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trouble, so she just downgrades the pressure ulcer from a IV to a II. Because the
hospital is going to get penalized for a IV and if its a bad hospital
administration, they will 'solve' the problem by having the nurse lie. I went to
Marty Makary's book signing not that long ago and a nursing student made the point
that they are being taught how to ""shave"" patient records to limit hospital
liability when things go wrong. It's part of the curriculum. It's part of the
culture. Second, while 30-40k files sound impressive, with about 5000 hospitals
accepting medicare, that is about 6-8 files per hospital. That is not enough for a
statistically valid sampling at the hospital level and allocating files on a per
hospital basis gets pretty messy pretty fast. I used to do federal agency contract
compliance. That would not be a methodology that would fly in other agencies,
including VA. That's why I think direct surveys to patients, validating data and
identifying issues, based on dx codes is a much more powerful method. Makary made
the point that most specialties have developed internal measuring methods that are
harder to game. Ask those questions of patients, and when you get a red flag, see
if the institution is telling the truth -- that is a much more powerful tool. The
medical records are 100% self-serving.third, even if you are going to go to all of
the work of gathering all of this data, what are you going to do with it? Because
if you are not taking enforcement action, its just a whole lot of hot air. that's
what bureaucrats do with problems they don't want to address. they have studies and
form working groups who have conferences and symposia and that keeps all of the
eager beaver people who they want to not bug them busy bugging each other and
making up power points and giving talks and feeling like they are accomplishing
something. They give them awards. And then they ignore them and go make policy
while the other folks are power pointing. So, if this is a giant power point
effort, which takes the heat off of a real effort, tied to real performance
measures, I think it actually gets in the way of real change. Because it acts as a
fig makes people think a problem is being solved when it isn't.""What are
the new incentives to lie? I truly don't know. Maybe I should.The sample I
referred to comes from 800 of the approx 3400 hospitals in the medicare sample each
year on a rotating basis. It's the Inpatient Quality Review sample that CMS
collects. I'm not a statistician, but people who are tell the same size is pretty
good. The 95% confidence intervals are pretty tight.I worked for VA for almost 10
years. They've done some great work, like developing NSQIP before ACS took it
national with AHRQ funding. But VA can't measure patient safety (they can measure
quality) any better than anyone else can. That's the huge challenge we're trying
to address.ACS's NSQIP is unconnected to accountability but it still seems to make
rates of quality problems go down, which seems to indicate that increasing
accountability is not the only way to improve outcomes.Which real patient safety
performance measures are you referring to that might be getting ""in the way of
real change?""Is someone in the government thwarting real change? If so, who and
what? How does any bureaucrat benefit from thwarting real improvements in patient
safety? What bad things would happen to bureaucrats if patient safety was shown to
have improved markedly?""Um, the penalties imposed by Obamacare. I used to do
contract compliance oversight and audit of federal agencies. Also not a
statistician, but we had statisticians set
up the sampling for each agency we did. I don't think you have a deep enough
sample. And I when I am talk about VA, I am talking about their contract
compliance. I don't see why we should be more careful about contracts to supply
toilet paper than we are about contracts to provide health care. But it is very
obvious to me that our government cares more about conforming TP. And given the
amount of money needed to do a proper sample and proper analysis, I think it would
be a huge waste of money if it were unconnected to actual enforcement.I look at HHS
and I see the Department of Defense in the era of $700 toilet seats. So we have an
organization dedicated to jawboning quality and reducing government waste.
Wonderful, but that is not going to touch the people who are dedicated abusers of
the system. Because they are unconnected to audited, real, data, I suspect that
the Obamacare 'penalties"" really function as penalties for telling the truth about
performance,and are not actual performance penalties. For example, Inova received