Now Viewing: Health Care Quality

Opening the Care Conversation through OpenNotes

May 4, 2015, 10:01 AM, Posted by Susan Dentzer

More than 30 health systems have adopted the practice of sharing clinicians' notes with patients, making OpenNotes more than just a revolutionary idea but a movement in health care.

A female patient gets an allergy checkup in a doctor's office.

It’s a memory aid. It’s truth serum. Using it can transform relationships forever. These may sound like come-ons for the type of product typically hawked on late-night television. But in fact, they’re some of the things people are saying about OpenNotes.

OpenNotes isn’t a product, but an idea: That the notes doctors and other clinicians write about visits with patients should be available to the patients themselves. Although federal law gives patients that right, longstanding medical practice has been to reserve those visit notes for clinicians’ eyes only.

But Tom Delbanco and Jan Walker, a physician and nurse at Beth Israel Deaconess Medical Center in Boston, have long seen things differently. Their personal experiences with patients, and inability to access care records for their own family members, persuaded them that the traditional practice of “closed” visit notes had to change. So, with primary support from the Robert Wood Johnson Foundation, they launched what has now become a movement.

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We Went to Oxford and Got Schooled in Primary Care

Apr 23, 2015, 9:00 AM, Posted by Maryjoan Ladden, Susan Mende

As other countries continue to spend far less on health care but perform better on measurable health outcomes, there's opportunity to learn what works abroad and apply those lessons stateside.

It’s a hard notion for many Americans to accept—although we spend more money on health care than any other country in the world, we are far from having the best health outcomes. When you look at measures that include life expectancy, infant mortality rates and preventable illness, other countries that spend far less than the U.S. perform better. But in many of these countries people of all ages and socio-economic status are able to easily access primary care that is comprehensive, patient-centered and rooted in local communities.

One of our goals as program officers at RWJF is to look beyond our borders to identify promising practices that might be incorporated into America’s health care system. Last fall we traveled to Oxford, England, to learn first-hand about promising primary care practices in Chile, England, the Netherlands and Canada—all high and middle income countries that spend less on health care yet have better outcomes than the U.S. We attended a conference organized by the Training and Research Support Centre (TARSC), an organization supported by Charities Aid Foundation of America through a grant from the RWJF Donor-Advised Fund. TARSC provides support and training to government and civic health organizations, and the conference was the next step after its report, “Strengthening primary care in the USA to improve health: Learning from high and middle income countries.” We came away with a lot of insights from both, but were struck by several themes that were constant throughout.

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Let's Keep the Payment Reform Momentum Going

Mar 31, 2015, 10:22 AM, Posted by Andrea Ducas

Recent advancements in payment reform have been massive and exciting. It's time to sustain the momentum and transform how we pay for and deliver care.

A hundred dollar bill. Modified image. Original photo by Ervins Strauhmanis.

When it comes to how health care providers are paid, change is in the air. I’m probably more excited than most people about trying to make sure our financial incentives are flowing the right way within the health care system. Here’s why.

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‘Good Morning, My Name is Aara’: Building Trust in Health Care

Jan 28, 2015, 8:00 AM, Posted by Aara Amidi-Nouri

Aara Amidi-Nouri, PhD, RN, is associate professor of nursing and director of diversity at Samuel Merritt University in Oakland, Calif. She is a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2014-2017) and has served as a project director for the RWJF New Careers in Nursing scholarship program at Samuel Merritt University since 2009.

Trust. Our health depends on it, and so do our lives.

Our very first stage of personality development as infants starts with trust, according to renowned developmental psychologist Erik Erikson. A newborn’s basic needs—food, shelter, and clothing—are entirely entrusted to a caregiver, one who hopefully recognizes that he or she does not yet have an ability to shiver, sweat, or shed tears.

When caregivers are attuned to babies’ environments and hunger cues, they are able to meet their needs and build their trust in other human beings. When caregivers hold newborns close, they meet their need for love and affection, building trust with every heartbeat and with every breath. We are social beings, dependent on one another. We must trust one another in order to survive. It’s no coincidence that our pennies—our most basic form of currency—are engraved with that very word.

