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Please share an example of a decision that was made to aid the organization rather than the patient(s).
1. Parking Lot Priorities
2. length of stay issuses and pushes for early dicharge
3. Medication Formularies Medicare's "three day rule" for SNF qualification
4. JCAHO requirements that become implemented are sometimes at odds with the real needs of patients even though they are supposedly driven to ensure patient safety. They take the control away from the physician/nurse-patient relationship where it should be.
5. Choice of process over active intervention for patient care. Lack of money and inability to obtain staff to care out activate plan
6. Financial triage in a fee for service environment
7. We must use Cipro po instead of Avelox po because "Cipro is cheaper and is 'essentially the same' drug as Avelox. We can give Avelox IV because the bulk cost is cheaper than Cipro IV (who would of thought?). Many of our "stupidvisors" where cone hats!
8. Administation protecting high producers despite obvious breaches of quality care
9. CPOE!!!!
10. Doing mchat or others for example to determine psychological or autistic problems in children. We have not istituted this as we have felt we already have enough things to do in our limited time to see patients and adding more is very difficult for us. We probably will do these in the future when we figure out how to do them with the time we have and also get paid enough to add more to our visits.
11. Medication reconciliation - should help the patient but has really been done to meet JCAHO requirements - time consuming, poorly done, doesn't currently aid the care of patients.
12. closure of an access gate at night to conserve security forces manpower...patients had to travel farther to get to ER entrance
13. Investing in bricks and mortar rather than state-of-the-art equipment.
14. Support staff does not match population growth.
15. We closed our inpatient rehab unit because it was losing money. We are considering eliminating our outpatient counseling program and our neonatology program for the same reasons. In both cases, patient care will suffer.
16. decision about how to implement e-prescribing where expense of handling mail-order or controlled substances was left to printing rather than using electronic transmission
17. There is an over zealousness in terms of rapidly moving patients through the system oftentimes much too comfortably overlooking clinical concerns of the medical staff who are more attuned to delivering care in addition to the disregard of the added workloads without adjustments of productivity expectations. The paper goals of documenting quality delivery without attentiveness to the increasing workloads will adversley impact care (ie. it's inevitable that staff time and energy per case will rise and touch time of care will decrease). Unless the system will pay for this extra energy we will likely see a decrease in care/communication (touch time) in the years to come which in my opinion is not a patient centered pathway.
18. next time
19. A service van ferrying radiation therapy patients was recently pulled out because of a perceived potential liability risk. This service was greatly needed and appreciated by the cancer patients and now sorely missed.
20. Quality measure of documenting circulatory flow, tcp02, bone scans for severe leg ulcers occurring in Rehab and SNF setting are discouraged since they will deplete the capped daily amount of Medicare reimbursement. Monetary resources of payment to SNF or Rehab are jeopardized when multiple needed exams are performed on these patients. Their profit is affected.
21. LENGTH OF STAY ISSUES AUTOMATIC SUBSTITUTION OF MEDICATIONS.
22. We have seen allowing a practice such as a anesthesia preoperative assessment to be done immediately before surgery than during the pre-op visit so the organization does not need to pay the anesthesiologists for the additional time needed.
23. standardization of surgical trays
24. Exclusive purchasing contracts that favor one vendor
25. bare bones staffing of nursing personnel
26. Need to hire psychiatrists first when there is a high need and there would be a better compliance rate (in my opinion) with a department or division of therapists and social workers working together with the docs. It may happen down the road, however, now there is a need.
27. Refusing to keep a deconditioned quad an extra few days in acute care for nursing care and antibiotics after a major flap reconstruction.
28. Timeliness: Schedule is often weighted to organization need - over bookings due to no-shows, daytime hours, ...
29. Selection of less expensive equipment/supplies in the OR
30. A request for participation in the NSQIP program of the ACS to track quality indicators in surgical cases has been sitting, unfunded, in the administration for two years.The reason? A tight budget, a lack of desire to spend the money and allocate personnel, and an apparent feeling that generating good quality data would force the institution to take action.
31. Processes set up to comply with perceived joint commission standards that hamper patient flow and service delivery
32. Patient wait in observation unit until Monday for diagnostics, due to tech/reader unavailibility (cost).
33. Disallowing the treatment of opiate addiction with buprenorphine in the outpatient clinics.
34. We have attempted to implement programs that would increase medication adherence/compliance yet have been thwarted by individuals who do not believe that there is an ROI there despite the published evidence that there is.
