DiversityNursing Blog

Glenn Llopis

www.huffingtonpost.com

Like many healthcare providers in the Los Angeles area, and well beyond to healthcare organizations throughout the United States, City of Hope has recognized the growing need for clinical professionals and staff that more closely mirror the patients it serves in its catchment area. And with a local population that is nearly half Hispanic, that means recruiting more Hispanics into the industry, as well as providing much needed career development opportunities. But whereas most in the industry are just beginning to acknowledge the need, City of Hope has taken the lead to recruit more Hispanics into the industry and also has started to build a Hispanic talent pipeline for the immediate and not so distant future.

According to Ann Miller, senior director of talent acquisition and workforce development, "Even when people in the industry recognize the need for more Hispanics, or just a more diverse workforce, it can feel overwhelming trying to figure out what actions to take and how to build a strategy around it. But once you see the data laid out in front of you, and see that 46 percent of your primary service area is Hispanic, you realize it would be optimal to figure out how to recruit a workforce that looks more like the population you are serving. Beyond that, it's also important to employ a bilingual staff that can speak the language and understand the culture to best meet the needs of the community being served."

Once you recognize the need, it's time to start asking the questions that will help you fill the gaps:

• How do you find and appeal to the types of people you need to start building relationships with? Who are the influencers and the connectors?
• How do you get your recruitment team looking toward the future and building a pipeline, when limited resources are focused on more immediate needs?
• How do you get buy-in from senior management and enlist other departments throughout the organization?
• How do you partner with others in the industry who recognize the need but have yet to become active in the pursuit of common goals? 

Here's how City of Hope has started to answer these questions as it takes the lead in addressing these timely industry issues. Stephanie Neuvirth, Chief Human Resources and Diversity Officer, has said that it's not easy to build a diverse healthcare or biomedical pipeline of talent, even when you understand the supply and demand of your primary service area and the business case becomes clearer. "Few in the industry are taking the helicopter perspective that is needed to really see the linkage between the different variables that must be factored in to solve the problem," she says. 

Even in healthcare, it's not simple, and it takes time to develop the paths, the relationships and the pipeline to cause real and sustainable change. It takes linking a workforce talent strategy to the broader mission and strategic goals of the organization. And it takes collaboration with the community, schools, government, parents and everyone who touches the pipeline to help achieve the necessary and vital missing pieces of the puzzle.

Talent Acquisition and Workforce Development

What you first have to realize is that there is an immediate but also a long-term gap to fill, which represent two sides of the same coin: talent acquisition and workforce development. We know we can best serve our community by mirroring the community that we serve, and that doesn't stop with the talent that we attract today; it's an imperative that depends on the talent pipeline that we build for the future.

City of Hope's approach has been to start fast and strong with some immediate steps that can then be built upon and cascaded out into a longer term strategy for the future. The good news is that if your goal is to look like the community you serve, you don't have to look far for the talent you need. It's right in your own backyard. But there's still a lot of work to be done in terms of educating people about potential careers in healthcare -- clinical and otherwise -- developing the workforce skills and knowledge that they will need, and planting the seeds in the next generation. 

It's particularly disheartening to hear about the young people graduating from high school and college who can't get jobs, when there are growing shortages in the healthcare industry - the nation's third largest industry, and projected to be its second largest in just seven years. According to a recent report by The Economist, U.S. businesses are going to depend heavily on Latinos - the country's fastest-growing and what it calls "irreversible" population -- to fill the gaps not just in healthcare but across all industries. 

If you look just at nursing, the single largest profession in California, you can see how far we have to go. Only 7 percent of the 300,000 nurses in the state are Hispanic. The clinical gaps extend to doctors, just 6 percent Latino; pharmacists, less than 6 percent; and the list goes on and on.

Teresa McCormac, nurse recruiter, is one of the people at City of Hope working to build the Hispanic talent pipeline, beginning with the need for Spanish speaking nurses. She is responsible for elevating City of Hope's presence in the community through word of mouth referrals and by getting active in broader outreach online, in publications and at local, college and national events, such as the National Association of Hispanic Nurses (NAHN) annual conference taking place in Anaheim, CA this July.

"It's important to have a passionate champion for the candidates, as well as our hiring managers and the organization. My role is to get the word out into the community about City of Hope and connect with the talent we need to fill our current and future openings," she says.

This requires a multi-prong approach to recruitment efforts, where you must act to attract candidates not only for current needs, but down the road five-ten years, and even further into the future. 

This begs the question: how do you get more Hispanics and other diverse students interested in the sciences and considering careers in healthcare? 

Traditionally, recruiters focus on those currently working in healthcare to fill immediate gaps, as well as those working in other industries with transferable skills, who might be interested in working in healthcare in a non-clinical capacity, such as IT or marketing. They also look at colleges with nursing and other clinical programs -- particularly those with high concentrations of Hispanics and other diverse students -- where they can conduct outreach efforts, build partnerships and establish a presence. 

But building a talent pipeline requires that you reach students well before the college years, when they are still in high school, and even earlier as middle and grade-schoolers. It takes time to get the message out there and have it stick, so the bigger and bolder you can go, the better. That was City of Hope's thinking behind the launch of its Diversity Health Care Career Expo in September 2014, which made quite an impact with the community and opened eyes to the variety of career opportunities within healthcare. It also opened City of Hope's eyes to the level of interest from the community when 1500 people showed up for this first of its kind event. 

What started as an idea for a diversity career fair to fill immediate positions quickly grew to encompass a workforce development component to include students, parents, as well as working professionals interested in transitioning into healthcare. The Career Expo brought a level of awareness never seen before in the community -- and did so very quickly. For example, it allowed healthcare professionals to connect the dots between math and science classes students were taking and how this learning applied in the real world of healthcare -- and the different careers these types of classes are helping to prepare them for if they stick with them. It also allowed parents to understand how to help their children prepare for jobs that are available and will continue to be available in the future. They also gained insights into how growing up with smartphones and other electronic devices has given their children a distinct advantage that previous generations didn't have -- enabling them to leverage their everyday use of technology into transferable skills that could lead towards a career in Information Technology, which offers a very promising career path within the healthcare and biomedicine industries. 

