The Customer is NEVER Right - A Nurse Practitioner's Perspective
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The following a comment to comments about a VA hospital raising their quality scores.

WOW! That’s a LOT to unpack. (VA raises quality scores! Video [IncidentReport 130])

1      Disclaimer: I am NOT a fan of VA Healthcare as it has LONG passed its intent and ought to be ABOLISHED.

2      Stick to making diagnoses and NOT judgement. A pediatrician, even at the VA, being the Chief of Staff is NOT unheard of, regardless board certified or NOT. The analogy (sticking with the VA theme)—A veteran DISMISSED for not serving in combat. An infantryman DISMISSED for NOT having earned the Expert Infantry Badge. Two short stories, (1) The company commander of a Forward Support Battalion Medical Company during combat a pediatrician who NEVER been in the field or in charge of ANYTHING, to include the pediatric clinic he worked at. (2) On 4 Apr 2004 the Battalion Aid Station physician during a battle in Sadr City, Iraq (Movie: The Long Road Home) was a pediatrician who managed 8 KIA & almost 60 wounded. Again, stick to diagnoses NOT judgement. If the Chief of Staff is a poor manager her diagnosis is a “poor manager”. Being a pediatrician, board certified or NOT, has NO merit to being a “poor manager” or NOT.

3      A NURSE, which you made clear by repeating it a number of times, overriding a physician’s disposition. Outrage or absurd? NOT sure which emotion you were trying to convey. While NOT the case of your point here I am sure you MUST have heard, “Physicians save lives. Nurses save physicians [licenses].” You MUST also know the position the nurse holds is NOTHING but cheap labor where the administration is NOT willing to pay a physician to do the same job—management! Because if the position were filled by a physician who made the same management decision then what would you say? Nonetheless, a poor managerial decision, regardless a nurse or physician making the call. Again, stick to making diagnoses and NOT judgement.

4      That said, to both above, you MUST know that healthcare administrators are recruited from clinical backgrounds after they show interest in looking after and doing good for their clinical colleagues. Sadly, over time, after crossing to the DARK SIDE, those naïve torchbearers, physician, nurse, whoever, find themselves siding more with their NEW administration colleagues OVER their FORMER clinical associates. SAD!

5      A VA hospital, got it. However, leave out that they are veterans and instead simply call them the patients they are. Because in that sense, or lack thereof, NO different than any other hospital in our nation. No different because rating healthcare, VA or NOT, has NOTHING to do with healthcare. Ratings that have done NOTHING for healthcare but leave behind an OVERWHELMING amount of collateral damage and our nation’s silent national crisis. NONE of that is NEW and the VA is NOT alone. As those pervasive incentives to obtain high rating scores are pandemic throughout healthcare, urban, suburban, rural, profit, nonprofit, public, private, teaching, or nonteaching, it DOES NOT matter, everyone is cashing in.

6      As to transferring patients out that is NOT new either. In 2012, Dr. J. Fenton from UC-Davis published a study that found “patient satisfaction linked to higher healthcare cost and mortality. Interestingly, in 2016, Dr. D. E. Wang from Harvard published a study  finding the opposite, “Higher CMS star rating associated with lower patient mortality and readmissions.” How is that possible? Interestingly, Dr. Fenton, a former locums provider working in rural healthcare organizations, pointed out a number of intervening and/or extraneous variables, lack of ICU, specialties, etc., as you mention lack at the VA you mention, were the variables that made the difference in Dr. Wang’s study. Dr. Fenton pointing out, as you noted, because those services lack the patients are transferred to outside facilities thus NOT a burden on the organization leaving them with better ratings. This is how misleading those practices are, the Women’s Choice Awards are an independent non-healthcare organization which represents women. The organization acknowledges a number of categories, automotive to travel and lots more in between, for their seal of approval. One of those categories, “America’s 100 Best Hospitals for Patient Experiences". Sadly, because the above mentioned the Women’s Choice Awards includes mostly rural or small organization which lack services/specialties thus leaving the organization with low acuity and good outcomes. What those numbers DO NOT disclose is who wants to go to any of those facilities’ emergency departments for MI/CVA care where they lack experience despite their scripts and signage, standard uniforms, valet services, and luxurious lobbies.

7      As if NOT enough, with the help of social media, Facebook in particular, healthcare organizations can now bypass HCAHPS and promote better scores on their pages than those published by CMS through HCAHPS. How? Organizations have TOTAL control over the content of their social media pages, i.e. Facebook, thus they WILL cherry-pick the ratings and comments that best service their goals. Additionally, those looking for services are more familiar with social media versus CMS sites thus likely will search social media first—and we ALL know that if it’s on Facebook it MUST be accurate.

8      For more than 15 years now my plight has been that rating healthcare has done NOTHING for healthcare but leave behind an OVERWHELMING amount of collateral damage, which includes decreased access to healthcare as so many LOSE in the survival of the fittest race, healthcare directed violence, bad outcomes as thousands are killed every year due to medical errors and/or unnecessary treatments, increase cost overall, poor nurse:patient ratios, opioid epidemic, healthcare worker turnover and/or leaving healthcare, BILLIONS of dollars LOST to fraud, waste, and abuse, and BILLIONS more chasing satisfaction scores. ALL those, and others, collectively our great nation’s silent national crisis.

9      In the past 15 years, I have also pointed out that our nation’s healthcare is NOT broke but as intended. If broke, steps would be taken to fix it. Instead, what has evolved is the proliferation of NEW INDUSTRIES without fixing ANY problems. Here is the evidence, take the following attached graphs

Healthcare Cost USA vs World (x2),

Life Expectancy vs Healthcare Expenditure Over Time,

Consumer Price Index for All Urban Consumers: Healthcare vs Consumer Price Index for All Urban Consumers: All Items

and plot the following timestamps 1980 and 2000. Why those two years? Those two periods in time can easily be identified as the impetus as to where healthcare is today. The beginning, the early 1980’s when the “Healthcare Service Excellence” mantra arrives. As a result, and the point of NO return, in the late 1990’s rating healthcare becomes a separate industry, separate from ALL other industries. Service industries healthcare copied as the blueprints for healthcare from which to deliver great service (NOT healthcare). Now, some 30+ years have gone by and BILLIONS of dollars WASTED and healthcare has NOTHING to show for that IDIOT-ology [sic]. Except! More expensive and inferior healthcare, a customer satisfaction needle that has NOT moved and, most significant, a DEVASTATING trail of OVERWHELMING collateral damage listed above just to name a few.

10   Lastly, correct me if I am wrong, as I just could NOT bear watching your video again and I might have misheard what you said about HCAHPS’ origin and/or purpose, but I believe you have the impetus and purpose of HCAHPS incorrect. Follow this link to HCAHPS’ history and intent (and somewhat the Affordable Care Act)—you will be shocked on how much every rated hospital forfeits because of (INTENTIONAL) unobtainable numbers and how those monies are needed to sustain the Affordable Care Act. Again, healthcare is NOT broke but as intended, PROFITS!

The point of ALL this:

(1) It is the responsibility of healthcare workers and NOT anyone else’s, NOT LAWS, NOT POLICIES, NOT UNIONS, NOT ADMINISTRATORS (nurse, physicians, whoever), and NOT OUTSIDERS, to steer healthcare in the right direction. YES, unfortunately, us versus them, board-certified or NOT.

(2) KEEP your eye on the PRIZE, which is taking healthcare back to MAKE HEALTHCARE GREAT AGAIN!

(3) To DO so we MUST take over and NOT simply take part. Thank you for reading. You may now return to your regular programing.

I AM A NURSE! The Knitted Brow.

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