Paul Yeager: So, are hospitals safer now than they were five or ten years ago? What diseases now present the greatest challenge to hospitals? And what technologies and practices offer the most promise to achieve healthier communities? To answer these and other questions we have with us tonight on the program Dr. Tom Evans who is president and also CEO of the Iowa Healthcare Collaborative and also on the program tonight is Dr. Douglas G. Merrill, Medical Director of Ambulatory Surgery and Patient Safety Officer at the University of Iowa Healthcare in Iowa City.
Paul Yeager: Gentlemen, welcome to the program, good to have you here on The Journal. First of all, Dr. Evans, I want to ask about Iowa hospitals. Are they a safe place to be going right now for your care?
Dr. Tom Evans: Iowa hospitals are one of the best places you can be going in the country. The Commonwealth Fund in I believe 2006, perhaps 2007 did a national survey taking all kinds of clinical information and putting it into a blender and then ranking the states from top to bottom and Iowa ranked 2nd in that. So, healthcare in Iowa, both with regard to the quality and the cost, is very, very good.
Paul Yeager: What were the factors that led to Iowa to be so high in a study like that?
Dr. Tom Evans: They take information from quality, from access to care, from public health, all kinds of different factors that are determined with regard to general public health and, again, put that all together and then rank the states out.
Paul Yeager: And did that differentiate between a larger or a smaller hospital across the state?
Dr. Tom Evans: It didn't rank out specifically the hospitals differently, what it did was it ranked the states themselves. So, essentially Iowa is number one in the mainland, Hawaii was number one.
Paul Yeager: That's very interesting to know but is there anything different outside of that study about care or quality between large and small hospitals in the state?
Dr. Tom Evans: Obviously large hospitals and small hospitals care for different product lines. There are some things that they just don't do at smaller hospitals. So, it really depends on the product. By and large, all of the things that are there in the smaller hospitals have to be done in the larger hospitals as well and interestingly Iowa hospitals, the smaller hospitals, performed very well as well.
Paul Yeager: Dr. Merrill, I have a question about specialty surgery clinics versus hospitals, whether it is a wart or some type of thing that you would go to an office -- are there concerns when we get to comparing quality between a hospital or a specialty office like that?
Dr. Douglas Merrill: I think what you can be assured of is when you go to a hospital or if you can to an accredited ambulatory surgery center what you're finding is that the folks there have had to work hard in order to meet certain requirements with regard to not only simple, straight forward things like cleanliness but how they monitor themselves in terms of their outcomes and how they report just as all of our hospitals do report.
Paul Yeager: Now, we're sitting here at a table having this discussion and I know part of your job is to get people at the university to get together at a table and discuss policies and practices and changes. How is it that you get folks together to talk about some of these main risks whether it's diseases or surgical care errors or how do you get people around just to talk about this type of thing?
Dr. Douglas Merrill: Well, I think one of the great things about being at the University of Iowa is this tremendous, innate desire on people's part to do the very best that they can. As a relatively recent transplant to Iowa just over two years ago I think the concept of the solid Iowa citizen is very clear at the hospital. People are highly motivated not only to see that their patients do well but to see that we're more efficient, clearly cost is a concern in all of healthcare these days and we want to do the best that we can to keep that down. So, it's not a problem to get people to the table. It's not a problem to have controversy once you get to the table because there's a lot of smart people.
Paul Yeager: How do you sort that out -- because there's study after study or report or training that would say, no, I know what's best or I know what's best -- how do you sort that and try to check the egos at the door and get Iowans cared for?
Dr. Douglas Merrill: I think that's a great question because right now one of the nifty things that is happening in U.S. healthcare across the board and very clearly at the University of Iowa is the movement to evidence-based care, the concept that we'll take a look at what is in the scientific literature, we'll take a look at what works on our own patients, what our outcomes are and try to direct everybody to start working in that way with a patient. It's something that I think is becoming easier to do in healthcare because it's something that is happening across the board in the United States in manufacturing, for instance. So, people are used to doing process improvement and shooting to do the right thing that is working over there, trying not to be an ego driven system and I think people are doing a better job of that.
Paul Yeager: Go ahead.
Dr. Tom Evans: Just to interrupt for a second here -- this is about how we bring teams together within an institution, within a unique situation and another thing that we have been able to get done in Iowa is because of our collaborative spirit whether it's the Iowa Health System or the University of Iowa or Mercy Health Network, each of these large systems and frankly individual practices as well have best practices that they do and we have been able to bring those different groups together to share with their competitors those best practices. So, again, raising the standard of care across the whole state.
Paul Yeager: We talked about it just briefly here with Dr. Merrill, but Dr. Evans, when it comes to if I'm a patient, if I'm coming into a hospital, if I'm bringing a family member into a hospital for care what is it I can do or have my family member as a patient do to make sure that they're not contributing anything or try to keep them as healthy and safe as possible?