Catching students early on to spark their interest and expose them to healthcare careers and professionals who can encourage and support them along the way requires that you go out into the community as well. Toward that end, City of Hope has partnered with Duarte Unified School District and Citrus College on a program called TEACH (Train, Educate and Accelerate Careers in Healthcare).

According to Tamara Robertson, senior manager of recruitment, the TEACH partnership provides students with the opportunity to gain college credit while still in high school by taking college-level classes at no cost. This puts them on the fast track to higher education and career readiness by giving them essential skills and capabilities to enter the workforce soon after graduating high school, or to continue their education with up to one year of college coursework already completed. Eighteen students were accepted into the program in its first year.

Each partner plays a valuable role in the program. City of Hope provides students with opportunities to gain first-hand exposure to healthcare IT by giving overviews of the various areas within IT, providing summer internships, and offering mentoring and development interactions. Duarte High School is the conduit for the program by selecting the students for the program and facilitating the learning, and Citrus College develops the curriculum that enables students to earn college credits and IT certifications. It's ideal for students who may not have the means to continue on to college, but can work for an organization like City of Hope that offers opportunities to start their IT career as a Helpdesk or Technology Specialist. In addition, they can take advantage of tuition reimbursement should they choose to further their education and development.

In today's world, social media must be in the recruitment mix, especially if you want to engage with Hispanics who index higher on time spent on social media than the general population and any other group. Statistically, 80 percent of Hispanics utilize social media compared to 75 percent of African Americans and 70 percent of non-Hispanic whites. It's also a great way to reach not just active candidates in search of a new position, but passive ones employed elsewhere whose interest may be peaked when a more interesting opportunity presents itself. 

This is where Aggie Cooke, branding and digital specialist, comes in -- leveraging social media as a core component of City of Hope's outreach efforts to potential candidates. She takes a three-legged approach to the use of social media for recruitment:

1.  Branding - offering relevant content that portrays the culture and appeals to a candidate's values and broader career aspirations;

2.  Targeting - identifying potential candidates who have skills and experiences that the organization needs today and in the future; and

3.  Engaging - creating a relationship by inviting candidates to dialog with City of Hope.

You can reach more people through social media -- even if they're not active job seekers -- by posting information that is relevant to their field and interests. For example, oncology nurses will be interested in what you have to say about the latest developments in the world of oncology. 

Though it can seem overwhelming with so many messages out there competing for people's attention, you can break through with content that is authentic, timely and purposeful. You can also make an impact by tailoring your content to the medium you are using. For example, a story about a scientific breakthrough at City of Hope would play well on LinkedIn, while pictures of happy employees taking a Zumba class together would engage potential candidates on Instagram. Social media also enables you to expand the reach and prolong the life of live events. For example, attendees of the Career Expo last year engaged online with live tweets and Instagram pictures from the event and later provided comments and feedback about their experience that will be instrumental in planning this year's event.

Going forward, successful programs and events, like TEACH and the Diversity Health Care Career Expo, will be expanded upon, as City of Hope continues to lead the way in talent acquisition, workforce development and creating a talent pipeline for Hispanics and the future of healthcare.

By Tracey Boyd

http://news.nurse.com

Informatics programs that allow med/surg nurses to cut down on documentation and increase patient safety at the touch of a button are becoming more essential in today’s fast-paced healthcare environment.

“Most all nurses use the electronic health record in their daily practice,” said Jill Arzouman, MSN, RN, ACNS-BC, CMSRN, president of the Academy of Medical-Surgical Nurses and clinical nurse specialist in surgical oncology at the University of Arizona Medical Center, Tucson. The university has computer stations inside each patient room for access to charting, she said, and some hospitals are investing in iPads to facilitate charting. Arzouman is a DNP candidate.

Med/surg nurses at New York’s Montefiore Health System in the Bronx use informatics throughout the day to document patients’ electronic medical records and provide direct care to patients, said Maureen Scanlan, MSN, RN-BC, vice president, nursing and patient care services and former director of informatics for the health system. “Electronic documentation has provided us the ability to track and trend patient outcomes data in a more efficient manner. We have the added benefit of decision support alerts to guide practice and documentation. We then can leverage information collected from the records to streamline workflows and improve patient safety.” 

According to a HealthIt.gov study “Benefits of EHRs,” (www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes), having quick, up-to-date access to patients’ information can also reduce errors and support better patient outcomes by keeping a record of a patient’s medications or allergies, checking for problems whenever a new medication is prescribed and alerting the clinician to potential conflicts. 

“The ability to clearly read a medication order printed from a computer is vastly different than trying to decipher a handwritten order,” said Arzouman.

In addition, staff can revisit patient information at any time. 

“Many of the systems are very intuitive and allow the entire interdisciplinary team to document and communicate with precision and ease,” she said “A medical/surgical nurse may be busy with another patient but she or he can go back and read documentation from the dietitian who may have visited the patient at the same time.“

A reduction in medication errors was the catalyst for a project using computerized EHRs at Abington (Penn.) Health. When staff realized that patients with heart failure were being readmitted largely because of incorrect medication lists upon discharge, Diane Humbrecht, MSN, RN-BC, chief nursing informatics officer, devised a plan to evaluate the accuracy of such lists. 

Humbrecht, a DNP candidate who is also a chapter director for the American Nursing Informatics Association, has worked in both cardiac and home care during her career and said she had experienced heart failure patients going home with medication lists that were either incorrect or missing information. 

“It was very frustrating for both the patient and the nurse who is trying to follow up,” she said.

As part of her DNP program, Humbrecht decided to focus on transitions of care for this vulnerable population to help correct their discharge medication instructions and reduce their risk for readmission.

“As I began researching, I saw medication errors on medication discharge lists were the main reasons patients were readmitted to the hospital,” she said. •

Her findings were validated, she said, when the transition nurses who were involved in the postop discharge process informed her of problems with patients going home with incorrect medication lists. “Medication reconciliation and discharge instructions are done by the physician, but the nurses are the ones who review them and they were finding these errors after discharge,” she said. 

