PHMI Blog - Blog from Partners Harvard Medical International

We know that increasing numbers of patients around the world are traveling outside their own country for health care, whether they’re looking for better quality, affordability, or both. An entire industry is growing out of the need to connect patients with faraway providers, manage travel and logisitics, and ensure that patients’ experiences abroad are satisfactory. One of the big questions raised by skeptics of “medical tourism” is this: how is one to assess the quality of hospitals abroad?

In recent years, accreditation by Joint Commission International has served as a kind of stamp of approval that patients look for when considering foreign providers. But JCI accreditation — like accreditation by the Joint Commission (formerly JCAHO) — isn’t really a measure of clinical quality. What it is, says PHMI Senior Consultant Dr. John Helfrick, is an indication that a hospital has the systems and processes in place to support high-quality, safe patient care:

“Accreditation” is generally not well understood. It is a process, not an event. There is a “validation” survey but it’s the maintenance of good processes and the improvement of deficient ones that occurs between surveys that really constitutes accreditation. Most “accreditationists” believe that health care outcomes are dependent on the quality of the structures and processes in place in a health care organization. The accreditation process is designed to assist organizations in implementing and then improving their structures and processes. The effectiveness of this process is borne out by the measurement of and, hopefully, the improvement in the outcomes of care.

In recent years PHMI has worked with several health care organizations who have used the JCI accreditation process as a guide for instituting a culture of quality. The process provides a roadmap that helps the provider to develop the kinds of structures they need to produce good outcomes. And while the distinction of earning JCI accreditation can be used as a marketing tool for as long as it is viewed as an indicator of attention to quality care, most clients believe that the process of earning accreditation is most important. From Dr. Helfrick:

Some hospitals pursue accreditation to give themselves a marketing advantage; others do it for the right reason. Interestingly, it’s this latter group that has the most effective marketing approach: commit to high-quality, safe care, and the patients will come. Hospitals that go through the triennial cycle once and then drop out have most likely become accredited for the wrong reason. 

Read what else Dr. Helfrick has to say about hospital quality improvement in the July-August issue of PHMI WORLD.

A quick mention on Paul Levy’s blog led me to the BIDMC-TV section of the Beth Israel Deaconess Medical Center website. Here you can find short videos on various health care topics organized in “channels.”  On the Breathing Easier Channel, for example, you can see Dr. Armin Ernst discuss chronic obstructive pulmonary disease. On the Cardiovascular Channel you can view a video about a minimally invasive procedure used to treat a stroke victim. The Women’s Health and Childbirth Channel has a good video featuring tips that can help new mothers learn how to handle their babies without hurting their backs. Other channels focus on fitness, cancer, men’s health, quality improvement, and much more.

For more, visit the BIDMC-TV website .

In the wake of the Institute of Medicine’s call for more geriatric medicine training, the Wall Street Journal’s Health Blog highlights how Hebrew SeniorLife, an organization that operates two nursing homes in Boston, is providing opportunities for students at Harvard Medical School and other Boston-area institutions to learn how to address the health care needs of our rapidly growing elderly population.

HMI WORLD correspondent Natalie Engler wrote about this topic in a 2006 Forum article. Read “Meeting the health care needs of an aging population.” An excerpt:

What’s the solution? Simply churning out thousands of geriatricians clearly won’t solve the problem, even if such a thing were possible. If geriatric training was required in every medical school today it would take more than 40 years for all practicing physicians to be replaced by those with geriatric training, says Greg O’Neill, PhD, director of the National Academy on an Aging Society. He adds that new geriatricians, like people in other medical specialties, tend to cluster, leaving an oversupply in some areas while others remain underserved.

 

Some geriatricians—like ILC-USA’s Robert Butler, and Dr. Lewis Lipsitz, chief of gerontology at Beth Israel Deaconess Medical Center, vice president for academic medicine and co-director of the Institute for Aging Research at Hebrew SeniorLife, and professor of medicine at Harvard Medical School—advocate for geriatrics as an academic specialty.

“My approach, and that of my colleagues, is to train the trainers. We want to train the academic leaders who are training the medical students and residents, so that every emerging doctor has a basic knowledge of geriatrics—the way every medical doctor has a working knowledge of cardiology,” explains Lipsitz. “In this way, geriatricians become the researchers who generate new knowledge, as well as the teachers and consultants who disseminate it to the existing  health care workforce”—including physicians, nurses, therapists, pharmacists, and social workers.

We will again join with the University of Lausanne to gather health care leaders in Switzerland for “Mastering the New Challenges of Health Care.” This five-day executive education course is designed to equip participants with the knowledge and skills required to understand and confront complex health policy issues.  

The program will again be led by Miles Shore, MD, Harvard University professor and HMI Senior Consultant and Director; and Alberto Holly, PhD, Professor of Economics and Director of the Institute of Health Economics and Management at the University of Lausanne. They will head a multidisciplinary faculty drawn from Harvard University, the University of Lausanne, the London School of Economics, and other top institutions. For further information and to learn how to register for the program, please click here.

Last year, while working with MEDEX Global Group to develop health information for travelers, our Communications group learned quite a lot about malaria: the conditions that allow it to thrive, the mosquitoes that transmit it, and the parts of the world where you really have to protect yourself against it.

There are an estimated 500 million malaria infections every year, a fifth of which are fatal.

This week a piece in the New York Times Health section looks at the possibility of eradicating malaria. The Bill and Melinda Gates Foundation has put $1.2 billion towards that objective, but if they really believe that malaria can be relegated to the lab, like smallpox, then they are in the minority:

Dr. Regina Rabinovich, the foundation’s head of infectious disease, said the Gateses knew it was a long-term undertaking, not possible without more money, better health systems and probably a vaccine, which is still far off.

