J. Deane Waldman

The shocking cost of turnover in health care.

Review of turnover costs at a major medical center helps health care managers gain insights about the magnitude and determinants of this managerial challenge and assess the implications for organizational effectiveness. Here, turnover includes hiring, training, and productivity loss costs. Minimum cost of turnover represented a loss of >5 percent of the total annual operating budget. Editors Note: This article is being reprinted with permission from Health Care Management Review 29(1), 2-7.

Overlapping spectra of SMAD4 mutations in juvenile polyposis (JP) and JP–HHT syndrome†

Juvenile polyposis (JP) and hereditary hemorrhagic telangiectasia (HHT) are clinically distinct diseases caused by mutations in SMAD4 and BMPR1A (for JP) and endoglin and ALK1 (for HHT). Recently, a combined syndrome of JP–HHT was described that is also caused by mutations in SMAD4. Although both JP and JP–HHT are caused by SMAD4 mutations, a possible genotype:phenotype correlation was noted as all of the SMAD4 mutations in the JP–HHT patients were clustered in the COOH‐terminal MH2 domain of the protein. If valid, this correlation would provide a molecular explanation for the phenotypic differences, as well as a pre‐symptomatic diagnostic test to distinguish patients at risk for the overlapping but different clinical features of the disorders. In this study, we collected 19 new JP–HHT patients from which we identified 15 additional SMAD4 mutations. We also reviewed the literature for other reports of JP patients with HHT symptoms with confirmed SMAD4 mutations. Our combined results show that although the SMAD4 mutations in JP–HHT patients do show a tendency to cluster in the MH2 domain, mutations in other parts of the gene also cause the combined syndrome. Thus, any mutation in SMAD4 can cause JP–HHT. Any JP patient with a SMAD4 mutation is, therefore, at risk for the visceral manifestations of HHT and any HHT patient with SMAD4 mutation is at risk for early onset gastrointestinal cancer. In conclusion, a patient who tests positive for any SMAD4 mutation must be considered at risk for the combined syndrome of JP–HHT and monitored accordingly.

Corporate Culture: The Missing Piece of the Healthcare Puzzle

Abstract The U.S. healthcare system requires radical, not incremental, change. Management issues in healthcare delivery are fundamentally different from those in the business world. Systems thinking forces a focus on corporate culture, about which there is little hard data. The use of cost/benefit analysis suffers from the lack of any accepted measure of long-term “benefit.” The authors make four observations: (1) corporate culture is both part of the cause and part of the cure for healthcare; (2) long-term financial and functional measures are necessary to make evidence-based decisions; (3) valid, nationwide data must be developed regarding the corporate culture of medicine; and (4) direct (unmodified) application of management theory or practices will not achieve sustainable improvements.

Twins in trouble (II): Systems thinking in healthcare and education

Abstract In an attempt to create new perspectives on the issues facing the US education and healthcare systems, we describe – in tandem – the root causes of system-wide dysfunction in both. A unifying concept is the lack of systems thinking. We assess: Timeline of causality; The substrate; The culture; Outcome measures; Micro-economic disconnection; Unending demand for resources; Incentives and accountability; and Organizational structure. Recommendations include: (1) do what is needed, not what is initially considered possible; (2) implement radical transformation, not incremental adjustment; (3) the Federal government must stand in loco parentis; (4) create a Champion-with-power; (5) develop a process for dialogue between practitioners and experts in education, healthcare and management, particularly systems thinking; (6) engage, educate and learn from the public early in the process; (7) create national databases; (8) reform the legal tort system in order to allow the blossoming of learning cultures.

From PediHeart: Inhaled Nitric Oxide—In Clinical Trial or in Clinical Practice?

The molecule nitric oxide (NO) is a potent but very short-lived smooth muscle relaxant. When administered by inhalation, NO effect is limited to pulmonary arteriolar musculature. INO Therapeutics, Inc. holds a use patent on iNO and recently announced its intentions to release iNO for use in neonates with pulmonary hypertension—the only approved use—for

Chapter 5 Strategic Management of Internal Customers: Building Value Through Human Capital and Culture

3000 for the first day. For other uses, one could apply to the company for free iNO on a research protocol. The problem is apparent to clinical pediatric cardiologists who use iNO to treat postoperative pulmonary artery hypertension or to test pulmonary vaso-reactivity in the cath lab. Is this going to cost

Endocarditis after balloon dilation of congenital pulmonary valve stenosis.