Humbrecht implemented three changes to remedy the situation. The first step was to bring the pharmacists in on the front end. Pharmacists already performed patient rounding on units, but they were not involved in medication reconciliation at all, she said. The new protocol called for pharmacists to come in within 24 hours of a patient’s admittance to review the co-medications. The input from the pharmacists on the front end was crucial. “The pharmacists had to change about 80% of the lists,” Humbrecht said.

Next, upon discharge, the nurses perform a thorough review of the co-medications list that was corrected by the pharmacist. “If anything needed to be corrected, the nurse then called the physician to tell them they need to change a medication,” Humbrecht said. “Once that was done, it caused the physician to perform medication reconciliation again, automatically updating the entire medication list.” 

The transition nurses were the final piece to the puzzle. Prior to the new protocol, upon calling the discharged patient and finding any errors, the nurse would make notations on paper. If the patient was readmitted, and the change was not transferred onto the patient’s EHR, the incorrect information was still in the system. Now, using the computerized medication list, any errors are updated immediately in the system. 

The changes worked. Since implementation last fall, the transition nurses have found one error on the medication list of a discharged patient, Humbrecht said. 

“We figured if we can get the home medication list correct on the front end by using the pharmacists and double-checked and changed as needed by the nurses on the back end, then the transition nurses should find less errors,” she said.

Besides documentation and patient safety, med/surg nurses are using informatics to enhance patient care. “Our staff nurses provide expert advice when we are defining a new process for delivering patient care,” said Scanlan, who holds board certification in nursing informatics. “A recent implementation of a new lab system that changed the way specimens are collected was successful due to workflow and hardware recommendations from the frontline staff.” 

Scanlan said staff nurses recently have contributed to revising the electronic skin assessment template as well. 

“Although not a clear time saver,” she said, “it has significantly improved the ability to track, trend and communicate hospital-acquired pressure ulcers [and] has supported performance improvement efforts that are led by the nursing staff.”

Arzouman also noted innovative uses. “For a postoperative patient who needs to continue to ambulate and exercise while at home, a medical/surgical nurse can teach the patient how to track his activity using a smart phone app,” she said. “I have had the opportunity to trial an app on my smart phone that translates basic medical information into many different languages without needing to use a translator. For something simple like ‘Hi, my name is Jill and I will be the nurse coordinating your care today,’ it is a very helpful tool.” 

Source: www.trocaire.edu/trailblazer-blog

Historically, both men and women have filled the challenging and rewarding role of a nurse. It wasn’t until the Civil War, when nearly 3 million men filled the ranks of two competing American armed forces, that women began to dominate the field.

Today, over 43 million Americans are aged 65 or older – a number that is expected to double over the next 35 years. A larger elderly population means a greater need for long-term health services, and as a result, the healthcare field is one of the fastest-growing industries.

Why does this matter?

 1. The U.S. is already on the verge of a nursing shortage. 

The American Association of Colleges of Nursing reports that the U.S. is experiencing a shortage of Registered Nurses (RNs) that is expected to intensify as Baby Boomers age and the need for health care grows.

Did you know only 7 percent of nurses are currently men?   According to the latest National Sample Survey of Registered Nurses conducted by the Health Resources and Services Administration, the percentage of male nurses has more than doubled in the past three decades, but still lingers at 7% today. This number is expected to triple within the next few decades as the need for both male and female healthcare professionals continues to grow.

2. A diverse population needs a diverse nursing staff. 

According to the American Association of Colleges of Nursing (AACN), men are enrolling in nursing programs at a higher rate compared to the past. The IOM report states that there still need to be an emphasis on gender diversification and inclusion in the workforce.

The IOM Report also states that the nursing profession “needs to continue efforts to recruit men; their unique perspectives and skills are important to the profession and will help contribute additional diversity in the workforce.”  The increase in men pursuing a nursing career will help create a more diverse healthcare environment. 

3. Discrimination issues must be overcome.

The idea that men cannot be nurses will never be eradicated until men take to the profession in greater numbers. While nursing is seen as a nontraditional career for men today, the stereotype must change -- nursing is simply too important of a job, and too attractive of a career.

“There are just far too many benefits that come along with nursing, such as a flexible schedule, a secure position, and high pay,” notes the website NursingWithoutBorders.org, “and so it’s therefore difficult for anyone to refuse to pursue a field that only continues to grow.”

Source: http://nursingonline.uc.edu

Publisher: http://nursingonline.uc.edu/ (University of Cincinnati Online)

Written by David McNamee

Male registered nurses are earning more than female registered nurses across settings, specialties and positions, and this pay gap has not narrowed over time, says a new analysis of salary trends published in JAMA.

Although the salary gap between men and women has narrowed in many occupations since the introduction of the Equal Pay Act 50 years ago, say the study authors, pay inequality persists in medicine and nursing.

Previous studies have found that male registered nurses (RNs) have higher salaries than female registered RNs. In their new study, researchers from the University of California, San Francisco, sought to investigate what employment factors could explain these salary differences using recent data.

The researchers analyzed nationally representative data from the last six quadrennial National Sample Survey of Registered Nurses studies (1988-2008; including 87,903 RNs) and data from the American Community Survey (2001-13; including 205,825 RNs). In both studies, the proportion of men in the sample was 7%.

During every year, both of the studies demonstrated that salaries for male RNs were higher than the salaries of female RNs. What is more, the researchers found no significant changes in this pay gap - which averaged as an overall adjusted earnings difference of $5,148 - over the study period.

In ambulatory care the salary gap was $7,678 and in hospital settings it was $3,873. The smallest pay gap was found in chronic care ($3,792) and the largest was in cardiology ($6,034). The only specialty in which no significant pay gap between men and women RNs was detected was orthopedics. The salary difference was also found to extend across the range of positions, including roles such as middle management and nurse anesthetists.