35. Financial burden of some quality/safety measures leads to acceptance of lesser goals.
36. Protocol for bed assigments in Critical Care, dischage criteria (from ICU) and criteria for "holding ICU patients" in ER
37. Delaying programs because the finance group argues that the budget does not allow.
38. Placing new technology for outpatient testing in the hospital environment rather than in an outpatient setting.
39. A misgiuded concept that CAM providers will help draw patirnts to the hospital, when surgical equptment and support personel are relatively ignored (althought bring in 70% of the revenue into the hospital). We need attention to the medicine we do better, not something new thought up by marketing.
40. Elderly patient who had malignancy diagnosed during hospitalization and patient waited until after discharge for staging MRI's as the hospital got full reimbursement for MRI's for staging as outpatient and gets none under DRG of hospitalization. patient from rural community had to drive back for staging MRI's to great inconvenience.
41. Slowness to adopt technology (bar code identification) because of money and not enough individuals to implement the practice.
42. Resistance to expanding OB services to the community health center because of low reimbursement for the organization.
43. Limited resources based on finances
44. Screen and treat all positive urinalysis in the ED to lower the risk of ahving to report a nosocomial infection
45. delays in mri/ or invasive procedures with certain back problems
46. decision to staff at a given level without flexibility to upgrade
47. not will to spend the money to institute Quality measures
48. Continued contractual relationship with needed physician provider group that struggles with some quality issues. No alternative provider available.
49. use of lower cost DVT prophylaxis
50. War readiness occasionally trumps patient care and quality in a military setting.
51. not to add an item of equipment because the return on investment would be marginal at best but the equipment would better quality/safety
52. Pressure for "customer satisfaction" instead what is actually appropriate for the patient. Example is not to "insult" pregnant asthmatic that presents wheezing about not smoking.
53. Time-intensive fiscal verification reduced access to clinical services in mental health system. This created barriers to treatment.
54. early discharge
55. Experimental and investigational procedures that are the best options for a cancer patient.
56. administration trying to keep less than acceptable physicians on staff, do to the income they bring in for the hospital
57. There are new implants either not reimbursed or inadequately covered which devices are truly superior to what has been used to date. We either wait for better coverage or potentially work ourselves into bankrupsy. Though not well reimbursed, our program/ministry is focused on the quality initiatives intensively with favorable measurable performance improvement. Yet the details being addressed are often offensive to the spirit of the practitioners. Example: illegal orders such a qd, "u", etc. Now physicians have to mark every possible interventional site (still wrong site intervention is occurring); recently the word is coming to write RIGHT rather than "R", LEFT, BILATERAL, etc. Now an administrator, but previously for more than 30 years a very human, but dedicated surgeon-I struggle with discouragement, but DO recognize benefit. Is there a balance that can be achieved?
58. The hospital has initiiated a policy that physicians can no longer prescribe a "patient istter"for patiens that have traumatic brain injuries, or ohter injuries that physicians beleive require a person monitioring at bed side to prevent the patient from harming self or getting out of bed. Theses iters also oftne propvide re assurance to the confused patient and reduce the need for physical and chemical restraints. Only nursing candetermine if the patient needs this 'sitter" for safety or medical care reasons
59. 10 am discharges
60. All transitioning babies are admitted to an intensive care area rather than a well baby holding area in order to be able to eliminate nursing positions.
61. Decision to transfer a patient to a less costly acute rehab facility (that had an available bed) rather than waiting 2 or 3 additional days until a bed opened at the optimal facility.
62. REFUSING TO BUY BEST EQUIPMENT, TO REDUCE COST. THEN GET LESS CONSISTENT SURGICAL RESULTS
63. Being too transparent due to fear of getting sued
64. discontinuing a successful anticoagulant clinic with data to support impact because of lack of business case.
65. Implementation of helath insurance system that need complete studies fo the impact of local socio economic factors.
66. Defering implementation of patient identification that includes some sort of mechanically readable format
67. improve the physical plant rather than improve the environment of care
68. The availabiliy of certain drugs.
69. pt need an extra day in the hospital might be difficult because of the insurance company watching
70. To keep pt referals within the organization rather than use the best qualified who can help the patient.
71. Discontinuation of a reminder program for women's health preventive care due to cost. Discontinuation of a compliance/persistence program for new start anti-depresants due to withdrawal of funding from Pharma company.
72. Thrombolytic administration for stroke policies accepted / pushed without resources to monitor following accepted protocols to assure patient safety. This was done to replicate a "standard of care" without assessing a facilities capabilities to support the protocols.