3000 for a 15–20 minute trial? Would insurance companies pay and, if not, would our hospitals deny us the drug? Should we submit phony research protocols to get iNO for off-label use? To assess the current “standard of clinical practice,” I surveyed the readership of Pediheart. The following question was posed on Pediheart on 2/3/00. “Do you consider inhaled nitric oxide (iNO) to be a clinically proven agent to test pulmonary vaso-reactivity in the cath lab, or should iNO be on research protocol?” Results: Sixty-five responses were received from the USA (52), Europe (9), and Canada (4). Sixty-one respondents (94%) answered “Yes” to the question, two had no opinion. Two answered “No” but their explanations suggested that their answer might actually be yes. Conclusion: Ninety-four to 98% of respondents considered iNO to be a clinically proven pulmonary vasodilator. While iNO is FDA-approved for neonates with pulmonary artery hypertension, most practicing physicians consider that its uses extend beyond the FDA-approved condition, for example in the cath lab or in the postoperative ICU. A large body of literature confirms the clinical efficacy of iNO. This survey provides support for physicians who wish to challenge the limitations on the clinical use of iNO imposed by any regulatory agency, by third-party payers or by the company holding a use patent for iNO.

Learning - the only way to improve health-care outcomes

This paper analyzes health care as a context for building value through human capital and culture. We examine how health care managers can nurture a favorable culture for providers enabling them to focus on customer service. A case study of a large medical center examines how organization culture affects clinicians versus support and managerial staff while adversely impacting patient satisfaction and organizational costs associated with turnover and the cost of replacing personnel. An agenda for managing internal customers and organization culture is presented.

From PediHeart: Inhaled Nitric Oxide—References

At 2 weeks of age, a male infant was diagnosed with severe pulmonary valve stenosis (62 mm Hg peak systolic gradient). The pulmonary valve was domed and thickened with a very small opening orifice (Fig. 1a). At 9 weeks of age, balloon dilation (BD) was performed with a Tyshak (NuMED, Inc., Hopkinton, NY, USA) BD (10 mm 9 2 cm) catheter, decreasing right-ventricular/left ventricular (RV/LV) pressures (mm Hg) from 71/57 mm Hg (1.25) to 21/80 mm Hg (0.26). The opening orifice became wide (Fig. 1b) with a peak instantaneous gradient of 12 mm Hg (down from 57 mm Hg). The child was discharged 4 hours after the procedure. Thirty-six hours later, the patient was readmitted for fever. He remained in the hospital for 2 days until blood cultures were reported to be negative. He was given oral amoxicillin for 10 days. One month after BD, echocardiogram showed a 20–25 mm Hg gradient and mild to moderate pulmonary regurgitation. The child appeared clinically well. At home during the next 2.5 months, the infant had febrile three episodes to a maximum of 103 F. The first two times, the pediatrician gave him antibiotics with apparent improvement. The third time, blood cultures were drawn and showed Enterococcus. Echocardiogram showed two vegetations: one adherent to the main pulmonary artery wall, labeled FV (fixed vegetation) in Fig. 1c; and one highly mobile, probably on a leaflet tip, labeled MV (mobile vegetation) as shown in Video 1. The patient was treated with intravenous antibiotics for 6 weeks. The vegetations gradually resolved. Fifteen months after BD, echocardiogram (Figs. 1d through 1f) showed a widely opening trileaflet pulmonary valve, mild pulmonary regurgitation, no pulmonary or tricuspid regurgitation, an estimated RV pressure of 25 mm Hg systolic, and no evidence of either vegetation: fixed or mobile. The child has remained clinically well for 3 years since BD.

Creating a favorable practice environment for nurses.

Attempts to improve health care have generally failed. Systems analysis urges addressing processes, such as learning, rather than isolated parts of a system. We apply learning curve theory to health care and then explicate the process of learning. Specific recommendations involve how we learn (and unlearn), who should learn, and what should be learned.