The flaws of those who make the rules

Jim Leyland was a good team manager for the Detroit Tigers. He laid down the law when he needed to. But he was also very good with maintaining the morale and motivating his players. 

There’s an art to making rules. It’s better to have no rule than to create a bad one. If you make a rule, ensure it serves a purpose, and most importantly, make sure it doesn’t cause harm. Rules made just for the sake of it are pointless. Put simply: it’s better to do nothing than to do something stupid.

Rules are generally created to improve a situation—or at least attempt to. Take, for instance, administrators trying to reduce infections in the emergency room. A noble goal, no doubt.

Now, consider an example involving suction equipment. For 30 years, we’ve ensured the ER trauma rooms are ready for anything. In a CODE situation, there’s no time to set up equipment, which is why we always have the suction canister ready, tubing attached, and a Yankauer nearby.

One day, I rushed into the ER for a CODE BLUE. The doctor was ready to intubate, and I had set up the endotracheal tube. But when I went to turn on the suction—nothing. No canister, no tubing, no Yankauer.

The equipment was there, but still sealed in its packaging. It took precious minutes to unwrap and set up, slowing us down at a critical moment.

During the post-CODE debrief, we learned why. The person responsible for following Joint Commission (JCAHO) guidelines had taken the suction apart, stating that JCAHO required everything to stay packaged until use. I replied, “If JCAHO has a rule preventing us from setting up vital equipment, then that rule needs to be changed. We need it ready when it matters.”

In this case, the rule that was meant to help ended up hindering care. This exemplifies the idea of letting us do our jobs without unnecessary interference.

Several years ago, a policy was introduced requiring us to rinse out nebulizers after each treatment with sterile water. This added unnecessary time spent in the room, and despite administration's insistence, no therapist complied. Eventually, the policy was forgotten. This serves as a reminder: you can make a rule, but you can’t force compliance unless you want to monitor us constantly. However, that would only decrease morale.

To conclude, I used to attend administrative meetings regularly. One time, during a discussion about an incident, an administrator said, “We have to do something.” I cautiously replied, “It’s better to do nothing than to do something stupid.” The point is to carefully consider both the benefits and consequences of any rule you make.

To illustrate this point, consider Jim Leyland, former manager of the Detroit Tigers. After a game where a third baseman made a costly error, a reporter asked Leyland what he said to the player. Leyland responded, “I didn’t say anything. He knows what he did wrong and will take the necessary actions to correct it.” He added that if the player repeatedly made the same mistake, he might intervene. This approach of allowing individuals to learn from their mistakes, rather than enforcing unnecessary rules, is a strategy hospital administrators would do well to adopt.

Can you staff for the what if?

Many bosses will say that you can't staff for the what if?  Most store managers will staff for the number of customers they had a year ago on this date.  If it's a holiday coming up, they look at the stats from the year before and stock and staff accordingly.  In the hospital you can't do that -- but they still do. 

In the hospital you should always staff a minimum number of OB nurses, a minimum number of CCU nurses, a certain number of floor nurses, a certain number of ER nurses, a minimum number of lab techs, a certain number of x-ray techs, a certain number of doctors, and a certain number of respiratory therapists.  This is simply the cost of doing business.

Sure some days, many days, people will be sitting around.  But when the patient comes in, you need coverage.  It's a law suit waiting to happen if you are not properly staffed. And, to be honest, this is the type of thing hospitals should be paying for, not therapies that are only done so the hospital can make money.

Think about it.  It's common sense.  Hospitals that staff properly have happier staff.  Hospitals that have a happier staff make happy patients. It's a win-wins -- staffing for the what if, that is.

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Doctors orders are held captive by a greater power

While few would admit it, and while you might find it hard to believe, most doctor orders are not necessarily what the doctor ordered.  In fact, most doctor's orders, and even some diagnosis's, are made for some other reason other than that they are needed.

Confused?  Well, if you don't work in the medical field so you can see it for yourelf, you probably are.  And considering we're all about honesty here at the RT Cave, I'm one of the few who will come right out and tell you that probably about 80% of the stuff doctors order is bull.

Now don't start thinking I think doctors are bull.  Doctors are brilliant.  I completely respect doctors.  They simply find that they have to order things just... well, just because.  It's just the way it is.  They don't have a choice. 

For example, here are some of the reasons many doctor's orders are bogus:

1.  Order sets:  the doctor didn't order the procedure, it was simply part of an order set for whatever your diagnosis is.  For example, if you are admitted to the hospital and your diagnisis is pneumonia, then you will get breathing treatments every 4-6 hours whether you need them or not.  I bet most doctors don't even know treatments were even ordered. 

2.  Intensity of Service:  This is part of the reason many hospitals create order sets.  In order for the patient to meet criteria for admission, you have to show that the patient needs to be admitted.  If a patient is admitted with pneumonia and you didn't order a breathing treatment, then some person sitting in a leather chair 3,000 miles away from the patient might think something like:  "If that patient didn't need a breathing treatment, then why did he need to be admitted?  Reimbursement DENIED!!!!!  To prevent this, the doctor better order whatever he thinks the government requires for said diagnosis. A treatment might not be needed, but so what. 

3.  Fake Diagnosis:  So you're scheduled for a pulmonary function test (PFT), yet your diagnosis is diabetes.  The doctor knows most insurance companies only cover PFTs if the diagnosis is COPD, cystic fibrosis, or asthma.  Even though your doctor obviously thinks you need a PFT, your insurance won't cover it unless he lies.  This should explain why on the PFT order form he gave you to take to the hospital it has "asthma" on the line next to diagnosis instead of diabetes.

4.  To cover their asses:  Doctors don't want to be sued, so they order whatever they think is needed so it looks like they did their best.  Much of what we do in the hospital has no medical benefit whatsoever, and the only reason we do it is becasue the doctor wanted to cover his own butt from potential litigation.

5.  Habit:  Doctors have a set list of things they order for each diagnosis.  After a while he simply writes orders based on habit and may not even know what he wrote.  For example, we have one doctor who orders breathing treatments for all his post operative patients.  I asked him why he writes this order once and he said, "What's a breathing treatment?"  Yet he continues to write the order.  It's for this same reason many foley catheters are inserted into patients and other invasive procedures performed.  Since no one questions the doctor, he has no incentive to update his ordering habits.