Employers and physicians 'need to examine pay structures'

"The roles of RNs are expanding with implementation of the Affordable Care Act and emphasis on team-based care delivery," the authors write. 

They conclude:

"A salary gap by gender is especially important in nursing because this profession is the largest in health care and is predominantly female, affecting approximately 2.5 million women. These results may motivate nurse employers, including physicians, to examine their pay structures and act to eliminate inequities."

The results of a 2010 survey looking at the impact of the economic crisis on nursing salaries published in Nursing Management found that a nurse leader's average salary fell by $4,000 between 2007 and 2010. In the same survey, almost 60% of nurse leaders felt that they were not receiving appropriate compensation for their level of organizational responsibility.

However, that survey found no evidence that workload for nurse leaders had increased. The respondents reported that they were still working the same number of hours per week as they had traditionally and were not responsible for more staff members than before the economic crisis.

"If you thought nursing was immune to the downturn, think again. The poor economy is keeping us working longer than we'd anticipated," said Nursing Management editor-in-chief Richard Hader, "and in addition to wage cuts, organizations are freezing or eliminating retirement benefits, further negatively impacting employee morale."

Source: www.medicalnewstoday.com

BY JENNIFER WALKER

In a Johns Hopkins Outpatient Center exam room, medical interpreter Julie Barshinger is working with a Spanish patient, a woman in her early 40s with a stocky build and a dark ponytail, who is concerned about complications related to her recent nose surgery.

But first, the woman must complete a medical history form. “¿Qué significa vertigo?” (“What is vertigo?”) she asks, as Barshinger goes through the list of symptoms on the form, verbally interpreting them from English to Spanish. Then later, “No sé qué es un soplo cardiac … ” Barshinger interprets the question — “I don’t know what a heart murmur is” — for the nurse who is preparing a nasal spray for the patient that will allow the doctor to look inside her nose.

“If it doesn’t apply to her, don’t answer it,” the nurse says kindly.

“I just want you to know that I have to interpret everything she says,” explains Barshinger, who is one of 18 full-time interpreters in Johns Hopkins Medicine International’s Language Access Services office. Part of Barshinger’s job is educating providers about her role. 

Later, the nurse starts to leave the room to see another patient before the woman has completed her medical history form. “I can’t continue if you’re not in the room with me,” Barshinger says. The patient is consistently giving additional information about her symptoms: She doesn’t see well since her operation; she has some nasal bleeding; she sees the room spinning when she lies down. It’s crucial for Barshinger to communicate these potentially important details to the nurse, who stays in the room, answering questions when needed, until the form is complete.

Throughout the interaction, Barshinger knows little about the full scope of the patient’s health history. But she doesn’t need to know. “I’m not in charge of her care,” she says. “I’m only her voice. I want to make sure her voice is being heard by the right people. I’m also the voice of the provider, so she can communicate the very necessary and important information that she has to the patient.”

While Johns Hopkins, like other hospitals that receive federal funding, has been providing interpretation services for 50 years — since passage of the Civil Rights Act of 1964, which prohibits discrimination based on national origin — requests for interpreters at The Johns Hopkins Hospital have grown dramatically since 2010, jumping from 23,000 to more than 50,000 annually.

This is due in part to the slightly rising limited English proficiency population in Baltimore City, which grew by about 4,000 people between 2000 and 2012, according to the U.S. Census. Today, the hospital also serves more refugees, about 2,500 of whom settled in Baltimore City between 2008 and 2012.

But Susana Velarde, administrator for Language Access Services at Johns Hopkins Medicine International, says the increase in requests is also due to the growing understanding among health care providers that they can do a better job treating their patients with limited English proficiency with the help of interpreters. 

Because they prevent communication errors, certified interpreters improve patient safety. A 2012 study in the Journal of General Internal Medicine found that patients with limited English proficiency who did not have access to interpreters during admission and discharge had to stay in the hospital between 0.75 and 1.47 days longer than patients who had an interpreter on both days. Moreover, when the interpreter has 100 hours of medical interpretation training — a qualification that researchers have found is more important than years of experience — they made two-thirds fewer errors than their counterparts with less training, according to a 2012 Annals of Emergency Medicine study.

The Language Access Services office’s full-time interpreters—who speak Spanish, Chinese-Mandarin, Korean, Russian, Arabic and Nepali — participate in an extensive two-year training program, which includes classes, tests and shadowing. Fifty percent of the team is certified; the rest are working toward certification, if available in their language. The office also has 45 medical interpreter floaters, and interpretation services are available 24/7 in person, over the phone or through a video monitor for patients with limited English proficiency who live in the Baltimore area and international residents who come to Johns Hopkins for treatment.

“We are the conduit, but also the clarifier,” says Spanish interpreter Rosa Ryan. “We are not simply repeating words but making sure the message is understood.”

For example, at the end of her visit on the otolaryngology floor, Barshinger walks to the front desk with the ponytailed Spanish woman to help her make a follow-up appointment. With Barshinger interpreting, the woman learns that she must get a Letter of Medical Necessity from her current insurer or change insurance companies before coming back to Johns Hopkins. When the administrator walks away, Barshinger checks in with the woman to make sure she understands the instructions.

“The patient might nod, but the information might not be registering,’” she says. “I try to check for clarification if I sense there is a disconnect.”  

Interpreters are also cultural brokers. Yinghong Huang, a Chinese-Mandarin interpreter, remembers when a nurse in labor and delivery tried to give a Chinese patient a cup of ice water. “In China, for a woman who has just delivered a baby, we don’t want her to touch anything cold, let alone ice,” Huang explains. This is one of the many rules that Chinese women abide by for a month to help the body recover from childbirth. With Huang present, providers knew to give the patient hot water with her medicine instead.

Despite the increasing demand for interpreters, their expertise too often goes untapped, says Lisa DeCamp, assistant professor of pediatrics at the school of medicine. She is the lead author of a 2013 Pediatrics study that found that 57 percent of pediatricians who completed national surveys in 2010 still reported using family members as interpreters.

