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Dear Editor: Customer/Patient care article draws responses. (Reader Feedback).

Patients not inventory

The article by John E. Whitcomb, MD, and Mehrclad Shafa, MD, ("Treating Patients Like Customers" The Physician Executive, September-October, 2001, 27(5): 16-2 1) discussed some useful ways to consider improving patient-centered care in hospitals.

I'd like to suggest, however, that their initial terminology is wrong. In a more conventional sense of the use of the term "inventory," it is a stockpiled resource sold or supplied. Inventory is not patients, but instead the resources we use to attend to patients' needs.

A hospital inventory includes all those personnel who provide personal care services (and their support staff), the disposable assets used for patient care (dressings, medications and catheters) and fixed assets (licensed beds, in-wall oxygen lines, food service capabilities).

The fixed and disposable assets are usually immediately available to care for patients. The problem is putting the resources to use efficiently, which means applying exactly what patients need when they need it--just-in-time health care.

Often, just-in-time health care demands immediate and frequent communication between all personnel providing care for each patient. If the physician were immediately contacted with X-ray or lab results and the physician immediately chose and communicated the test-dependent course of treatment, and the nurse/unit staff immediately implemented that course of treatment, much time would be saved, more efficient care provided and improved patient care outcomes would result.

One of the aspects of hospital inventory--personnel--have a second extremely important, but often overlooked, component that makes for the more efficient use of inventory and improved customer service--personnel interaction/communication.

Just-in-time health care is, of course, the big problem throughout U.S. illness care today. If patients could get the precise health care they need exactly when they need it we could mitigate the use of unnecessary or duplicated tests, physician office visits, ER visits, prescriptions and telephone calls (to say nothing of saving patients the time and expense they waste arranging and having such tests, visits, and medications), while ensuring patients get the care they do need.


West Hartford, Gonn.

Halley S. Faust, MD, MPH, FACPE, FACPM

Insights and misstatements

With 30 years practicing internal medicine, for 15 of those years I have been deeply involved with utilization review, particularly the hospitalist concept. My points (about the article, "Treating Patients Like Customers") will be mixed between strong affirmation of some excellent insights and what I believe to be serious misstatements.

Several points in the article I can wholeheartedly endorse:

"Decisions are made once a day...." The daily rounding is arguably the foremost inefficiency in our hospitals. Whitcomb and Shafa are very tactful indeed, because mismatched information, i.e. path report, PT. progress, CT/XR reports and consultant contributions commonly aren't quite available at that critical once-daily time, causing even worse delays.

To make matters much worse, weekends are often "decision-free zones" due both to cross-coverage and institutional semi-coma.

The solution to both types of delays is a hospitalist arrangement. In 2001, an inpatient is a full-time job for an on-site, institutionally savvy clinician. Daily rounding at the margins of a busy office schedule can, under 2001 UR pressure, approximate absentee landlord status.

The hospitalist will drive institutional efficiency naturally, but I repeat and emphasize the points by Whitcomb and Shafa at the very end of page 18; the payors have so bled the hospitals of revenue, they use survival thinking in place of risk-taking, which stalls creativity and exploration.

Having acknowledged that both physicians and institutions have efficiencies still available for them, let me point out what is the deeper problem we have when caring for our ill, the sabotage of ex-hospital care by the insurance industry.

Historically, 10-15 years back, the first phases of UR were focused on reduced ALOS, with an implied goal of reducing total beds by increased turnaround of cases. The insurance industry mantra was "lower level of care," with ample reassurances that the care would be provided, only with a change-of-venue, e.g. the anywhere-but-inpatient hospice-benefit program by HCFA, whereby generous in-home care was available if further inpatient care was foresworn.

Over the last decade, all payers have retrenched from good/full post hospital care, through a combination of reduced payment, bureaucratic harassment i.e. "compliance," and failure to compensate/acknowledge the sacrifices of family members to implement outpatient (or "home") care plans.

But wait! We haven't even mentioned the time-off-work to go to radiation Rx, lab and CT, various specialists' offices (each with their unique form to be filled out, hours of access, parking, and payment arrangement) support groups, and primary care physician as always, the oncologists and other specialists commonly won't see them for a cold, carpal tunnel or flu vaccine. Thus, family members are conscripted by insurance companies and hospitals alike to do their work without reimbursement, without regard to jobs, schooling or financial outcome to family unit. Such is the everyday scam, dressed up in Sunday best verbiage such as "medical necessity," good utilization or coverage.

While I won't contest the "doctor-centric" term directly, my point is that inpatient care is also patient-centric, family-centric and society-centric. Is a teacher, fireman or day care operator best at their own job, vs. unpaid/untrained nurse/physician therapist/ambulance company?

As hospitals and their insurers seek to shift care of sick/older/complexer patients to their families while offering less and less to them to offset their unavoidable sacrifices, the hospitals will approach gridlock. I submit that progressive hospital (ER plus inpatient) overload is not entirely, or even mainly, "doctor-centric," but rather represents a major social breakdown: the payer who won't.


Dan H. McDougal, MD

Hagerstown, Md.
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Publication:Physician Executive
Date:Jan 1, 2002
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