Dr. Tom Evans: In this particular situation you're talking about coming in as a companion with someone so first of all, be engaged, participate with them, communicate effectively, listen to everything that is happening. Healthcare is a very, very technical and a very complex situation and when someone is sick they are often somewhat compromised in their ability to absorb information. So, being that partner with that person is very, very important. For ourselves, however, I can't resist the plug for wellness and prevention. One of the most important things we can do to reduce costs and improve quality in this state with regard to healthcare is for patients, for consumers to get serious about their own healthcare, watch your weight, smoking, all the different -- get your immunizations, exercise, all those things are very, very critical.
Paul Yeager: You make it sound like there's a checklist of sorts. There was a mention in the piece about Waverly, what they're going through, hospitals go through that all the time. What is the importance of checklists and practices and things like that?
Dr. Tom Evans: Pilots have a checklist that they use before they take off. More and more in healthcare -- what we know is we can improve the product, the quality of any product by decreasing the variability with how we build that product. So, the pilot will check everything off to make sure they have a safe takeoff and landing every time. We're doing the same thing in healthcare today. We're using checklists to make sure on complex procedures and even not complex procedures that we're actually following along, check, check, check, did we do this, did we do this, didn't miss anything and decrease the variability so those outcomes are consistent and excellent every time.
Paul Yeager: What about the electronic health records that we're having? Are those helpful in going down that checklist?
Dr. Tom Evans: Electronic health records help us automate processes so they help us not lose information and give us ease with which we enter information and so we can use data to manage populations. They are very, very important and frankly they are something that all of healthcare is working very hard to deploy. That said, they aren't the answer. The answer is changing the processes so that we can automate them for the electronic health record to move forward.
Paul Yeager: Do you agree or disagree on that?
Dr. Douglas Merrill: I completely agree. I think Tom made the point earlier that the key to safety is teamwork, the key to safety is communication and everything whether we're talking about checklists or we're talking about electronic health records to the degree that it supports communication is going to make us safer. So, as we use checklists in our operating rooms, we use checklists prior to giving chemotherapy, as we use checklists prior to sending a mom home with her baby the idea is that we are saying out loud the things we need to do. Most of the errors that we make whether we're working in a mechanic shop or working in a hospital are things we inadvertently omit rather than things that we do that we shouldn't have done. Checklists help us to remember the things we're supposed to do and also make sure that everybody else hears that we remembered to do that and that we're doing it.
Paul Yeager: We talk about electronic, let's move a little bit quickly to technology here in the last couple of minutes. We talked about the eICU. Should there be one in every county? What are your thoughts on that?
Dr. Tom Evans: The eICU is a wonderful thing and we have a couple of hospitals in this region that have done something like that. The problem that we have is best practice would tell us that it would be ideal to have an intensive medicine specialist in the Intensive Care Unit 24/7. The problem is there aren't that many of them. As a matter of fact, I believe the study in 2003 from the University of Iowa showed that we had enough intensivists to staff two Intensive Care Units in this state 24/7. The electronic ICU not only allows people to do things within that facility but we can take care of patients 20, 30, 100 miles away and it allows us to keep those patients in a more intense environment near home. So, it's a new innovation in healthcare today that I think is a very good application to a rural environment like ours.
Paul Yeager: And the cost, is that the biggest opponent to this? What is preventing us from getting to there? Is it hospitals investing from the top down?
Dr. Tom Evans: Well, this isn't just like going to a software company and just pulling it off and loading it up. This is a very complex endeavor and I can't be complimentary enough of the hospitals that have done it. It requires the physicians and the hospitals and all of the facilities to work together to choreograph this thing. But doing it allows us to provide much better care to a larger population over a broad geographic spread.
Paul Yeager: Dr. Merrill, you mention you've been outside of this state, you've been in the state for a couple of years here. How does Iowa grade if you had to give Iowa a grade on its healthcare system when it comes to the topic we're discussing?
Dr. Douglas Merrill: I'm a pretty tough grader but I would say that we're in the A's. One of the things that I think has been most impressive and it's been very clear to me at the University of Iowa is number one, we had a board of regents and our senior leadership say that safety, patient safety is the number one priority at the University of Iowa Hospitals and Clinics. You don't hear that everywhere. And the second thing that I think is most impressive is the work that's already been alluded to here between the University Hospital and all the hospitals within the state so the shared work on trying to prevent hospital acquired infections is something I haven't seen anywhere else and I think is a tremendous testament to the dedication of the nurses and the physicians in the state to try and make patients better whether I'll ever see them or not.
Paul Yeager: You only get to give a grade but what would you give Iowa's grade?
Dr. Tom Evans: A.
Paul Yeager: Fantastic, that's Dr. Tom Evans and Dr. Douglas Merrill. I appreciate you gentlemen coming in tonight to The Iowa Journal.