This is a bad practice for many reasons, she says. For one thing, family members often don’t have specialized knowledge of medical terminology. Moreover, both patients and family members may censor information. “If you’re talking about something that is intimate or personal and your son is translating for you, you might not want to disclose something about your sexual activity, your drug use or anything else sensitive that could be contributing to your problem,” says DeCamp, who is also a pediatrician at Johns Hopkins Bayview Medical Center.

Even physicians with basic skills in a particular language should use an interpreter to prevent misunderstandings. “I [know] some high school Spanish, but I’m nowhere near fluent, so I need an interpreter,” says Cynthia Argani, director of labor and delivery at Hopkins Bayview, where about 70 percent of her department’s patient population speaks Spanish. “It’s not fair to the patient not to use one. The message can get skewed.”

DeCamp, who has passed a test certifying her as a bilingual physician, offers a real-life example from the literature that shows how this can happen. A pediatrician with limited Spanish language skills instructed parents to use an antibiotic to treat their child’s ear infection. In Spanish, “if you use the preposition, it really means, ‘put in the ear,’” she says. “So the family was putting the specified amount of amoxicillin that should be taken by mouth in the ear. That child is not going to die from an ear infection, but he’s having pain and a fever, and the family doesn’t have clear instructions on how to provide medication.”

On Barshinger’s rounds, after her otolaryngology visit, she walks at an impressively fast pace to The Charlotte R. Bloomberg Children’s Center, where a mother recognizes her and asks her to be her interpreter. The provider who requested Barshinger’s services is not ready yet, so she has time to help.

A doctor carrying a sheaf of papers joins them in a busy hallway. She points to a long list of care instructions translated into Spanish, then begins to explain them to the mother. Because the doctor is verbally giving the instructions, Barshinger interprets. The mother needs to buy an extra-strength, over-the-counter medication and give her daughter a second medication three times a day, which she will need to “swish and spit,” the doctor says. A third medication will be applied to the daughter’s face two times a day, and a special shampoo is needed to wash her hair. Before an upcoming dentist appointment, she’ll also need to give her daughter three amoxicillin. When the doctor steps away, the mother asks Barshinger a question about her daughter’s dental visit, which Barshinger interprets when the doctor returns.

While interpreting, Barshinger stands to the side of the patient’s mother, allowing the doctor and the mother to face each other and communicate directly with one another. This simple tactic encourages providers to develop a rapport with their patients with limited English proficiency.

The goal? “To make the patient feel like the appointment is with him and not with the interpreter,” says Velarde. “The interpreter is just the voice. We want providers to have a bond with their patients, like they do when everyone is speaking English.” 

Bonding Moments

Tapping the expertise of interpreters doesn’t have to complicate things for physicians, says Lisa DeCamp, a bilingual physician at Johns Hopkins Bayview Medical Center. Her advice for colleagues:

• Educate the interpreter about what you’re doing so they’re not going in blind. Say a patient has severe abdominal pain. Providers can quickly explain to the interpreter that the first job is to rule out appendicitis.

• Sit across from the patient, with the interpreter standing at the patient’s side, and talk directly to the patient. The goal is for the provider and the patient to feel like they have a relationship with each other despite language barriers. When possible, use short phrases to help the interpreter keep up with the conversation. 

Found In Translation

Arabic translator Lina Zibdeh remembers the first time she saw the recommendation in a patient education document that leftover medications should be discarded in used cat litter or coffee grounds.

There isn’t a direct translation for this concept in Arabic, a language that is spoken in different dialects by 22 countries but written in one common form. “It can take hours and extensive research to make sure a concept like this is translated correctly,” says Zibdeh, who translates written materials, such as informed consent forms, welcome packets, care instructions, brochures, video scripts and more. In this case, Zibdeh had to add an additional sentence to explain that medications should be disposed of in this way so they are not enticing to children and pets. 

While translation programs like Google Translate are readily available and easy to use, they often produce inaccurate translations, which can confuse patients and lead to poor health outcomes. This is because words in sentences can be organized in different ways from one language to another. Thus, when online programs translate those sentences from, say, English to Chinese, they can change the meaning, says Chinese-Mandarin interpreter and translator Yinghong Huang. Some English words, such as discharge, also have multiple meanings. “It’s very rare for a program to get the right meaning,” Huang says. Even Huang has to use tools, such as her cellphone and an online dictionary, to produce accurate translations.

Along with improving health outcomes, documents that are available in a patient’s own language can make him or her feel more comfortable and secure, says Zibdeh, who organized the American Translators Association’s first webinar for the Arabic Division on Arabic Medical Translation in early 2014. “It helps that patient feel closer to home,” she adds.

Source: www.hopkinsmedicine.org

Heather Stringer

In 2010, the Institute of Medicine issued eight recommendations that dared to transform the nursing profession by 2020. This year marks the midway point for reaching the goals outlined in the report “The Future of Nursing: Leading Change, Advancing Health,” and statistics at halftime offer a glimpse into nursing’s progress so far.

Although the numbers in some areas have altered little in the first few years, infrastructure changes have been set in motion that will lead to more noticeable improvements in the data in the next several years, said Susan Hassmiller, PhD, RN, FAAN, the Robert Wood Johnson Foundation senior adviser for nursing. The RWJF partnered with the IOM to produce the report. 

“I am a very impatient person and would like things to move faster, but we have to remember that we are changing social norms with these goals,” Hassmiller said. “We are trying, for example, to convince hospital leaders, nursing students and educational institutions that it is important for nurses to have a baccalaureate degree, and that takes time.”

Hassmiller is referring to Recommendation 4 of the report, which calls academic nurse leaders across all schools of nursing to work together to increase the proportion of nurses with a baccalaureate degree from 50% to 80% by 2020. The most recent data collected from the American Community Survey by the Future of Nursing: Campaign for Action found that the percentage of employed nurses with a bachelor’s degree or higher only climbed 2% between 2010 and 2013. However, Hassmiller suggested the percentage is likely to increase rapidly in coming years because nursing schools have increased capacity to accommodate more students. As a result, the number of nurses enrolled in RN-to-BSN programs skyrocketed between 2010 and 2014, from about 77,000 nurses in 2010 to 130,300 students in 2014, according to the American Association of Colleges of Nursing — a 69% increase. 