Dr. Arata Kochi, the W.H.O. malaria chief, went further than other skeptics, arguing that the specter of eradication is counterproductive. With enough money, he said, current tools like nets, medicines and DDT could drive down malaria cases 90 percent.

“But eliminating the last 10 percent is a tremendous task and very expensive,” Dr. Kochi said. “Even places like South Africa should think twice before taking this path.”

False hopes, he said, lead governments to hope for miracles instead of accepting the mundane budget-draining control policies that he endorses. For example, health officials from Rwanda and Zanzibar, having drastically cut malaria within their borders, have asked him about seeking money for elimination.

Even relatively wealthy countries rarely succeed at that. South Africa, Saudi Arabia and Mexico all control cases but see new ones imported — from Mozambique, Yemen and Guatemala, respectively, he said.

Dr. Awash Teklehaimanot, director of the malaria program at the Earth Institute of Columbia University, said he worried that calls for eradication raised expectations too high, inviting frustration and a loss of political will.

“Maybe 10, 15 years from now, we should consider this,” he said.

Gulf Region publication Trade Arabia details plans to develop a medical simulation center in the new home of the Harvard Medical School Dubai Center Institute for Postgraduate Education & Research. HMSDC, launched in 2004, is the focal point of efforts to develop high-quality education infrastructure and training in the Gulf Region. Since its inception, its Continuing Medical Education programs have been attended by thousands of physicians, nurses, and allied health professionals in the region.

The medical simulation center will be the first in Dubai. Occupying over 20,000 square feet in the new HMSDC facility, it will provide postgraduate medical trainees and other health care professionals the opportunity to undergo simulation-based training in rooms designed to replicate operating theaters, intensive care units, emergency rooms, and inpatient ward rooms. Dr. Robert L. Thurer, Chief Academic Officer at HMSDC, said the simulation center would help “support Dubai Healthcare City in its efforts to become the regional center of excellence in health care informed by education and research.”

Today the February 2008 issue of leading academic journal Academic Medicine is online and in mailboxes. The theme of this issue is global health, and the lead article is authored by Robert K. Crone, MD, the founding president and chief executive officer of HMI.

Entitled “Flat Medicine? Exploring Trends in the Globalization of Health Care,” the article presents the context in which we at HMI collaborate with our partners around the world. Drawing on examples from our work in Dubai, Turkey, and India, the article describes a global health care landscape that is undergoing a major transformation, with ramifications for patients, providers, and governments not only outside the United States, but in our own  local communities.

From the article abstract:

Trailing nearly every other industry, health care is finally globalizing. Highly trained and experienced expatriate health care professionals are returning to their home countries from training in the West or are staying home to work in newly developed corporate health care delivery systems that can compete quite favorably with less-than-perfect providers in Europe and North America. In turn, these health care systems are attracting patients from around the world who are interested in exploring high-quality, lower-cost health care alternatives. Much of this activity is occurring in the emerging economies of the Middle East, South and Southeast Asia, and beyond. Three Harvard Medical International collaborations-in Dubai, Turkey, and India-highlight these trends and demonstrate the potential for new models of global health care, as well as potential ramifications for patients and providers in the established economies of the West, including the United States. Although globalization is not a cure-all solution to achieving universal access to health care, it is not only a significant first step for patients in these emerging economies, but may also present alternative solutions for those patients in wealthier nations who nonetheless lack adequate health care coverage. The increase in health care quality and competitiveness around the globe is important, but these improvements will need to be matched by the development of comprehensive payer solutions, to benefit as many people as possible.

You’re probably familiar with Atul Gawande’s writing on medicine for the New Yorker magazine, but if you’re not, his most recent piece will serve as a great introduction to his work. In the December 10, 2007 issue, Gawande, who is a surgeon at Brigham & Women’s Hospital in Boston, writes about how the use of detailed checklists are enabling ICUs to provide complex care and save lives in the face of what used to be extremely long odds. In addition to providing a fascinating nuts-and-bolts analysis of an interesting element of clinical quality improvement, Gawande gets at how what is now achieveable in the hospital is pushing against traditional ideas about what makes for good doctors:

Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.

Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.

In the new issue of “Global Health Update” (a Partners Healthcare System publication), Dr. James Thrall, Radiologist-in-Chief at Massachusetts General Hospital, talks with the editor of HMI WORLD about his rapidly evolving field. Choice quote: “The future is going to take us to smaller dimensions. Just as scientists are very excited about nanotechnology, radiologists are very excited by our ability to image not just at the level of the whole organ, but at the level of molecules and cells.”

As scored and ranked by the U.S. News & World Report in their annual Honor Roll of American hospitals:

1. Johns Hopkins Hospital (Baltimore, MD)
2. Mayo Clinic (Rochester, MN)
3. UCLA Medical Center (Los Angeles, CA)
4. Cleveland Clinic (Cleveland, OH)
5. Massachusetts General Hospital (Boston, MA)
6. New York-Presbyterian University Hospital of Columbia and Cornell
7. Duke University Medical Center (Durham, NC)
8. University of California-San Francisco Medical Center
9. Barnes-Jewish Hospital at Washington University (St. Louis, MO)
10. Brigham & Women’s Hospital (Boston, MA)

Food for thought: of the hospitals on the list, do you know which ones are engaged in work outside the United States, in some form or fashion?

Update: Answer to the question above in bold.