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My solution to fixing the healthcare industry

Running a medical care facility is as complicated as caring for an end stage COPD patient.  While a doctor will need to find the right balance of medicines to deal with all the facets of lung disease -- bronchospasm, heart failure, anxiety -- hospital administrators need to find the best potion to keep the hospital afloat.

Finding the best potion is accomplished by balancing the following core goals:

1. Improving patient care
2. Reducing costs
3. Creating a good image of the institution
4. Maintaining a good morale among employees

What is the current trend?

The current trend is to focus on 1-3 above, and to incorporate employee morale into a public relations campaign which involves things like midnight meals provided by administrators, summer parties, Christmas parties, giveaways, and having administrators participate in meetings.  While this is a step in the right direction, it has done nothing to improve morale.  However, studies show the current trend has improved patient care.  

All of the above goals can be accomplished through the creation, implementation and monitoring for the following methods:

1. Order sets
2. Protocols

Quite often these two terms are used as synonyms, and more frequently an order set is called a protocol.  I think this is done more as window dressing, because most people in the medical profession believe every patient and every situation must be treated individually.  It didn't used to be this way, yet this is the current trend.

In reality, the difference between order set and protocol is similar to the difference between capitalism and socialism.  One allows for individualism, and the other creates equality.  While one might "sound" like it solves problems better, the other actually does.

So what are hospitals presently doing right, and what can they do better?  To answer these questions we must first have some definitions:

Order set:  Synonym:  Social Justice, socialism.  Every patient with a given diagnosis (DRG) is treated the same.  Once a patient is admitted with a certain DRG, these sets pre-determine what you order for that patient.  The purpose of these is to make sure best practice medicine is followed for every patient.  Basically, a committee -- usually in Washington -- determines what is best for the patient, and this assumes that the caregivers at the bedside are not capable of critical thinking.  Another advantage of order sets, and the reason they are being initiated in most hospitals, is to make sure intensity of service is met.  This assures that the patient will meet reimbursement criteria.  In the past physicians were presented with a sheet that listed all the options.  Today, however, many of these options are pre-checked and automatically ordered whether the doctor wants to or not.  The reason for this is to make sure reimbursement criteria is met (see below).

Cook book medicine:  Treating all patients the same.  This is generally the theme created to describe order sets, especially order sets that have pre-checked boxes that result in procedures being automatically ordered for a particular DRG.

Protocol:  Synonym:  Capitalism, individualism.  Every patient and every patient situation is treated individually and uniquely given the patient status and the wisdom of the caregivers.  The institution has set guidelines, and the caregivers use their education and wisdom to solve the problem at the bedside. Given proper training and well written protocols, best practice medicine should occur by default because protocols encourage critical thinking.

Ideally, according to Egan, a protocol would work like this:

1. Therapy can be adjusted more frequently in response to changes in patient status.
2. Physicians can still be contacted for major changes, but not minor adjustments, thus reducing nuisance calls.
3. Consistency of therapy can be maintained and nonpulmonary physicians can use appropriate up-to-date methods by simply requesting that protocol therapy be used.
4. RCPs (Respiratory Care Practitioners) become actively involved in achieving good patient outcomes instead of performing rigid tasks. This enhanced responsibility attracts and retains better educated and qualified practitioners.

Advantage of protocols:

1.  Benefits the patient:  The medical professionals working with the patient (RT and RN) decide what the patient needs at the moment the care is needed.

2.  Less calls to physician:  Doctors will receive fewer irritating phone calls

3.  Improved morale and apathy:  RTs and RNs will be able to use the wisdom they obtained by education and through experience, and this will improve their dignity, mercy and self worth.   

4.  Less burnout:  With only those patients who need therapy receiving it, there is a good chance the RT or RN won't feel so run down and overwhelmed, and the patients who truly need their services will benefit as a result.


Reasons your hospital might choose not to use protocols:

1.  Procedure counts:  RT bosses need procedure counts to justify staffing load.  They fear, and often needlessly so, that protocols will result in less work for the department

2.  Reimbursement criteria:  Quality Assurance (see below) wants to make sure government quotas are met for each given patient.  If the RT decides a patient doesn't need certain procedures (such as bronchodilators), then the hospital may not be reimbursed.  This is one of the main reasons many smaller hospitals avoid protocols (note:  see reimbursement criteria below).

Order set/ Protocol combination:  This is where a hospital committee creates order sets for a given DRG yet allows the medical staff freedom based on well designed protocols to use critical thinking in determining what is best for the patient.  Once order sets are initiated, the caregivers at the bedside (RN and RN) decide which ones are to be followed and how.  For example, a post operative order set may include an incentive spirometer order.  By using the protocol, the RT will decide whether the IS is appropriate, or if cough and deep breathing might be better for that particular patient.  An Albuterol breathing treatment is another example.  A pneumonia order set may automatically order Q6 breathing treatments.  The RT will give an initial breathing treatment and monitor it's effectiveness.  If there is no benefit to the patient and the patient the order would be changed to as needed or discontinued.  This would save the hospital money (treatments are $80 to 100 each) and allow the RCP an opportunity to help patients with greater needs.

Order sets are the current trent.  Personally, I think these have some advantages.  It assures that best practice medicine is followed.  So, what is best practice medicine?

Best practice medicine:  Based on scientific evidence, this is what is proven to work for a given DRG.  For example, breathing treatments improve work of breathing for asthmatic patients and should be ordered.  Likewise, oxygen should be an option.  This also focuses on preventative medicine.  Incentive Spirometers use is proven to reduce post operative pneumonia and atelectasis, and therefore an IS order is automatic with post operative order sets. 

Intensity of Service:  Basically, does the patient meet reimbursement criteria?  Is the patient sick enough to be admitted?  Doctors would prefer to use their own judgement to decide which patients go home and which patients are admitted for observation.  Yet the Centers for Medicare and Medicaid Services (CMS) will refuse to reimburse the hospital for a patient admission unless the patient is sick enough to need certain pre-determined procedures.  For example, if a patient admitted with asthma didn't receive any breathing treatments, then why did he need to be admitted?  If no treatments are given, CMS has a right to refuse reimbursement.  Order sets make sure what is required is given regardless of need.

