has performed the specific operation you will undergo. If you are planning on open heart surgery, for example, it would be important to know how many times a doctor has performed that operation. In fact, the number of times a doctor has performed a specific procedure is one of the most predictive factors in determining the success rate of future medical care. Patients, however, should not limit their analysis to just the total number of times a doctor has performed a specific operation. A much more predictive metric is the number of times a doctor has performed a specific operation at a given healthcare facility.
As with all things, context matters — particularly in a complicated area such as healthcare where teamwork is vitally important. In cardiac surgery, for example, a successful patient outcome depends not only on the individual surgeon, but the varied contributions of many healthcare providers such as anesthetists, intensive care specialists, intensive care nursing, ward nursing, junior medical staff, and so on.
In the May 9, 2018 episode of Malcolm Gladwell’s excellent podcast Revisionist History, Gladwell discusses the effect of context on individual performance. In the podcast, Gladwell highlights the landmark 2006 study by Harvard Business School Professors Robert S. Huckman and Gary P. Pisano, The Firm Specificity of Individual Performance: Evidence from Cardiac Surgery. Surgeons often have privileges at different hospitals and facilities, meaning a given surgeon may perform the same operation at several different hospitals. Using patient mortality as the metric, Huckman and Pisano found that the quality of a cardiac surgeon’s healthcare at given hospital improves significantly with increases in his procedure volume at that hospital, but does not improve significantly with increases in the same procedure at other hospitals.
Huckman and Pisano demonstrate that increases in procedure volume for a surgeon at a given healthcare facility lead to a decrease in patient mortality at that facility. However, the same surgeon doing the same procedure at a different healthcare facility may be just as deadly at operation number 1 as they are on operation number 1,000 at that facility. Mere procedure volume is not predictive.
Huckman and Pisano’s findings are not entirely surprising because a surgeon is but one part of a team of doctors providing healthcare to a patient. Like any person, a surgeon has strengths and weaknesses. The team of doctors at a specific hospital may have worked together in the past with knowledge of their strengths and weaknesses with established routines to maximize strengths and minimize weaknesses. In essence, the skill, expertise, and success rate of healthcare is team specific.
As a result, a vital factor to consider when selecting a doctor is the healthcare facility and team where the operation will be performed. Without breaking down procedure volume to the level of a given healthcare facility, the statistic loses its predictive value. Such a general number fails to account for the fundamental importance of a healthcare team and facility in successful patient outcomes. As part of that, one should consider the number of specific procedures a doctor has performed at a given facility.
 E.L. Hannan, J.F. O’Donnell, H. Kilburn, Jr., H.R. Bernard & A. Yazici, Investigation of the Relationship Between Volume and Mortality for Surgical Procedures Performed in New York State Hospitals, Am. Med. Assoc. (1989), available at https://www.ncbi.nlm.nih.gov/pubmed/2491412.; E. Hannan, H. Kilburn, H. Bernard, J. O’Donnell, G. Lukacik & E. Shields, Coronary Artery Bypass Graft Surgery: The Relationship Between Inhospital Morality Rate and Surgical Volume After Controlling for Clinical Risk Factors, 29 Med Care 1094–107 (Nov. 1991), available athttps://www.ncbi.nlm.nih.gov/pubmed/1943270.
 A. Merry, W. Brookbank, Merry and McCall Smith’s Errors, Medicine and the Law 366 (Cambridge University Press, 2017).
The attorneys at Frith Ellerman & Davis have extensive state and federal trial experience representing individuals across Virginia who have been seriously injured or in business litigation disputes. A small firm by choice, we feel honored to help individuals with their legal needs.
Frith Ellerman & Davis Law Firm 303 Washington Ave. SW Roanoke, Virginia 24014
Mailing Address P.O. Box 8248 Roanoke, Virginia 24014