73. not offering weekend hours due to overhead costs when some pts can only come on a Saturday
74. Information system implemented that did not have the best of patient care in mind
75. The decision to delay the full scale implementation of a compliance program for the providers
76. Ex
77. Nursing to patient ratio, particularly in our PRU(Patient Recovery Unit). The outpatient PRU was intended to be separate from the inpatient PACU(Post Anesthesia Care Unit). Unfortunately, due to financiual concerns as it relates to nurse staffing, often the 2 units are combined in the PRU facility. One nurse is not infrequently struggling with patients in separate 4 patient bays, as well as discharging outpatients while receiving a new patient for recovery from general anesthesia. For the first time in about 10 years, we had to resucitate an apneic inpatient who was not one on one with a PACU nurse - the sole reason being that the patient was not one-to-one, and the nurse was attending to another patient at the time of the apneic episode.
78. Staffing ratios.
79. Taking commonly used medication off formulary, for example, Wellbutrin XL- forcing the physician to prescribe the less expensive Wellbutrin SR.
80. Decisions related to the eligibilty of patients and the consequences of providing managment and support
81. Scheduling for outpatient testing when the appointment schedule is more important than the convenience for the patient.
82. encourage testing at the short end of time frame for benefit of P4P program
83. patients with life endangeing situations are denied care for technicalityonly example , multiple facial fractures with functional abnormalities
84. Limitation of services and consultations due to elegibility
85. N/A
86. Lack of an active QC audit process in Radiology because it "takes too much time".
87. Setting co-payment levels high on expensive injectable medications.
88. Delay in implementing clinical recommendations until funding available
89. redirecting patients to inside providers
90. Scheduling procedures to minimize effect on workforce, not at appropriate time for patients.
91. Reusing disposable instruments in the OR to save a little money.
92. can't think of one at the moment
93. making the providers fill out more forms rather than spend time with patients.
94. Hospital discharge
95. decision to NOT hire a half time pt safety officer
96. Discriminating candidates for ICD insertion.
97. Constructed Pay for Performance program that addressed revenue enhancement more than quality improvement.
98. Limited our capcity to provide services due to lack of compensation.
99. Prescription drugs
100. Decision to supply glucose meters based on cost rather than ease of use and accuracy
101. anesthesiology was required to administer propofol in our electrophysiology lab. Patients and providers were inconvenienced, delayed or cancelled to satisy organizational legal concerns.
102. Staffing ratios too slim.
103. Slow implementation (Deliberate delay?) more the issue
104. Not starting a "fault free" error reporting system because of "timing" in the organization.
105. Nurse staffing ratios
106. discharge of patients prematurely because hospital will lose money
107. Avoidance in rewriting and financially restructuring old OB anesthesia contracts that would improve the back-up call problem at the facility and most likely improve the risk management situation.
108. Decisions about the use of an Observation status vs. an Inpatient admission.
109. Bedside glucose monitoring taken over by the lab to ensure QI testing. It's now a major issue just to get a blood sugar, and treatment is sometimes delayed as a result.
110. Limit resource expenditure for disease management --- saves dollars while meeting regularoty requirements, but does not allow care for any but the sickest potients with the disease.
111. Our hospital uses an in house corporate developed "home health" organization routinely for stroke rehab patients. A local rehab hospital devoted to such rehab is available but seldom used even though the only two physiatrists on staff work there exclusively. Our home health rehab is primarily physical therapist managed with little real input from physiatry.
112. Lock the ER door, allow only ambulance crews through with a key. Creates a huge barrier. patients in pain much travel around the building to find an entrance. I tell pts "Go ahead - call an ambulance."
113. We had the option of using smart cards for our patients that were quite enhanced. These cards would have allowed patients to essentially have copies of their medical records in a secure chip on a card that they could have taken outside of our system. It would have allowed things like current medications and allergies to be coordinated between different systems. They also facilitated communication with the insurance company that was sponsoring them. Our Leadership team declined to move forward with this because we are in a major initiative with our EMR, and we are also at a point where we are developing an interface with our partner institutions for electronic information. It was felt that we do not have the resources to do all 3 major projects at once, and although it would be safest and best for patients, we will not be part of the smart card initiative.
114. Patient population growth not supported with the need for more support staff,ie nurses.
115. usually it involves money and the inability to do it all. It is impossible to get everything, but, over time I feel we eventually get there
116. I work at a very large state psychiatric hospital. The patient bathrooms are being renovated at our hospital to reduce the risk suicide. Due to the expense this will not be done all at once, but as money becomes available. Higher risk areas have been given priority.