Keystone Committee:  This is a committee formed to make sure intensity of service is met, reimbursement criteria is met, and best practice medicine is met for each DRG.  The goal is to reduce costs for the hospital,  make as much money for each DRG, and to provide best practice medicine for each DRG that results in improved care for the patient. 

Core Measures:  These are measures set by the Keystone Committee that work as goals for the hospital to improve patient care and reduce costs.  They are based on best practice medicine and reimbursement criteria.

Quality Assururance (QA):  This is the fastest growing area of the medical field, especially since the passing of Obamacare.  This is the department responsible for checking charts and making sure core measures are met.  The goal here is to make sure the hospital is making as much money for a given patient as possible.  They also work on committees with other department heads in the hospital to create methods of assuring best practice medicine and reimbursement criteria is met. T'his is a noble department set to make sure the patient is getting the best care possible and the hospital is making a profit.  However, because of government regulations on the medical field and new regulations imposed by Obamacare, one of the main emphasis's of late is on meeting these regulations. 

This department hides under the guise of best practice medicine, although their real intent is always to make sure the patient is profitable.  They're often referred to as the nitpickers of the hospital, or the people who make sure we dot all our i's and cross all our t-s per se.

Quality Assurance Analyzer:  This is one member of the QA team who is a former nurse who has the responsibility of reviewing charts to make sure intensity of service is met for each patient.  They carry a book around with them created by an independent company that lists all the orders for a given DRG that must be ordered for that patient to meet reimbursement criteria.  It is illegal for the QA analyzer to tell a doctor the patient doesn't meet criteria because a certain order was not made.  For example, it is illegal for the QA analyzer to observe treatments were not ordered for an asthma patient and to tell the doctor he must order them so the hospital gets reimbursed.  However, doing this is part of their job.

Reimbursement criteria:  This is criteria set by CMS that must be met for each DRG.  If not, CMS has a right to reject reimbursement for that patient.  If CMS deems a patient was not sick enough to be admitted, they will not reimburse the hospital.  It does not matter that the doctor was worried about the patient and wanted him admitted for observation.  This is one of the main reasons many procedures are added to order sets that are not needed:  Ted stockings for every patient, neuro checks every two hours, IVs, EKGs every morning times 2 days for chest pain patients, bronchodilators for RSV patients and pneumonia, etc. We must also note that the purpose of reimbursement criteria is to reduce cost to the government, not to reduce cost to the hospital.  Since these actually increase the number of procedures ordered to meet criteria, this actually results in increased cost to hospitals.

The only way to reduce costs when you have order sets is to also add protocols.

Public relations:  Creating a good image of the hospital in the community and among staff working for the facility.

Diagnosis Related Group (DRG):  This is a diagnosis related group and each patient is assigned one.  Based on the DRG chosen, the hospital will receive a set payment.  Because hospitals know in advance how much they will make for that patient, this may help determine the type of care this patient receives.  Because there is a flat profit, hospitals therefore have an incentive to do only those procedures that are essential.  Thus, the fewer procedures the hospital does the more money the hospital will have once the bills are paid.  This is an incentive to do more with less.  One of the best ways to do more with less is to have order sets and protocols.

What are the current trends? 

The current trend is for hospitals via keystone committees (or something similar) to create order sets for every DRG.  In the past this included a list to remind a physician of his options.  However, more recently it's evolved into simply checking options so that nothing is missed.  The goal is to meet core measures.

However, we must keep in mind that while the intent is to improve quality and decrease costs, it is my assessment that due to government intervention, not enough common sense is involved in the process.  The emphasis is moving away from protocols and toward order sets that make certain orders are mandatory regardless of need.

The result of this is the following:

1. Increased workload on all staff
2. Increased ordering of procedures that are not needed
3. Increased burnout
4. Decreased critical thinking
5. Decreased morale
6. Increased apathy
7. Decreased dignity, mercy and feeling of self worth
8. Worsening of patient care (due to burnout and apathy)

What is the best approach to take in the future?

I believe the best approach to accomplishing the four core goals for hospitals is to take a combination approach to public relations, order sets and protocols.  I believe order sets will assure core values are met, and protocols will assure costs are reduced and morale is improved.

With a fine balance of public relations, order sets and protocols, the following will be the result:

1. Improved patient care results in improved patient satisfaction and outcomes
2. Improve individual choice results in improved worker morale and feeling of self worth
3. Reduce unnecessary procedures lessens burnout and reduces apathy
4. Improved option results in a reduction of redundant  and unnecessary phone calls to physicians
5. Increase critical thinking at the bedside likewise improves patient care, reduced calls to physicians, and improved worker satisfaction
6. Improved morale would result in better word of mouth advertising by staff and physicians

However, due to government regulations and reimbursement criteria, hospital committee members are forced to make reimbursement criteria a top priority, and, unfortunately, this comes at the expense of patient outcomes and worker morale.  Due to order sets that pre-mark and automatically have certain procedures ordered, this results in the staff becoming overwhelmed.

A good example of this is if a patient is admitted with sepsis, COPD, pneumonia, asthma, heart failure and anxiety.  The order sets for all those DRGs must be followed.  The unit secretary can be bogged down for hours just on one patient, and implementing those orders will bog down a single nurse, and often require a second nurse and a nursing assistant.

With limited focus on creating protocols, there are no methods of getting rid of redundant and unnecessary procedures.  This results in staff being overwhelmed, it causes burnout, and it results in apathy.  Due to the recession, most hospitals are unable to hire new nurses to help out.  Burnout, decreased morale and increased apathy is the result.

This effects public relations too, because a staff that is burned out is going to have a poor view of the institution and the administration, and will be less likely to spread a positive word about the hospital.  This makes the job of public relations more complicated.

With any future approach to medical care, you'll obviously want to continue positive trends and get rid of what doesn't work, and add what has worked at other hospitals.  The problem is due to government intervention, most hospitals are a) forced to set core measures based on reimbursement criteria, and b) forced to do things the same way.

This takes away individualism.  Since all hospitals are doing things the same way, this decreases  the implementation of new out of the box ideas that might revolutionize the medical industry in the future.  If forces hospitals to focus in one area (reimbursement) and slack in others (worker morale).

