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June 9, 2017

These 10 health care rules are bad for care, providers and patients argue

Daily Briefing

    Providers and patients have identified the top 10 health care rules that they say should be changed to improve care quality—and health care executive and managers can take action on the vast majority of them, according to according to a new JAMA viewpoint from the Institute for Healthcare Improvement (IHI).

    5 myths physicians believe about patient experience


    The Leadership Alliance—a group of 42 North American hospitals, associations, and care systems convened under IHI—urged members in January 2016 to ask patients and staff, "If you could break or change any rule in service of a better care experience for patients or staff, what would it be?"

    According to the viewpoint authors—IHI leaders Donald Berwick, Saranya Loehrer, and Christina Gunther-Murphy—the Alliance posed the question as part of its initiative to deliver on the promise of the "triple aim" of health care. The Alliance has established multiple principles aimed at progressing toward that goal, one of which is "Make It Easy"—an effort aimed at identifying and eliminating unnecessary health care rules and regulations. The "Breaking Rules for Better Care" challenge fell under that principle.

    Key findings

    According to the authors, 24 Alliance members participated in the challenge. Overall, participants listed 342 rules, regulations, and hospital practices that they said posed little or no value to patients. The top 10 rules that respondents said should be changed are: 

    1. Visiting hours and other policies that limit visitors' ability to spend time with patients, which garnered 15 mentions;

    2. CMS' three-day rule mandating that a patient spend three consecutive days as an inpatient to qualify for Medicare coverage for a skilled nursing facility, which garnered 13 mentions;

    3. Restrictions that prevent members of the care team from operating at the top of their license, which garnered 13 mentions;

    4. Limited access to same-day appointments and limited access to providers between appointments, which garnered 10 mentions;

    5. Long wait times for appointments, procedures, and discharges, including policies that respondents said worsened the situation, such as double-booking, which garnered 10 mentions;

    6. HIPAA regulations and misinterpretations that respondents said lead to delays and undermined communication between patients, family members, and providers, which garnered eight mentions.

    7. A lack of engagement with patients' loved ones to support patient recovery, which garnered six mentions;

    8. Unnecessary interruptions while patients are sleeping, which garnered 5 mentions;

    9. Overcomplicated and unnecessary paperwork, including the collection of duplicative information, which garnered five mentions.

    10. Not fostering patient mobility during their hospital stay, which garnered five mentions.

    Leaders can take immediate action on most rules, authors say

    According to the viewpoint authors, contrary to expectations that statutory and regulatory barriers would comprise most of the cited rules, the majority of rules mentioned "were fully within the administrative control of health care executives and managers to change."

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    Specifically, the authors said that of all the 342 cited rules:

    • 62 percent were rules particular to individual organizations that could be changed without violating any formal statute or regulation, such as mandating that patients and family pay for parking spaces;
    • 22 percent were statutory and regulatory rules, such as CMS' three-day rule; and
    • 16 percent were habits established by organizational behaviors that are based on little or no foundation in legal, regulatory, or administrative requirements, such as the prohibition on making drinking water available to staff at nursing stations.

    Next steps

    After surveying patients and providers, many organizations took some form of action, the authors wrote, such as clarifying myths and misinterpreted rules, requesting clarifying information from regulatory agencies on the scope and intent of certain regulations, changing local policies that weren't well-founded, and/or lobbying policymakers on any regulations deemed harmful or wasteful.

    Ultimately, the authors concluded, "Health care leaders may be well advised to ask their clinicians, staffs, and patients which habits and rules appear to be harming care without commensurate benefits and, with prudence and circumspection, to change them" (Rappleye, Becker's Hospital Review, 6/7; Berwick et. al, JAMA, 6/6).

    5 myths physicians believe about patient experience

    5 myths physicians believe about patient experience

    Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.

    Clinician-patient communication, leadership of the care team, and support and empathy for the patient across the unit are the most important factors for success, and they're all driven by the physician as the "Influencer in Chief."

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