New education models

Campaign for Action leaders also are optimistic about the profession’s ability to approach the 80% goal because nursing schools are beginning to experiment with new models of education, such as bringing BSN programs to community colleges. 

Traditionally, students spend at least three years in a community college earning an associate’s degree to become an RN — at least a year for prerequisites and another two to complete the nursing program, Hassmiller said. These RNs may work for a few years before returning to school to earn a BSN — and some may not return at all, said Jenny Landen, MSN, RN, FNP-BC, dean of the School of Health, Math and Sciences at Santa Fe Community College in New Mexico. To avoid losing potential BSN students, leaders from New Mexico’s university and community colleges began meeting to discuss a new paradigm: students who were dually enrolled in a community college and a university BSN program. 

The educators started by forming a common statewide baccalaureate curriculum that would be used by all community colleges and universities, Landen said. The educators also discussed how to pool resources, such as offering university courses online at local community colleges. “This opens the opportunity of earning a BSN to people who need to stay in their communities during school,” she said. “They may have family commitments locally, and they can take the baccalaureate degree courses at the community college tuition fee, which is much less expensive.”

Four community colleges in New Mexico have launched dual enrollment programs within the last year. At Santa Fe Community College, there are far more applicants than the program can hold, Landen said. Community colleges and universities in other parts of the country also are working together to create programs in which nursing students can be dually enrolled. In addition to nursing schools buying into the need for more BSN-prepared nurses, there also is evidence that employers are moving toward this new standard as well. According to a study released in February in the Journal of Nursing Administration, the percentage of institutions requiring a BSN when hiring new RNs jumped from 9% to 19% between 2011 and 2013. 

Beyond the BSN

So far, the national data related to Recommendation 5 — double the number of nurses with a doctorate by 2020 — suggests there have been minimal changes in the number of employed nurses with a doctorate, yet there has been a significant increase in the number of students pursuing this level of education. According to the JONA article, on average about 3.1% of employed nurses in all institutions had a doctorate in 2011. This rose to 3.6% in 2013. This percentage likely will increase in the coming years because of the proliferation of doctor of nursing practice programs since 2010. These programs are geared for advanced practice RNs who are interested in returning to the clinical setting after earning a doctoral degree. Between 2010 and 2013, the number of students enrolled in DNP programs doubled from just over 7,000 students to more than 14,600. There was a lesser increase in the number of students enrolled in PhD programs, up 12% from 4,600 to 5,100, according to the AACN. 

“When the DNP degree became an option, it opened the opportunity of a higher level of education to the working nurse, not the researcher, and that was attractive to many nurses,” said Pat Polansky, MS, RN, director of program development and implementation at the Center to Champion Nursing in America. “Getting a research-based PhD takes longer and not every nurse can do that, so the DNP has become a wonderful option.”

Leaders at the Campaign for Action, however, acknowledge that it is important to find strategies to boost the number of PhD-prepared nurses because the profession needs those nurses in academia and other administrative, research or entrepreneurial roles where they are contributing to the solutions of a transformed healthcare system, Hassmiller said. To encourage more nurses to pursue the path of a PhD, in 2014 the RWJF launched the Future of Nursing Scholars Program, which awards $75,000 per scholar pursuing a PhD. This is matched with $50,000 by the student’s school, and the funds can be used over the course of three years. 

Forging ahead

In December, the nursing profession will have another opportunity to assess progress on the recommendations when the IOM releases findings from a study that is under way to assess the national impact of the Future of Nursing report. The changes happening in areas such as education are remarkable, Hassmiller said, and she is eagerly anticipating the results from the current IOM study. 

“I would never modify the goals because you need something to strive for in order to affect change,” Hassmiller said. “I am extremely encouraged because we have never seen anything like this. For the first time in history, more than half of nurses have a bachelor’s degree, and it is going to keep climbing. The most challenging part has been the number of people that need to be influenced to make the business case as to why it is important, and it is finally happening.” 

Key recommendations from “The Future of Nursing: Leading Change, Advancing Health”

1) Remove scope-of-practice barriers.
2) Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. 
3) Implement nurse residency programs.
4) Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. 
5) Double the number of nurses with a doctorate by 2020.
6) Ensure that nurses engage in lifelong learning.
7) Prepare and enable nurses to lead change to advance health. 
8) Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data.

Source: http://news.nurse.com

JENNIFER SCHMIDT

There are many reasons women need cesareans. Sometimes the situation is truly life-threatening. But often the problem is that labor simply isn't progressing. That was the case for Valerie Echo Duckett, 35, who lives in Columbus, Ohio. After receiving an epidural for pain, Duckett's contractions stopped. By late evening she was told she'd need a C-section to deliver her son, Avery. Duckett says she has vague memories of being wheeled into the operating room, strapped down and shaking from cold.

"They were covering me up with warm blankets,"she says. "I kind of slept in and out of it." Her only memory of meeting her newborn son for the first time was from some pictures her husband took.

This is the experience many women have. The cesarean section is the most common surgery in America — about 1 in 3 babies is delivered this way. But for many women, being told they need a C-section is unpleasant news. Duckett says she felt like she missed out on a pivotal moment in her pregnancy.

"It took me a long time even to be able to say that I gave birth to Avery," she says. "I felt like I didn't earn the right to say I gave birth to him, like it was taken from me somehow, like I hadn't done what I was supposed to do."

Duckett's reaction to her C-section is unfortunately a common one, says Betsey Snow, head of Family and Child Services at Anne Arundel Medical Center, a community hospital in Annapolis, Md.

"I hear a lot of moms say, 'I'm disappointed I had to have a C-section.' A lot of women felt like they failed because they couldn't do a vaginal delivery," says Snow.

Now some hospitals are offering small but significant changes to the procedure to make it seem more like a birth than major surgery.