117. Medication reconciliation not done on ER patients s it takes too much time and use of duplicate forms (too costly)
118. Using a contracted specialist known for poor performance rather than allowing referral to other specialist providers. Keeping the poor performing specialist on contract to save money.
119. Limitation of ancillary services on weekends
120. xxxxx
121. Limiting where a patient can go for physical therapy to a hospital owned facility.
122. starting up a hospitalist program; giving people CHF education while in the hospital instead of in an outpatient setting;
123. choosing more profitable method of testing than one that is supported by the clinical evidence. Radiologists commonly recommend additional testing, forcing the tests to be done (or liability would result) only for the profit of the organization (and the radiologists) and not to the benefit of the patients.
124. limited budgets causing chronic understaffing
125. Frequently resources (equipment, supplies, and/or staff) is sacrificed in order to cut costs as much as possible.
126. A case management program for the frail elderly was recently cancelled despite a proven track record of reducing hospital admissions and ED visits while saving the Medicare program 11% PMPM when compared to a similar control group. The CEO of the hospital came to me one day and asked: "Tell me again why we have a program that decreases my admissions and reduces the utlization of my ED?" To tell you the truth, I couldn't blame him. Despite our best efforts we couldn't get the medicare intermediary to see the wisdom of financially supporting the program and my CEO wasn't paid to do preventive care.
127. Nurse patient ratios and staffing standards. Staffing decisions based on money rather than patient safety. The benchmark data that had been previously used by the institution was ignored.
128. Insurance decision not to coverage for gastric bypass surgery ( we are a health insurance company)
129. Primarily around the issue of IT resources to support data gathering and reporting, i.e., not much capital investment to date. There is a very high committment on the part of the patient care teams, and it would make the work much more meaningful if data gathering were not so people intensive.
130. In general, there are QI initiatives that could be done, but cost can be a factor. I feel this puts the organization above the patient.
131. Reduction of our urgent care center hours to save money
132. Pulling privileges from radiology group, replacing them with smaller, less competent, inadequately staffed captive group to have more control and deliver a message to large multispecialty clinic.
133. Putting in an emergency department "screening exam"to decide if pt is truly 'ER' material, and charging if they are not.
134. Hiring a physician that is a very high producer even though he presents challenges in compliance with core measures, etc.
135. cutting back hours of an urgent care facility, which was one of the few places to get care due to costs and utilization.
136. We have allowed a physician with unacceptable attitudes and demeanor towards patients and staff to continue to practice in our group. We have counseled her and fined her to no avail. I think she should be removed from the group. (Its gone on for four or five years).
137. Admitted patients are left in the Emergency Department for extended periods of time. This causes dangerous delays in the care of newly arriving patients. The organization fails to allocate adequate resources to care for admitted patients in appropriate inpatient settings.
138. failure to adopt a computerized order entry system
139. I'd rather not
140. It would be better care to screen hearing in all patients per the AAP guidelines, but we just don't hvae the staff or time to dedicate to this yet, so we dont' screen hearing in my office
141. Programs not funded that would not have a positive bottom line.
142. Not supporting electronic order entry/electronic medical record.
143. Screening procedures.
144. Generally, simply due to the inability of physicians and nurses to do the extra to comply with policies and initiatives that are supposed to be in place.
145. Credentialing mediocre providers.
146. Staff reluctance to accept timely patient appointments because of disruptions to established staff routines. Access is, after all, a key component of the patient value equation.
147. 1.Patients without resources are turned away despite threatening medical conditions 2.Staffing ratios are maintained at the lowest levels despite critically ill patients
148. Early discgarge of a patient with a pulmonary mass to be evaluated as an outpatient without assurance the patient would indeed get the workup
149. We have a separate Children's Hospital, with Operating rooms reserved for children. Our facility is better, more modern and more functional than the adult hospital. The administration decided to use the rooms for adult patients. This interferes with the care of pediatric patients and families. The two hospitals are under the same management.
150. Decisions to NOT implement quality initiative due to lack of personnel to gather and analyze data.
151. staffing reductions inclinical areas
152. I would have to sat the ridiculous over use of antibiotics for what could turn out to be pneomonia or the administartion of ASA and a Beta blocker for any hint of a coronary event. Most of the times not indicated but you don't want a "ding".
153. delay in implementing electronic order entry, bar coding, etc.