What happens when, instead of building trust, we create mistrust? What happens when we can’t trust our health care system or our health care providers—our own caregivers, the very people who hold our fate and our lives in their hands? 

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'Getting What You Want': Aligning Goals with Actual Care in Patients with Serious Illness

Jan 22, 2015, 3:00 PM

The Institute of Medicine recently released a report entitled Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The news headlines read: “Panel Urges Overhauling of Health Care of End of Life.”

Here’s why: Most Americans wish to die at home and want to avoid heroic measures to keep them alive. Yet most die in institutional settings like hospitals and nursing homes, and 20 percent die in intensive care units.

The transition of death from the home to institutional settings over the past 40 years has been promoted by the advent of new medical technologies. While these remarkable technologies can be life-saving for certain patients, for many others aggressive therapies may simply prolong the dying process and extend suffering. In addition, many patients who die in institutional settings die with undertreated pain and difficult or labored breathing. And many report inadequate communication with their physicians about their end-of-life preferences.

Numerous studies show that patients want to have conversations about their end-of-life care and expect their physicians to initiate these discussions. When these conversations occur, there is greater alignment between patients’ wishes and the care they receive; higher patient quality of life; less frequent use of non-beneficial life-sustaining treatments; more use of hospice care; reduced family distress; and reduced resource use and costs. However, many physicians do not feel comfortable having these conversations and, in fact, identify more barriers to having these discussions than do patients.

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Restoring Dignity to Those with Dementia

Jan 21, 2015, 4:00 PM

Judy Berry is the founder of Dementia Specialist Consulting and the Lakeview Ranch Model of Specialized Dementia Care in Darwin, Minn., and a 2010 recipient of the Robert Wood Johnson Foundation (RWJF) Community Health Leaders award.

I live in rural Minnesota, and my passion is to make a significant contribution to improving dementia care in our society and to be an advocate for all seniors with dementia in their quest to maintain their basic human right to dignity, choice, and quality of life until their death.

My mother, Evelyn Holly, passed away 16 years ago. She spent the last seven years of her life being bounced from one nursing home or residential dementia facility to another, and in and out of hospital geri-psych units, all because of her so-called “challenging and aggressive behavior.” She spent the last year of her life strapped in a chair and drugged so she would be “compliant.” I imagine many of you have had similar experiences. Click on this link to view a video about my personal struggle with dementia care—a struggle that has fueled my passion to improve it.

After many years of heartache and frustration in my struggle to find appropriate care for my mother, and after being told repeatedly by others in the health care industry that the kind of dignified care that I visualized was impossible because it was too expensive, I discovered that I could not find any financial support for trying something different. I decided to use my own life savings to try to develop a model of specialized dementia care that would focus on the unmet emotional and spiritual needs of persons with dementia, many of whom are unable to communicate those needs, and to meet their physical needs as well.

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Achieving Health Care Equity Begins with Relationships

Jan 19, 2015, 9:00 AM

Have you ever had the experience of being sick and in need of help from a health professional? How about having a parent, child, other family member, or friend who had some health issue for which he or she was seeking answers? What was that like for you? How did you feel, and what were you looking for from that doctor, nurse, or therapist?

Did you ever feel afraid, and alone? Confused?  That no one understood what you were going through? Or cared? Or even worse, that the health professionals may have made some assumptions about you or your family member that were wrong – even perhaps blamed you for having your condition or judged you for how you were dealing with it?

Scholars Forum 2014 Logo: Disparities, Resilience, and Building a Culture of Health.

If so, you are not alone. Many people who find themselves in the role of a patient have felt these same feelings and had these same thoughts. And if you are poor, don’t have private health insurance, or if you are a person of color or belong to another minority group in our country, you are more likely than others to encounter these problems.

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RWJF Executive Nurse Fellow Brings Nursing Perspective to Bioethics

Jan 14, 2015, 9:00 AM

Cynda Rushton, PhD, RN, FAAN, is the Anne and George L. Bunting Professor of Clinical Ethics and a professor of nursing and pediatrics at Johns Hopkins University. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program (2006-2009). In 2014, she was named a Hastings Center Fellow for her work in bioethics.