I think Keystone Collaborative Core Measures have improved patient care.  One recent study shows that critical care core measures have reduced ventilator acquired pneumonia and reduced readmission rates for pneumonia and COPD.  Yet gains in this area have not improved worker morale  and have not improved hospital image within the institution and the community.

Likewise, when worker morale is low, so too is patient morale.  On top of this the patient is needlessly having to be awakened every time a staff has to come into his room to do a certain procedure. Apathetic and overwhelmed RTs and RNs aren't going to care about working together to make sure the patient isn't awakened every hour.  Apathetic and overwhelmed staffers are simply going to do what they have to do to get their assigned work done.

They, in essence, become overwhelmed button pushers and automatons.  They become robots.  This is bad because these RNs and RTs are right at the bedside and provide an image to the patient of the hospital.

I believe the best way to accomplish all of the above four hospital goals this is via the following:

1. Reduce government regulations on healthcare industry that discourage innovation and create an emphasis on reimbursement criteria over patient outcomes and worker satisfaction
2. Continue the Keystone Collaborative to set core measures that focus mainly on best practice medicine and less so on government regulations and reimbursement criteria.
3. Creating a combination of order sets that remind doctors of the core values 
4. Creating protocols to allow point of care fine tuning of order sets to meet patient needs and improve worker satisfaction which will in turn result in improved patient satisfaction with the hospital
5. Reduction of costs because only procedures that are needed will be given

It's a tough balancing act to find at potion that works to improving patient care, reducing costs while creating a positive work environment that lends itself to good worker morale, and lends itself to good word of mouth advertising to compliment a positive public relations campaign.  

Yet I truly believe less government intervention will result in more creativity by individual medical institution in accomplishing the four goals:  improving patient care and outcomes, reducing costs, creating worker satisfaction, and improving the hospitals image.

A combination of core measures that result in a positive balance of order sets and protocols that assure best practice medicine is met at the same time as worker and patient satisfaction is accomplished.  

It is possible to accomplish all the above goals at the same time, yet it will take a collaborative effort on the part of hospital administrators, nurses, respiratory therapists, patients, and Congressmen and Senators on both the state and federal level.  

The goal should involve increasing individual thought, and decreasing cook book medicine.

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Core goals for all hospitals

The following are the core goals for all hospitals:

1. Improving patient care
2. Reducing costs
3. Creating a good image of the institution
4. Maintaining a good morale among employees

Many of these goals have an inverse relationship, which means that quite often accomplishing one may come at the expense of another.  For example, order sets can improve patient care, yet the increase in workload results in burnout that reduces morale of workers, and creates negative word of mouth advertising.

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How not to hire a supervisor or boss or editor

If you are going to hire a person to be a supervisor to a particular department of a business (in our case a hospital), or anyone who is in charge and has to lead, there are certain rules you should follow in your hiring practice to assure success.

Ideally, you should hire someone within the hospital.  This person would have a good understanding of all the personnel involved, the doctors, equipment needed, and a good understanding of the company.  Likewise, the hiring party would know this person's strengths and weaknesses.

However, sometimes this isn't possible.  So you have to hire from the outside.  If you are going to hire someone from outside your institution, make sure you hire someone who has a plethora of expererience in that  particular department.  If you are hiring a critical care coordinator, for example, that person should feel completely comfortable working in that area.

Likewise, you must NOT hire someone who is just out of school and has only a few years experience working in a particular area.  This would be akin to throwing that person to the wolves.  It's not fair to your institution, yet it's also not fair to that person.  You are setting that person up for failure.

Some people might succeed in this situation, yet the odds are not very good.  Here you have someone with only 2 years experience bossing people around who have 30 years experience and know a ton of a lot more than that new boss.  In this instance, this new person will probably lack the life's experience to know that he should admit what he doesn't know.

Likewise, how can a person with no experience, or little experience, know how to help out when she has no idea what's going on to begin with.  If I say, "Hey, this pulse oximeter isn't working. We need to get it fixed or get a new one."

The new boss should be able to either a) know how to fix it, or b) know who to call to get it fixed.  If this person can't think out of the box on a simple task like this, then she's not qualified to lead this department.

She must also be strong and thick skinned to be able to handle the various personalities within the department, especially strong personalities.  She must be able to accept complaints regarding the schedule, and likewise be thick skinned about it.  She must not be afraid to be hated by a majority of those who work under her, and, in some cases, even hated.

I think that these skills can be developed given the proper training and orientation, yet lacking training and orientation, and lacking life's experience, I think the odds are pretty difficult this leader will succeed at least at this given time.


I write this post with my own experience.  I went to school to be a journalist, and the first job that became available when I graduated was editor and sole staff writer for a small weekly newspaper.  I was excited to get this job, yet thrown into it full force, I wasn't prepared.

I was 25 years old, and here I was in charge of not just writing the stories, but coming up with the ideas for stories.  I also had to come up with ideas for the inserts and special sections that were created and already filled with advertisements.  This ultimately became overwhelming for me.

I ended up becoming so stressed that I forgot how to write. I couldn't think of any story ideas, so the stories I did write sucked.  So I became stressed and even depressed.  After 3 months on this job I was fired/ quit.

However, I do think I would do fine on this job today, given my lifes experience.  I think I could do a better job dealing with the different personalities, with the mayors calling me and complaining about a story I wrotee.

And I would have had a better idea what to do when the mom called me because she didn't want her son's name in the courts record for the week.  Back then I was stressed and called my boss, who told me I had no choice but to put the name in.  The mom was mad.  I felt bad.

Today I would simply take the name out and have the mom bring the child in.  I'd make the child work with me for a week.  I'd have him promise me he wouldn't do it again.  And if he did I wouldn't even hesitate to put his name in the paper.

I think I would have succeeded if I had better orientation, yet the people who hired me did not properly orientate me and they did not mentor me.  They threw me to the wolves.  I failed.  I failed because I was hired to do a job I never should have been hired to do.  It ruined my confidence and it ruined my journalism career.

So I think hiring a young person to a coordinator position would be a mistake.  The odds are that morale in the department will sink, and you are also dooming that person to failure.  You will ruin that person's confidence and may even ruin her career. 