154. Avoid implementing new protocols for patients with pain out of control for patients at the end-of-life because of a perceived need to have the patients in a cardiac-monitored setting. Not supporting more counseling/bereavement programs/personnel because of cost, despite patient's families at high risk of suicide after their death.
155. administration backing off an initiative to put in place telemedicine critical care services because of objections of a high volume pulmonologist who wasn't capable of providing the comprehensive 24 hr. critical care services that the telemedicine group, manned by board certified intensivists,would have been able to provide increasing both the level of intensity of care and quality that our hospital would have been able to provide.
156. We came up with a medication reconciliation system that focuses on completing the paperwork to show compliance rather than ensure that patients have a clear understanding of their medication requirements when they leave the hospital
157. Tolerating physician and staff quality that is sub par due to financil considerations and critical shortages.
158. Transferring outpatient services to Part A billing
159. Delay in adding new equipment because of budget constraints
160. lack of availability of venous duplex ultrasound after 4:30pm 7 days a week.
161. We instituted a consent form that makes us document and mark the site of surgery when a patient comes into our out patient practice to have a wart removed.
162. low cost CT scanner
163. MRSA patients sometimes cohabitated with healthy
164. Improve the bottom line even if means shutting down or not funding needed patient safety initiatives. Because of the emphasis upon the bottom line, it makes it more difficult to be proactive in improving safety with cultural initiatives or initiatives that could use a bit more FTE support.
165. Understaffing clinics so they are open at times convenient to the organization and not to the patients.
166. Until recently, razors were stll allowed as a means of pre-op hair removal because several of the surgeons felt that the national recommendation to eliminate razor use should not be forced upon them. This has been allowed for years for fear of decreasing physician satisfaction.
167. Reduction of access to certain preventive services for uninsured adults
168. Budgetary considerations in implementation of bar coding.
169. Decrease nursing staffing, not mandating adequate controls on overtime, double standards with regard to limiting overtime on nurses but not docs
170. IV drips in units only
171. We are implementing an EMR. This has been a very painful process due to the steep learning curve involved and an increase in the lengths of patient encounters. The decision to implement at 100% pulls resources away from other patient-centered initiatives.
172. Not allowed by the Corp that practices medicine here.
173. Increasing the number of patients seen in a day, by shortening the length of visit to increase the clinic through put and RVU per provider per day.
174. Organization can't afford the personnel to provide ideal care.
175. Discontinuation of rigid datqa management to track quality efforts due to cost cutting
176. Financial bottom line driven decisions to not purchase standardized, computerized, patient instructions that would have had the added benefit of automated medication reconciliation at discharge.
177. nurses are allowed to do site marking and obtain consent for procedures
178. It is more an issue of priority or timing. Administration is slow to move the computerized record along to full CPOE. There is little support for geriatric care.
179. no comment
180. Locking up the drugs to satisfy JCAHO leaves us unable to respond in a timely manner to urgent/emergent issues with our pediatric patients in the OR. Being unable to treat laryngospasm immediately because the drugs are inaccessible occurred to me YESTERDAY in the PACU.
181. Many of the current JCAHO rules, while well intentioned add extra burden to the care team with little or no benefit to the patients. The organization sometimes puts compliance with these mandates ahead of patient care
182. The "Donut Shop" theory of medicine. This is from a new (and very young) CNO who--at our facility--was serving as COO as well. "We are like a donut shop. Our job is to sell donuts. If we don't sell a lot of donuts we go out of business. Your job, as Chief of Emergency Services is to convince patients they need to be in the hospital and to convince doctors they have to admit patients. It is not your job to decide if the admission is good for patients. Donut shops still force donuts on the morbidly obese and the brittle diabetics. We need to force admissions on everyone. What might be 'best' for the patient really isn't relevant." I resigned shortly thereafter.
183. adequate monitoring equipment
184. Eliminating our in-house cytotechs and using a more cost effective company to read our pap smears. The problem is it takes 3-6 weeks to get the results.
185. Phone menu system Hospitalist care instead of continuity in the hospital.
186. Alot of protocol orders.
187. Restriction of all appts to 20 minutes regardless of new or prev patient and regardless of complexity of care necessary--chronic conditions like HTN, Hyperlipidemia, CHF, CAD, Obesity, Depression, Chronic pain, Asthma, Diabetes--all chronic conditions with excellent nationally recognized guidlines and collaboratives but to document, educate, exam, treat patientand chart the documentation definitely takes more than 20 min yet the organization needs the productivity head count because that is how they get paid. All this while singing the song of document quality over and over.