Human Capital Blog: Congratulations on being named a 2014 Hastings Center Fellow. What does this fellowship mean for you and your career?

Cynda Rushton: It’s a wonderful honor to be included in this interprofessional group of scholars of bioethics. It’s a terrific opportunity to cross-pollinate with great thinkers and leaders and to think about some of the most vexing ethical issues in health care. It’s going to be a rich container for dialogue, learning, and leadership.

HCB: How will the fellowship work?

Rushton: Fellows have the opportunity to help guide the direction of the Hastings Center, which is an independent, non-partisan and nonprofit bioethics research institute in New York. The center’s mission is to address fundamental ethical issues in the areas of health, medicine, and the environment, and we’ll be bringing up issues that we think deserve more in-depth scholarship and research. This summer, we’re having a retreat where we will be able to work together around issues of common concern, particularly in the area of bioethics.

HCB: What will you focus on as a fellow?

Rushton: My focus has been on how to create a culture of ethical practice in health care. I’m interested in what is required to create that culture and what kind of individual competencies need to be in place to support people to practice ethically and reduce moral distress.

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Understanding Microcultures of Health: It’s Time for a ‘Deep Dive’ into Culture & Social Networks to Produce Lasting Health Change

Jan 6, 2015, 9:00 AM

Jason M. Fletcher, PhD, is associate professor at the La Follette School of Public Affairs, Department of Sociology, Department of Agricultural and Applied Economics, and Department of Population Health Sciences at the University of Wisconsin-Madison. He is an alumnus of the Robert Wood Johnson Foundation Health & Society Scholars program at Columbia University, where he researched the intersection of health and social networks.

While an important priority for improving health and health care in the United States is in focusing on broad notions, such as creating a Culture of Health, there is also a need to consider targeted approaches that make use of the structure of relationships that influence health. Most people consider only a small number of social contacts when discussing important matters. Even though our Facebook friends number in the hundreds or thousands, the number with whom we share close and regular geographic or social space is considerably smaller. Network science is leading the way in uncovering what our microcultures look like and how they operate; these findings should be put to further use to improve population health.

These “small worlds” of influence are known to have substantial impacts on health—as shown by numerous careful, gold-standard empirical studies. College freshman who are randomly assigned a roommate who binge drinks are more likely to binge drink, themselves. Adults whose spouses stop smoking through a clinical intervention are themselves much more likely to stop smoking. These positive and negative impacts on health spread not through broad culture but through the “microcultures” of close social ties.

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'We Need People to be Incensed by the Health Inequality that Persists in This Country'

Jan 5, 2015, 9:00 AM

Felesia Bowen, PhD, PCPNP-BC, is an assistant professor at Rutgers University School of Nursing, and a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar (2014-2017). Her research focuses on community-based pediatric asthma care.

Scholars Forum 2014 Logo: Disparities, Resilience, and Building a Culture of Health.

When I first began working as a pediatric nurse in New Jersey 20 years ago, I was committed to getting asthma care right. I worked hard to educate my young patients and their families about the disease, how to avoid the triggers that cause attacks, and how to use their medications. I wrote asthma action plans and prescribed the correct medications to control symptoms. 

It wasn’t always enough. One Monday morning, one of my young patients experienced asthma symptoms. The family followed his asthma action plan, “stepping” his medications in an effort to relieve his asthma symptoms. On Tuesday, he wasn’t feeling better, and went to the nurse practitioner (NP) in his school’s health office, who appropriately modified his treatment plan and called the asthma specialist to get a next-day appointment for him.

She remembers the young man telling her that he really needed to feel better, because he was going to his middle school graduation dance Wednesday night. On Thursday morning, he visited the NP again, still with asthma symptoms. He told her that he had missed the appointment with the asthma specialist because his mom couldn’t make it—she had health issues of her own, and three other children to care for. But he’d gone to his dance and proudly showed her his middle school class ring.

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