Yes I've seen it many times.  Now I'm to the point I predict, "That person will be gone within a year."  I'm usually laughted at and told I'm being a jerk.  Yet the truth is I'm being realistic, and I'm almost always right.  you can't hire a private to lead the troops.

Bottom line, hire someone with experience.  Hire someone with a little age.  Or, at the least, start that person at a little lower position, perhaps as assistant, and then move that person up the ladder once she proves her worth.  Orientate that person.  Mentor that person.  Yet please don't throw that person to the wolves. Doing so will not only harm your department, it may destroy that person.

So please regard my rules of hiring bosses here, and you'll find yourself more likely to benefit your company and those who work for you. 

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What do you need to know about liability insurance

It's rare that this happens, but there may come a time when you have to be a participant in a lawsuit where you or the hospital is being sued by a patient or patient's family. The question of the day is: Are you as an individual covered by the hospital's malpractice insurance?

This was the topic of a column by Anthony L. DiteWitt in the February, 2011, issue of the AARC Times. He writes that Insuranse policies are like "contracts" and they only cover those who are named on the contract. In most cases, the name on the contract is not the individual RT or RN or doctors, it is the institution -- the hospital.

Most liability contracts also list the officers of the hospital, such as administrators. Yet it's rare for RNs, RTS and doctors to be listed. So then, is it essential that you as an individual care provider at a hospital get your own malpractice (liability) insurance?

He says it's up to you to decide, and then he provides some examples.

You as a worker have a personal liability to the patient. Howeve, under the law of respondeat superior, "the hospital is also accountable for the negligent acts of its employees. This is also called vicarious liability."

He expounds:

"In most cases the plaintiff sues the hospital because the hospital is more likely to have assets than the employee, and the hospital's policy provides coverage to the corporation for the negligent acts of its employee. But if the patient sued only the employee and did not sue the hospital, the hospital's insurer would provide no coverage to the employee. While this is rare, it can and does happen, particularly where the patient has a personal grudge or doesn't use a lawyer."

Then there is indemnity and contribution.
So, what is indemnity? He defines it this way:

"Indemnity provides that where a master pays for the wrongs of his servant under respondeat superior the servant must indemnify (or repay) the master. Most hospital insurance policies provide for the insurer to seek indemnity from any liable employee. Thus, if the hospital pays $300,000 to settle a claim arising from the negligence of a therapist, the insurance company can sue the therapist for indemnity to recover what it paid. Again, while this is rare, it does occur."

So what is contribution? He defines it this way:

Contribution is a separate doctrine and arises where, for example, the physician and not the hospital is sued for negligence. Suppose the physician settles a claim for $300,000 and alleges that had the therapist communicated the blood gas values to him, the harm would not have ensued. He can sue the therapist for contribution and force him to pay all or part of the amount he paid in settlement.

He adds that some hospital administrators might tell you that you don't need your own malpractice insurance and yet they say this because they don't fully understand what was described above. They'll tell you that the hospital policy will protect you, yet, as you see above, that is not necessarily the truth.
The hospital lawyer is not your lawyer, he is the hospital's lawyer. "If you ask the lawyer whom he represents and he is honest, he will tell you that he represents the hospital. He may provide you with legal advice and help defend your case; but he is duty-bound to protect the hospital, and not you."
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Pneumonia readmissions on the decline

It appears Shoreline Medical is doing something right, at least when it comes to pneumonia readmission rates. As, compared to the national pneumonia readmission rate of 18%, our hospital had only a 2% readmission rate for the given time period of about a year.

Because of this, I was chosen to give a presentation to a group of respiratory therapy supervisors and managers. This was a unique and exciting opportunity for me, especially considering I was the lowest ranking RT at this meeting. Plus my boss chose me among all my peers to give the presentation.

I worked with the Quality Assurance Analyst for our hospital and created this really nice presentation. Then I spent quality time interviewing, going through charts, and researching all the things we do once a patient is diagnosed with pneumonia, and what we do to keep pneumonia rates down.

I actually learned quite a bit in this process about the administration side of things. What follows here is a summary of my presentation:

A goal at Shoreline Medical is that we all have our priorities in order.

Shoreline Medical is in a small town only a few miles off the shore of Lake Michigan. It's in a small town, a close nit community. And being a close nit community results in a close nit hospital. One of the reasons I chose to work here is because I felt Shoreline was kind of had a down home feel to it. Everyone got along, were good friends, had pot lucks, and stuff like that.

We started the process of getting our ducks in a row by focusing on the CMS Core Measures. To make sure all doctors, nurses and respiratory therapists are always thinking about the core measures, we are all in serviced on this every year by the Quality Assurance Department.

In the chart, before the doctor's orders section, is a bright orange laminated sheet that has all the core measures on it. This way, every time anyone looks at the orders he or she has to flip this page aside. And even if you don't read it, you know what's on it: the core measures. This is one simple reminder to everyone to focus on the core measures when writing and fulfilling orders.

The Core Measures for pneumonia are as follows:

1. Initial Antibiotic Timing (given within 6 hours)
2. Pneumococcal Vaccination if eligible
3. Influenza Vaccination if eligible (October to March)
4. Blood Culture drawn before initial antibiotics
5. Appropriate antibiotic selection
6. Smoking cessation advice and counseling given if indicated (if patient has smoked within the last 12 months)

The most important of the above are the pneumococcal Vaccination, Influenza vaccination and smoking cessation, as studies have linked all three with a reduction in secondary pneumonia. So our major emphasis was on these three.

These core measures are what works according to the most recent best practice evidence to improve patient outcomes and decrease costs for pneumonia patients. The question we had to ask ourselves is: how do we use these core values to get our ducks in a row

Data from our core values back in 2007 showed that Shoreline Medical was about 80% in all of these core measures except for antibiotic timing within 6 hours. In this, we had no data whatsoever, which means we probably didn't even do it.

Yet if you look at data from the first and second quarters of 2010 you can see that we are at or near 100% on nearly every core measure. When it comes to smoking cessation we were at 92%, yet that was basically due to a miscommunication between a doctor and a nurse. So even while we've improved, we still use this data to improve even further, as there is always room for improvement.