In a typical C-section, a closed curtain shields the sterile operating field. Mothers don't see the procedure and their babies are immediately whisked away for pediatric care — a separation that can last for close to half an hour. Kristen Caminiti, of Crofton, Md., knows this routine well. Her first two sons were born by traditional cesarean. She was happy with their births because, she says, it was all she knew. Then, just a few weeks into her third pregnancy, Caminiti, who is 33, saw a post on Facebook about family-centered cesarean techniques catching on in England.

"I clicked on the link and thought, 'I want that,' " she says.

The techniques are relatively easy and the main goals simple: Let moms see their babies being born if they want and put newborns immediately on the mother's chest for skin-to-skin contact. This helps stimulate bonding and breast feeding. Caminiti asked her obstetrician, Dr. Marcus Penn, if he'd allow her to have this kind of birth. He said yes.

When Caminiti told Penn what she wanted, his first thought was it wouldn't be that difficult to do. "I didn't see anything that would be terribly out of the norm," he says. "It would be different from the way we usually do it, but nothing terrible that anyone would say we shouldn't try that."

Family-centered cesareans are a relatively new idea in the U.S., and many doctors and hospitals have no experience with them. Penn and the staff at Anne Arundel Medical Center quickly realized the procedure would require some changes, including adding a nurse and bringing the neonatal team into the operating room.

And there were a bunch of little adjustments, such as moving the EKG monitors from their usual location on top of the mother's chest to her side. This allows the delivery team to place the newborn baby immediately on the mother's chest. In addition, Penn says, the mother's hands were not strapped down and the intravenous line was put in her nondominant hand so she could hold the baby.

At the beginning of October, Caminiti underwent her C-section. She was alert, her head was up and the drape lowered so she could watch the delivery of her son, Connor. Caminiti's husband, Matt, recorded the event. After Connor was out, with umbilical cord still attached, he was placed right on Caminiti's chest.

"It was the most amazing and grace-filled experience to finally have that moment of having my baby be placed on my chest," Caminiti says. "He was screaming and then I remember that when I started to talk to him he stopped. It was awesome."

And the baby stayed with her for the rest of the procedure.

Changes like this can make a big difference, says Dr. William Camann, the director of obstetric anesthesiology at Brigham and Women's Hospital in Boston and one of the pioneers of the procedure in the U.S. At Brigham and Women's, their version of the family-centered cesarean is called the gentle cesarean. Moms who opt for it can view the birth through a clear plastic drape, and immediate skin-to-skin contact follows.

Camann says the gentle C-section is not a replacement for a vaginal birth; it's just a way to improve the surgical experience. "No one is trying to advocate for C-sections. We really don't want to increase the cesarean rate, we just want to make it better for those who have to have it," he says.

So why has the procedure been slow to catch on? Hospitals aren't charging more for it — so cost doesn't seem to be a major factor. What's lacking are clinical studies. Without hard scientific data on outcomes and other concerns like infection control, many hospitals may be wary of changing their routines. Betsey Snow of Anne Arundel Medical Center says the family-centered C-section represents a cultural shift, and her hospital is helping break new ground by adopting it.

"It is the first time we have really done anything innovative or creative with changing the C-section procedure in years," she says.

Kristen Caminiti says her hope is that these innovations become routine. She says she'd like nothing more than to know that other women having C-sections are able to have the same amazing experience she had.

Source: www.npr.org

SABRINA TAVERNISE

When it came time to have the baby, Shirita Corley was alone. Her mother was at the casino, her sister was not answering her cellphone, her boyfriend had disappeared months earlier, and her father she had not seen in years.

So she got in her green Chevy TrailBlazer and drove herself to the hospital.

“I feel so down,” she texted from her hospital bed. “I’m sick of these deadbeats. I’m sick of having to be so strong.”

The message went not to a friend or family member, but to a nurse, Beth Pletz. Ms. Pletz has counseled Ms. Corley at her home through the Nurse-Family Partnership, which helps poor, first-time mothers learn to be parents.

Such home visiting programs, paid for through the Affordable Care Act, are at the heart of a sweeping federal effort aimed at one of the nation’s most entrenched social problems: the persistently high rates of infant mortality. The programs have spread to some 800 cities and towns in recent years, and are testing whether successful small-scale efforts to improve children’s health by educating mothers can work on a broad national canvas.

Home visiting is an attempt to counter the damaging effects of poverty by changing habits and behaviors that have developed over generations. It gained popularity in the United States in the late 1800s when health workers like Dr. S. Josephine Baker and Lillian Wald helped poor mothers and their babies on the teeming, impoverished Lower East Side of Manhattan. At its best, the program gives poor women the confidence to take charge of their lives, a tall order that Ms. Pletz says can be achieved only if the visits are sustained. In her program, operated here by Le Bonheur Children’s Hospital, the visits continue for two years.

It is Ms. Pletz’s knack for listening and talking to women — about misbehaving men, broken cars, unreliable families — that forms the bones of her bond with them.

She zips around Memphis in her aging Toyota S.U.V. with a stethoscope dangling from the rearview mirror. Her cracked iPhone perpetually pings with texts from her 25 clients. Most of them are young, black, poor and single. Few had fathers in their lives as children, and their children are often repeating the same broken pattern.

“I was lost, going from house to house,” recalled Onie Hayslett, 22, who was homeless and pregnant when she first met Ms. Pletz two years ago. Her only shoes were slippers. “She brought me food. That’s not her job description, but she did it anyway. She really cares about what’s going on. I don’t have many people in my life like that.”

Infant mortality rates in the United States are about the same as those in Europe in the first month of life, a recent study found, but then become higher in the months after babies come home from the hospital — a period when abuse and neglect can set in. (The study adjusted for premature births, which are also higher in the United States partly because of poverty. They were kept out of the study, researchers said, because the policies to reduce them are different.)

