Tim at HIS-Talk has a great post up today (what a hard workin' guy) with thoughts about health care quality and technology adoption. Washington Monthly ran an article about how the quality of care at the VA is better than in U.S. hospitals in general. While admitting that he's, "like most Americans, ... scandalously uninformed, yet highly opinionated," he has some excellent points that highlight challenges facing hospitals today.

Do "low quality" hospitals not believe the standards matter, or are they simply indefensibly negligent in not using universally accepted medical knowledge? Unfortunately, I think it's the latter. Physicians practice pretty much like they were taught in medical school. I've seen convincing studies that older docs practice much further away from currently accepted norms than younger ones. Not because of age, but because of the time passed since their training.

Senior management insight, passion and will are critical to an effective organization.  Without their support and involvement quality initiatives or initiatives of any kind will languish.

We cannot fix healthcare's problems by mandating hospital quality. The assumption that hospitals will enforce the standards "down" to their doctors is absurd. Physicians work for themselves, in most cases. They make their money in the office, not in the hospital. They pay scant attention to the passive, untrained ex-nurses who often push paper in hospital "quality" departments, and they have little fear of having their privileges revoked. No one with any real influence hounds them about treating patients outside accepted guidelines. Rarely have I seen docs demand higher quality from hospitals, chastise poorly performing peers, or volunteer to lead the charge. They were trained work solo under whatever conditions prevail. Organizational quality doesn't interest them much, unless it impacts them personally.

And I don't want to make physicians the bad guys here either; this is as much a structural problem as anything.  But doctors can impact patient flow significantly.  Making rounds less than once a day and late orders (especially discharge orders) can greatly impact LOS and resulting bed capacity.

The VA has advantages over private hospitals. Their salaried practitioners don't benefit personally from overutilization. I'm guessing they have fewer specialists treating observable but meaningless phenomena, prideful in making an obscure lab value go up or down even while the patient is deteriorating overall... They run hospitals, clinics, pharmacies, and nursing homes, all under common leadership and with easily mandated processes and information-sharing. They can enforce rules and mandate computer usage by physicians, even firing those who won't comply. In terms of technology, they already have the benefits that NHII would give the rest of us...

What about VA's use of technology? They have advantages there, too: 100% utilization by a captive audience, money to custom-build a system around their own processes, a universal medical record, and a single leadership structure to advance an agenda across all caregivers and sites. By controlling clinicians, they can control the quality indicators. They also had motivation to change, since they were being threatened with dissolution if they didn't get their act together. Give them credit -- the technology only helped them accomplish what they did, it wasn't itself the solution. Plug it into a bad hospital and you'd still have a bad hospital.

The above are all reasons why running a hospital is tough.  The good news is that there are many outstanding facilities that have overcome these structural challenges.

Read the whole thing.