So basically back in 2007 we did not have all our priorities in order, and in 2010 we did. So how do we get our priorities in order?

Actually, if you look at pneumonia readmission data other than the above mentioned three month period our hospital at at 16.5%, which is no different than the U.S. National Rate. .

Yet from January to March 2010. During that span we had 52 pneumonia patients, and only one readmission rate.

These improved statistics based on the core measures show we are doing something right. They prove that we have our ducks in a row. The question you are asking is: how did we get our ducks in a row?

The first thing we did was back in 2007 we joined the Keystone Collaborative. We have a champion Internist, a physician from ER, and one from surgery and general practice as our champions. Then we have one nurse from critical care, the general floors, and one from the emergency room.

We also have a representative from lab, x-ray, pharmacy, quality assurance, computer analysis, respiratory therapy (that's me) etc., and we meet every month to analyze data from core measures to create and improve clinical pathways and order sets to improve patient outcomes and reduce costs for our hospital.

The key here is that we review modern wisdom and come up with better practices for our hospital. Anyone can do research, or come up with new ideas, and can share them with any member of the keystone

committee, and then this new wisdom is brought to and reviewed by the committee and changes are made as appropriate.

Basically the point of the Keystone Committee is to do what works and skip doing what's not working.

The following is our pneumonia order set:

Our order set includes the following as options for the doctor to check:

• Code status
• Vitals routine or ___________
• Record input and output, daily weight, pulse oximetry every shift
• EKG on admission
• Chest x-ray on admission and on day 3
• Lab work (if not already done): CBC, CMP, UA, Sputum for gram stain, culture and sensitivity, blood culture prior to administration of antibiotic (this has to be done within three hours of admission)
• AM labs_______________
• Oxygen at _______ lpm or per protocol or _________
• Respiratory treatments: Albuterol 2.5mg with 3cc normal saline Q6 hours, up to ____ hours prn
• Respiratory treatment: Atrovent 0.5 mg in 2.5 ml normal saline QID
• Antibiotic therapy (1st dose to be given in ER) or immediately after blood culture drawn)
• Community Acquired Pneumonia (non CCU): Levaquinn 500 mg IVPB Q24 hours times 3 days, then Levaquin 500 mg PO daily
• Community Acquired Pneumonia (CCU or stepdown patients): Rocephin 1 gm IVPB Q24 hours and Zithromax 500 mg IVPB Q24 hours and Levaquin 750 mg IVPB Q24 hours and Azactam 2 GM IVPB Q12 hours
• Nosocomial Pneumonis (check all that are indicated from list of meds and doses)
• IV Fluid ____________
• Tylenol 650 MG PO Q4 hours prn for pain
• Xanax 0.25 mg PO Q6 prn for anxiety
• Restoril 15 MG PO QHS prn for insomnia
• MOM 30 ML PO BID prn for constipation
• Robitussin 10 ml PO Q4 hours prn for cough

(I left a few things off, but that's basically the gist of it).

This is our pneumonia hymn book. It's all the things that the best practice evidence shows works to help pneumonia patients get well. It's one sheet of paper, which makes it very simple.

As you'll note, some of the things on here are automatically ordered -- the doctor has no choice. For instance, x-ray on admission and in the am times three days, and certain labs on admission and in the am.

The ER nurses are involved right away, because if that patient is in the ER at the five hour mark, they have to make sure a sputum is obtained, and that the patient has been given that initial antibiotic within 6 hours. They have a system to assure this is done, and checks and balances.

As soon as the patient is admitted, the orders are entered into the computer system, and reminders are automatically sent to all the respective departments as to what they have to do and when. In RT department sheets are printed off so we know what our role is for that patient.

For lab and x-ray, what they have to do is printed up on their respective printers, and plus the procedures they have to do are put on the tracker when they are due so they are reminded in that way too.

It's simple. This order sheet is our hymn book: it makes sure we are all singing from the same hymn book.

Then we have our extubation protocol (to see our extubation protocol click here). This order set is part of the ventilator bundle. It works similar to the pneumonia bundle, in that when it comes to intubated patients, it makes sure we are all singing from the same hymn book.

The neat things about our extubation protocol is that when we were in school in 1995 we learned that the cuff pressure should never exceed 20 cwp. Now we are taught to always exceed 20 cwp. The reason is to prevent aspiration , and to prevent ventilator acquired pneumonia.

Another thing to prevent pneumonia is that the circuit not be broken. To do this we use MDIs instead of nebulizers. Also, we do not disconnect the circuit to suction, and use in line suction catheters instead.

Another key is the daily sedation protocol. Every night around 2 a.m. we automatically take all our patients off sedation so that by 6 a.m. we can analyze the patient for readiness to wean.

Here comes another laminated sheet. As part of our ventilator protocol we have a sheet that acts as an algorithm to speed time from intubation to extubation. Actually, the key to a good extubation protocol is that as soon as the patient is intubated we start thinking about extubation.

If the patient can be extubated in 2 hours, now that's possible. Years ago if the attending went on vacation the other doctors didn't extubate because they didn't want to offend the attending. Sometimes we RTs would wonder why the patient was still intubated. Now, that never happens, or rarely happens.

Our Algorithm goes something like this:

Weaning Screen:

1. FiO2 less than or equal to 40%
2. PEEP less than or equal to 5
3. HR greater than 50 or less than 120
4. Temp. less than 100.5
5. SpO2 greater than 90 unless otherwise directed by physician
6. Systolic BP greater than 90
7. Minimal or no sedation
8. No Vasopressors
9. No signs of respiratory distress
10. Able to follow commands
11. Adequate cough
12. Secretion thin and minimal
13. Plateau pressure less than 30 cwp

If the answer is no, then you stop and reanalyze the next day. If the answer is yes, then you move on to the next step, which is to do a 5 minute spontaneous breathing trial (SBT). (ETT 8.0 or greater use a CPAP of 5 and PSV of 0, ETT 7.5 or smaller use CPAP of 5 and PSV of 5)

Now you do a second weaning screen based on the same criteria as above.