188. Early discharge fom the hospital when a primary Care MD wants to keep the patient a few days longer but administator wants early discharge!!
189. An elderly lady (Patient) admitted due to a confusional episode i.e. wandering/ driving aimlessly with her cat in middle of the night. PAST : Healthy, employed, non-contributory. Should have received full neuro-investigational work-up, but discharged due to insurance deficit and refered to be taken care SOMEWHERE as outpatient.
190. extremely tight nurse staffing numbers - mean they always feel understaffed - and often are.
191. staffing patient ratios that are adjusted to show quality statistics but in reality are made in favor of saving money for extra staff.
192. Unlimited visitors are allowed 24/7 in the ICU at one hospital I work in. This is hazardous to the patient in many ways including increased incidence of infections and it also hinders good care as the family is always hanging around questioning every single move by the physician, nurses and paramedical staff. Administration refuses to limit visiting hours since they want the hospital to have a family oriented reputation.
193. complex and wasteful cmr system comp med records
194. would not like to comment.
195. Not encouraging ED physicians to decrease resource (radiology, lab, etc) use in low index of suspicion patients. Both medical staff and organizational barrier to improved quality.
196. Not purchasing more expensive, more easily attainable urine STD testing for adolescents due to cost
197. Preventing defined consequences to physician outliers because of the size or scope of their hospital practice.
198. )Economics made decision of where to provide chemotherapy for Welfare patients 2)Regulatory issues made decision of where to provide chemotherapy for Medicaid 3)Insurance made decision of where to provide lab testing (Insurance controlled venue not our organization's decision)
199. After acquiring a competitor which resulted in a 50% increase in patient volume, the ancillary staff was cut by 35%. Wait times increased and time alloted per patient went down.
200. Premature dishcarge from the hospital.
201. Inadequate triage staffing despite documented need for additional triage nurses, resulting in prolonged delays and Left without treatment, justified on the basis on budgetary concerns, even though the solution would have been a net financial gain to the hospital
202. Implementing chronic disease management continues to be a struggle. As an employed physician with little input to administrative decision making even at the office practice level it has been very difficult to proceed with chronic disease management. We continue to face opposition based on a productivity model. It is time to get on with providing value based care and competing based on performance and not perception. Furthermore, continuing to provide compromised care based on productivity limitations instead of developing robust patient centered programs challenges one's ethical integrity. As a result, one of my partners and I began utilizing the CDEMS registry 3 years ago for diabetes care, entered the data ourselves since no support was forthcoming from administration, met standards to be listed by NCQA in their diabetes provider recognition program and can document the supriority of the care we provide compared to the non CDEMS users in our office. Despite this success, obtaining additional support for this program and developing new ones remains a dream.
203. Non-medical patient admitted from the ER to avoid becoming an unfavorable statistic --this effectively took the pressure off case management and administration to effect an appropriate disposition (inpatient psychiatric facility or nursing home) in a timely fashion--i.e. they'd rather have the patient sit on the floor for two weeks than have the patient in the ER for DHEC or Joint Commission to notice while seeking a bed).
204. A poorly designed patient care policy created to satify vague regulatory requirement but entirely unrealistic from either the current hospital practice as well as from an efficient workflow point of view
205. physician messaging re: safety; too expensive to implement
206. The issue of providing sedation services when inadequate anesthesia services avaible.
207. None
208. Delay in implementation of an Intensivist program
209. Schedule an MRI as an OP rather that an inpatient where part of DRG.
210. Actually "organization" as refers to medical staff autonomy and the reluctance to combat the inertia and change required to do what's right. The perceived conflicts are not always based on the evidence but the danger thet is perceived in dealing with demanding change in staff practice. I do not see a self-serving concern of comprimising care for other health system objectives- just not enough resolve to correct variances in practice. This is changing dramatically, however.
211. Continued focus on productivity and workforce reduction with minimal system process change to make the sytem lean. This would then get rid of the work arounds and allow for some reduction.
212. retained a physician with poor outcomes vs. his high referral/income for hospital factor.
213. Exhausting ALL drugs in a given category of pharm Rx before you could use a non-formulary drug (knowing that eventually you would need the non-formulary drug).
214. Attempt to regionalize some parts of community medical practice without consulting physicians or patients affected.
215. A general apathy and desire not to take the physicians out of their comfort zone.
216. denying biologic to senior hmo patients
217. No echocardiography coverage on weekends
218. Starting a breast center at the hospital rather than in an ancillary setting (where more mamography is done) because the high end procedures are done at the hospital
219. in a prior job the organization decided to "redefine" HEDIS immunization criteria in order to significantly improve outcome data
220. Pression to shorten lenght of stay, in some cases, when the main reason is not the patient health, but hospital´s benfits.
221. Timings, frequency of consults, prescription costs
222. Delay in buying new, better, safer equipment.
223. Not sure I can come up with a specific example; we generally do very well in this area with our quality initiatives, yet I have to believe we are not perfect.
224. Lack of appropriate types of personnel needed based upon cost
225. State funded Managed care organizations severely restricting the use of appropiate medications.
226. Not performing PET scans on inpatients because of the cost of the radiopharmaceutical
227. The amt of $ dedicated toward IT, which supports clinical care needs to increase
228. Medication reconcilliation handwritten forms improve compliance of the organization but are actually inefficient and lead to more medication errors. This will improve with electronic health records but not before.
229. Informational systems delayed because of lack of resources. Drug substitutions. Pressure to decrease length of stay.
230. cost factor of drugs used
231. It is important to know if the patient has Sleep Apnea. But to get a Sleep Study will cost money and time in making final report. Return patient to his PCP and let the PCP order the test.
232. Staffing of parts of the hospital may be reduced at times.
233. Underpaying experienced high-quality physicians, and replacing them with younger, more naive physicians that are more controllable and will work for less money.
234. A decision to "save money" made by the Director of the Veterans Affairs Medical Center (where I worked for three and one-half years before resigning) altered the quality of compensation and pension (C&P) examinations. A cadre of up to 12 physicians on a fee basis had done excellent work with timely reports and complete objectivity for veteran examinations related to the veteran's claim of disability for 6-10 years. The contract for these physicians was down priced by the director who hired nurse practitioners to take up the C&P examinations of those fee basis physicians who departed as a result of the one sided decision of the director, even though it was within her scope of authority. After receiving a maximum of a few days training, the nurse practitioners were assigned cases. This ia an example of a penny wise and dollar foolish decision by an administrator whose entire focus was on the BOTTOM LINE = DOLLARS SAVED regardless of the effect(s) on quality.
235. Discourage colonoscopies for those with higher risk factors.
236. Closing down operating rooms because of lack of nurses and anesthestetist instead of hiring replacement (to save money) leading to delay in surgery and increase wait times
237. As an imager / Radiologist I see too many unnecessary studies (particularly CT with the sig radiation dose) by docs and especially NPs whose level of supervision is ??. Was not a decision per se but a lack of action Only with national attn to rad dose hospital taking note. Hospital sponsered a CME session by national expert at recent med staff meeting. A start ! major ch
238. Resistance to performing bilateral joint replacements even when there are medical, logistical, or social reasons because of finances.
239. homeless child admitted for RSV - not severe; mother new to area without any support system; I wanted to hold the child an additional 24 hours to get the needed support systems in place believeing that the quality of what we do goes beyond the hospital walls; got into a bit of a tussle with URM and had to really go "to the mat" on this matter; finally started nebulizations prn (really not needed) to allow the longer stay to be justified.
240. Capital $$$ for building rather than necessary infrastructure for safety/quality
241. Allowing physicians to "direct admit" patients rather than having a coordinated effort between the Emergency Dept., the admitting physician and the hospital administration to more effectively and efficiently determine the patients needs and the hospitals ability to meet that paticular patients needs at the time. The institution does not want to "make" physicians change the way they have "always done it".
242. not purchasing a Homium laser for uro pts. necessitating transfer out if needed
243. Retention and reward of physicians who provide significant clinical volume but have known, measured marginal quality and have been documented to treat staff with contempt.
244. The organization moved to a centralized call center to save money. The call center had a direct negative impact on the patients who, for years, had called and spoken with the staff they knew at the office site.
245. Selection of one medication over another (Heparin rather than Lovenox).
246. Failure to hire a locum tenens to provide minimal ICU experience during a period when we lost current staff.
247. Deferring GYN care because of incresed demand for obstetric services.
248. Our disease management efforts focus on our HMO patients. We are paid on a capitated basis for our HMO patients. There is insufficient financial reward for extending many of our disease management efforts to fee-for-service patients.
249. Bedding of pts on sub-optimally staffed units in order to support census. Discontinuation of practice of providing medication samples to pts that are d/c'd from the ED after local pharmacies are closed.