If the patient fails the screen, the SBT is stopped and patient returned to previous settings.
If the patient passes, the following is completed and analyzed:

1. NIF greater than 20
2. VC greater than 10 ml/kg
3. VT greater than 5
4. RR less than 30
5. VE greater than 5 and less than 15
6. RSBI (f/vt) less than 100

If the patient passes this criteria, continue SBT for 30-120 minutes. Then do another weening screen as mentioned above. If patient passes do an ABG and call physician for order to extubate.

So basically we no longer simply do weaning parameters every day, we are actually completely assessing the patient using the common sense, best practice evidence approach. Patients are getting extubated quicker, and VAP is now pretty much nonexistent at our hospital.

Another key is education. As soon as the pnuem order set is initiated the emergency nurse educates the patient about pneumonia. Then the nurse on the floor educates the patient, and then the RT is in the room every six hours, and he or she educates the patient some more.

We make sure not only do our patients learn about pneumonia, they also know about their disease. For example, if they have COPD we make sure they know the early warning signs of an exacerbation so they can nip it in the bud next time and don't have to be readmitted.

We make sure they know if they start to get more short of breath than usual, or have increased cough or sputum production, or change in color of sputum, that they call their doctor or come into the emergency room.

Plus, as soon as pneumonia order set is entered in the computer, an order for RT to do smoking cessation is printed off in the RT department. Several studies show that if when a patient is vulnerable, when he's sick in the hospital, that if someone nudges them to quit they are more likely to quit.

And then when the patient is discharged another paper is printed off that is a pneuminia fact sheet for the patient to take home with them. It is basically a reinforcement of everything they've learned about pneumonia, and is reviewed by the discharge planner.

It's also a reminder to the RN to make sure the patient has had his vaccines while admitted, and to reinforce to the patient that they get their annual pneumonia and flu vaccines.

So basically the pneumonia order set is our hymn book: it gets everyone on the same page from the RT to lab to nurse and x-ray and lab and doctor. We all know exactly what our role is for that patient

Another thing we have an emphasis no is good hand washing. We have signs over every sink that remind of the importance of hand washing. Another sign over every sink describes proper hand washing technique.

We also have hand sanitizer in every room and in various locations, and we encourage or professionals to use this between every patient, and after touching anything in the room, and before touching anything even on their own possession. We also encourage use of hand sanitizers before leaving the room, even if they ultimately wash their hands.

We have some of our nurses are anonymous spies who make note of who they see not washing their hands, or not doing so correctly. We have other pamphlets around the hospital that remind nurses, RTs, and even patients to keep your eyes open, and "It's okay to ask."

So good hand washing is key to preventing the spread of infection.

Another bonus at Shoreline is we are a close nit hospital. This results in really good communication. For example, if I'm in the room and I see something wrong with the patient, I talk to the nurse or sometimes I go right to the doctor.

Instead of the nurses calling the doctor and assuming they know what's wrong with the patient, they often call RT instead so we can use our experience and education to work with the nurse in deciding what needs to be done.

Likewise, many times the doctor calls me up and asks me what I'm thinking is wrong with the patient and what we should do. This is great for morale.


We also have a Rapid Response Team. And another thing is we have good support and encouragement. For example, if an RN calls me to assess a patient, and the patient is fine when I get their, is on the crapper or something, I don't say, "You stupid dummy. Why did you waste my time?"

Instead I say, "Hey, that's fine. You were being proactive. That's good. It's better to be safe than sorry. You did great."

Besides, it's better to be proactive than reactive. If you're proactive you are nipping it in the bud. If you're proactive you may stop the problem from occuring, and then you get no credit. But it's better to be proactive and get no credit becasue the problem never occured, than to be reactive. If you're reactive, that means the problem already occured.

It means the patient is already septic, or in failure, or whatever. If you're being reactive, it means the patient is already in need of critical care services, and may need to be in the hospital longer, and cost the hospital more. If your'e proactive, that means improved outcomes and reduced costs.

So it's better to be proactive than reactive.

So starting with the core measures, the keystone collaborative and weekly keystone meetings, to the pneumonia bundle, and then with the small town close nit touch, we have been able to get all of our priorities in order here at Shoreline Medical. That's how we did it.

Thank you. Any questions.

For more information, check out the following resources:

• AHRQ (Agency for Healthcare Research and Quality) http://www.ahrq.gov/
• MHA Keystone Center http://www.mhakeystonecenter.org/
• MPRO http://www.mpro.gov/
• Quality Net http://www.qualitynet.org/
• Blue Cross/Blue Shield www.bcbs.com/innovations

The latest Hospital Statistics, RT and RN statistics

Here are some general statistics regarding the healthcare profession.  For statistics regarding the respiratory therapy profession, see below.

The following statistics are according to the American Hospital Association (AHA):

• Number of registered hospitals in the U.S...................5,795
• Total number of registered beds...................................944,277
• Total admissions..............................................................37,479,709
• Total expenses.................................................................$726,671,229,000

The trend in health care spending has increased exponentially since 1965 (see graph). Total health expenditures were:

• $41.6 billion in 1964
• $75.2 billion in 1970
• $232.9 billion in 1975
• $250.1 billion in 1980
• $420.1 billion in 1985
• $666.2 billion in 1990
• $1,101.9 billion in 1995
• $1,739.8 billion in 2000
• $7,681 billion in 2010 (16.2% of GNP)

Total cost of health care according to KaiserEDU.org:

• $253 billion in 1980
• $714 billion in 1990
• $2.3 trillion in 2008
• Total health care expenditures grew at annual rate of 4.4% in 2008 (slower than recent years, yet outpacing inflation and national income)
• Since 1991, employer sponsored health coverage has increased 131%, placing increased burden on employers and workers
• Medicare and Medicaid spending has increased 6.8-7.1% per year from 1998 to 2008, a little slower than the rate of private insurance spending

According to Centers for Medicare and Medicaid Services (CMS), here's how U.S. heathcare 2008 dollars were spent (see graph )

• 31% hospital care (down from 40% in 1995 NHS stats)
• 21% doctor and clinic services (same as 1995)
• 10% prescription drugs
• 7% administration
• 7% investment
• 6% nursing home care (down from 7% in 1995)
• 6% other professional services
• 4% dental
• 3% gov't public health activities
• 3% other retail projects
• 3% home health

Why the cost of healthcare costs?
Who has healthcare coverage (% below will be greater than 100 because some people have more than one insurance coverage and are approximated):