250. Early OR cut off time due to staff comfort.
251. Our health system is completely sold on the idea of Informatics permeating every facet of medical care without due consideration for both the short and long term effects. For them it is sound logic to spend millions on EMR, but cut every corner on staffing, education for the staff, and pay increases.
252. Focus on throughput, getting patients out of the ED quicker, can lead to poorer workups
253. Institution of an EMR that was meant to provide better patient care by improved readily accesible documentation, when after all other parties(Worload acctouning, RM etc ) got done adding modules is now so cumbersome and non-user friendly That its orinianl intent is diluted and does not do any function well.
254. Mandatory signing, timing and dating of verbal orders. No clinical benefit yet Hospital and Organizations require it.
255. Limiting computer alerts
256. hospital refuses to allow patients to wait in the hallway when boarding is an issue. therefore, patients wait MUCH longer in the waiting room instead of having their problems addresses in a timely manner.
257. Failing to upgrade patient information system despite many problems. Failure to upgrade equipment to newer, more diagnositally acurate systems due to cost.
258. To increase compliance in seeking early prenatal care, our institution began to offer sonograms at the first visit for our clinic (residents') patients, as they entered the clinic. They then saw the physician. Abruptly, this was stopped without notice, making patients angry, and some walking out of the clinic.
259. Emergency Department Crowding, due to admitted cases "boarding" in the ED waiting for an open bed for many hours, leads to significant delays in care in the ED. If the ED is full of boarders, there are no beds to accept new patients from EMS or the waiting room. ED Crowding (although multifactorial)directly correlates with the functionality of the whole hospital. Although we have fixed this issue now (a new CEO helped this happen)
260. Extensive work was done on a patient safety initiative in for the ambulatory setting, but the initiative was halted due to cost concerns.
261. Our local community hospital opened a " Peds ED" with great fan fare. Their purpose was to compete with the Hospital 10 miles away that has 24 hours peds hospitalist. The real problem is the perception in the community thta the hospital provides poor quality ( both MDs and Patient). The real solution was to look into a Peds ICU and Surgeon to back up the current ED and community pediatricians. But that does not make money. The same hospital has stopped a competing hospital from opening a tertiary care center in the county by manipulating the Local Development Board. Yet often they have to board patients in the ED for days and the waits in the EDs not during Flu season can be 3 to 6 hours.
262. Unwillingness to agressively roll out IT which has been shown to benefit both data collection and clinical decision support
263. nurse to patient ratio's have increased
264. decision to shortcut the "timeout period" in the OR because of surgeon preference
265. referral for outpatient procedure when that procedure is likely not avaiable on d/c
266. Failure to add additional FTEs for patient care
267. not granting care to patients who have previously not paid bills but need our assistance
268. Limiting salaries and affecting nurse reecruiting, ratios, etc.
269. At some hospitals I work at: stool guiac cards needing to go to the lab to be read. No urine dip sticks in the ER, must go to lab for them to review. (Both deemed necessary to be congruent with JCAH objectives--both delay care). No pH strips in the ER at my major site of practice--laboratory took them away (delays prompt care in a chemical splash to the eyes).
270. Inability to order supplies that are a safer quality than those which are less expensive for the hospital because of contracts.
271. Financial considerations implementing programs.
272. We changed practice management system to improve revenue cycle but disrupted our web portal with the pts in order to do this
273. failure to expend resources to fiully implement a piece of the 100,000 lives campaign
274. Delay in implementing a more streamlined patient notification of lab results due to clinician resistence.
275. Refusal to negotiate prices with ANY insuranace carrier
276. Implementation of a component of the EMR that was so buggy that it distracted the care giver form the patient in an inordinent manner. After four months and several patient care accidents it was finally removed and taken back to the drawing board
277. Community general surgeons taking trauma call were not being paid a stipend and so they would take call because the Chairman forced them to but never came to see patient that did not need an operation
278. Strick enforcement of policy limits when a benefit exception would have resulted in a better over-all outcome for the member
279. Not implementing a safety initiative because resources where tied up elsewhere or that had enough negative impact on physicians that would cause some disenfranchisement.
280. Delay in the implementation of Smart Pumps
281. Expansion of services mandated without additional increments of manpower, leading to dangerously overworked providers--all because of financial and productivity pressures on the organization.
282. We really need to upgrade our defibrillators for safety reasons but due to finances this was nixed.
283. The requested increased # of pts to be seen/hr in name of efficiency.
284.