• 86% of U.S. population has healthcare coverage
• 75% of those covered have private healthcare insurance
• 61% with private insurance are covered through employers
• 13% with private insurance purchase their own insurance
• 13% of population has insurance through Medicare
• 10% of population has insurance through Medicaid
• 4% of population has insurance through military or veterans programs
• 17% of population has no health insurance (up from 14% in 1995) This is about 50 million people.
• Under insured has grown 60% bankruptcies are due to medical expenses

The following facts regarding hospital admissions from the AHA:

• 35 million people are admitted to a hospital each day
• 118 million are treated in emergency rooms each day
• 481 million other outpatient services per day
• Hospitals deliver 4 million babies per year
• In 2006, hospitals provided $35 billion of services that were not reimbursed
• Hospitals employ more than 5 million people
• Hospitals are the 2nd largest private sector employers (behind restraunts)
• When accounting for hospital purchases of goods and services from other businesses, hospitals support 1 in every 10 jobs in the U.S.
• Thus, hospitals account for $1.9 trillion in economic activity
• 1/3 of hospitals lose money on operations
• Hospitals operating margins (money left over after paying costs) were 4.0 in 2006, down from 4.6% in 1996 prior to the balanced budget Act of 1997.
• Medicare and Medicaid paid for 55% of care provided by hospitals
• 64% of hospitals are paid less than cost of services provided by Medicare services
• The Medicare funding shortfall exceeds $18 billion
• Hospitals receive 86 cents for each dollar spent on a Medicaid patient
• 76% of hospitals are paid less than cost of services provided by Medicaid services
• The Medicaid funding shortfall exceeds $11 billion
• Medicaid and Medicare shortfalls have been found to add costs (12% in California) to private insurance programs to make up for the shortfall
• 47% of hospitals reported their emergency rooms were at or exceeded full capacity
• 56% of hospitals transport overflow patients to other hospitals
• There are 116,000 nurse vacancies
• By 2020 it's estimated there will be a nursing shortage of 1 million nurses

Nursing statistics from Minority Nurse:

• There are 2,909, 357 registered nurses in the U.S. (2010 statistics)
• Approximately 168,181 registered nurses are men
• Only 8% of nurses are under 30
• 30.1% of male nurses are under 40
• 26.1% of female nurses are under 40
• 65.7% of male nurses are under 50
• 57.4% of female nurses are under 50
• 56.2% of all RNs work for hospitals
• 10.7% of nurses work in community/public health community
• Average salary of full time nurses is $57,785
• Average salary for nurses with a Master's degree is $74,377
• Nurse practitioners average $70,581

Respiratory Therapy Statistics according to the American Association for Respiratory Care (AARC) and National Board of Respiratory Care (NBRC):

• There are 105,900 RTs working in the U.S.
• 75% of RTs work in the hospital setting
• 48 states regulate the practice of respiratory therapy
• Employment of RTs is expected to grow 19% from 2006 to 2016, or 211% from 2008-2018 (faster than average for all occupations)
• 25% reported making $7e,000 or more
• 50% reported making $60,000 or more
• 25% reported making $48,000 or less
• New RTs reported earning $42,078 to $42, 497
• Median annual wages for RTs was $52,200 in 2008
• The middle 50 percent earned between $44,490 and $61,720
• The lowest 10 percent earned less than $37,920
• The highest 10 percent earned more than $69,800.

Overall hospital workers (stats from ehow.com:

• The U.S. Department of Labor estimates there are over 700 different job categories in teh healthcare industry
• 661,000 doctors in the U.S. as of 2008 American Bureau of Labor Statistics (ABLS).Most doctors earn more than $150,000 annually
• Anesthesiologist mean salary $197,570 or $94.99 per hour (ABLS)
• Internists make $176,740 per year, or $84.90 per hour (ABLS)
• Family Practitionars make $161,490 annually or $77.64 per hour (ABLS)
• Obstetritians and Gynecologists make $192,780 annually or $92.68 per hour (ABLS)
• Pediatritians make $153,370 annually, or $73.74 per hour (ABLS)
• Surgeons make $206,770 annually or $99.41 per hour (ABSS)
• Psychiatrists make $154,050 annually or $74.06 per hour (ABLS)

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Simple sputum may assure reimbursement

One of the things that has been incorporated into our pneumonia protocol is that a sputum must be obtained before an antibiotic is initiated. Another is that on all ventilator patients a sputum must be obtained as soon as possible.

The purpose of both of these is to prove the patient did not have community acquired pneumonia upon admission. If these tests come up negative, and the patient is later diagnosed during the admission with pneumonia, it is then termed nosocomial pneumonia.

This is important, because in 2005 the Deficit Reduction Act passed by Congress requires the Centers for Medicare and Medicaid Services (CMS) to identify conditions that could have been prevented by implementing practices based on best practice evidence, and nosocomial pneumonia is one such instance.

Hospitals are now encouraged to screen patients on admission (hence the sputum sample being obtained) and procedures and therapies are ordered based on best practice evidence (this is accomplished via the pneumonia and ventilator extubation protocols*) are completed for that particular patient.

If proper procedures are not followed, and that patient develops an infection CMS believes could have been prevented, and no additional reimbursements will be given to the hospital to offset the cost of that admission.

This is why it is essential for hospitals to implement a program similar to Shoreline, which has a monthly Keystone meeting to review and analyze best practice evidence to improve order sets and clinical pathways based on the CMS core values. (You can read about core values here).

So you can see why it's so important to follow your hospitals order sets, protocols, and procedures to a tee. This is why many hospitals have anonymous people (like this) on duty who watch out to make sure everyone is washing their hands, or at least using hand sanitizer.

I know there have been instances here at Shoreline where CMS did not reimburse for a patient because a sputum sample was not obtained. Since the government is paying the bills, it has a right to tell you what to do in this way. I guess you can say this is a perfect example of every new law taking away another freedom.

Yet the ultimate goal here is to make sure nosocomial infections are minimized, and so the hospital gets full reimbursement for that patient. Not even close to the ideal system, yet that's the way it is when Uncle Sam has it's grip around an industry.

*Where I work order sets are called protocols. The reality is order sets and protocols are the opposite of one another.

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