In Memphis, where close to half of children live in poverty, according to census data, the infant mortality rate has long been among the country’s highest. Sleep deaths — in which babies suffocate because of too much soft bedding or because an adult rolls over onto them — accounted for a fifth of infant deaths in the state, according to a 2013 analysis of death certificates by the Tennessee Department of Health.

When Ms. Pletz recently visited Darrisha Onry, 21, she saw Ms. Onry’s week-old child, Cedveon, lying beside her on a dark blue couch. The room was warm, small and crowded with a large living room set, a glass table, porcelain statues of dogs and an oversize cage holding two tiny, napping puppies.

“Where is he sleeping?” Ms. Pletz asked.

Cedveon started to cry, and Ms. Onry walked out of the room to make his bottle.

“The safest place for him is alone by himself on his back in his crib,” Ms. Pletz said, scooping up Cedveon, who had launched into a full-throated squall.

A little later, Ms. Pletz said, "You know never to shake the baby, right?”

Ms. Onry nodded.

Ms. Pletz continued: “Nerves get shot and sometimes people lose their cool. If that happens, just put him on his back on a bed and close the door, and take a little rest away from him.”

The program is unusual because it is based on a series of clinical trials much like those used to test drugs. In the 1970s, a child development expert, Dr. David Olds, began sending nurses into the homes of poor mothers in Elmira, N.Y., and later into Memphis and Denver. The nurses taught mothers not to fall asleep on the couch with their infants, not to give them Coca-Cola, to pick them up when they cried and to praise them when they behaved. The outcomes were compared with those from a similar group of women who did not get the help.

The results were startling. Death rates in the visited families dropped not just for children, but for mothers, too, when compared with families who did not get the services. Child abuse and neglect declined by half. Mothers stayed in the work force longer, and their use of welfare, food stamps and Medicaid declined. Children of the most vulnerable mothers had higher grade-point averages and were less likely to be arrested than their counterparts.

The program caught the attention of President Obama, who cited it in his first presidential campaign. His administration funded the program on a national scale in 2010. So far, the home visits have reached more than 115,000 mothers and children. States apply for grants and are required to collect data on how the families fare on measures of health, education and economic self-sufficiency. Early results are expected this year.

“The big question is, can the principle of evidence be implemented in a large federal program?” said Jon Baron, president of the Coalition for Evidence-Based Policy, a nonprofit group in Washington whose aim is to increase government effectiveness in areas including education, poverty reduction and crime prevention. “And if so, will it actually improve health?”

Experts say federal standards are too loose and have allowed some groups with weak home visiting programs to participate, even if they show effects on only trivial outcomes that have no practical importance for a child’s life. Congress should fix the problem, Mr. Baron said, warning that the program in its current state is “a leaky bucket.”

“If left unchanged, essentially anyone will figure out how to qualify,” he said.

Its future is not assured. Funding for the home visiting initiative runs out as early as September for some states, and if Congress does not reauthorize it this month, programs may stop enrolling families and the $500 million the Obama administration has requested for 2016 will not be granted. Last week, its supporters urged Congress to extend it.

In Tennessee, where home visiting programs have bipartisan support, infant mortality is down by 14 percent since 2010, and sleep deaths dipped by 10 percent from 2012 to 2013. State officials credit a multitude of policies, including the home visits.

Ms. Pletz worries that she has helped only a handful of her clients truly improve their lives. But Ms. Corley, 28, the mother who drove herself to the hospital, said Ms. Pletz, who has been visiting her for two years, had made a difference. She “has been my counselor, my girlfriend, my nurse,” Ms. Corley said. Ms. Pletz helped her cope with the disappearances of her children’s fathers, taught her to recognize whooping cough and pushed her to set career goals, she said.

“She knows more about me than my own family does,” Ms. Corley said. “I feel like I’ve grown more wise. I feel stronger for sure.”

The morning after Ms. Corley gave birth, Ms. Pletz brought her breakfast: eggs, flapjacks and bacon. The new baby, Daniel, lay in a clear plastic crib next to Ms. Corley’s hospital bed, and the two women talked over his head like old friends.

“Can I pick him up?” Ms. Pletz asked.

Ms. Corley replied: “I think he’s waiting on it.”

Source: www.nytimes.com

  PAULA SPAN

What she wanted, the patient told the geriatricians evaluating her, was to be able to return to her condominium in Boston. She had long lived there on her own, lifting weights to keep fit and doing her own grocery shopping, until a heart condition worsened and she could barely manage the stairs.

So at 94, she consented to valve replacement surgery at a Boston medical center. “She never wanted to go to a nursing home,” said Dr. Perla Macip, one of the patient’s geriatricians. “That was her worst fear.”

Dr. Macip presented the case on Saturday to a meeting of the American Academy of Hospice and Palliative Medicine. The presentation’s dispiriting title: “The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients?”

Like Dr. Macip, a growing number of physicians and researchers have grown critical of 30-day mortality as a measure of surgical success. That seemingly innocuous metric, they argue, may actually undermine appropriate care, especially for older adults.

The experience of Dr. Macip’s patient — whom she calls Ms. S. — shows why.

Ms. S. sustained cardiopulmonary arrest during the operation and needed resuscitation. A series of complications followed: irregular heartbeat, fluid in her lungs, kidney damage, pneumonia. She had a stroke and moved in and out of the intensive care unit, off and on a ventilator.

After two weeks, “she was depressed and stopped eating,” Dr. Macip said. The geriatricians recommended a “goals of care” discussion to clarify whether Ms. S., who remained mentally clear, wanted to continue such aggressive treatment.

But “the surgeons were optimistic that she would recover” and declined, Dr. Macip said.

So a discussion of palliative care options was deferred until Day 30 after her operation, by which time Ms. S. had developed sepsis and multiple-organ failure. She died on Day 31, after life support was discontinued.

The key number here, surgeons and other medical professionals will recognize, is 30.

Thirty-day mortality serves as a traditional yardstick for surgical quality. Several states, including Massachusetts, require public reporting of 30-day mortality after cardiac procedures. Medicare has also begun to use certain risk-adjusted 30-day mortality measures, like deaths after pneumonia and heart attacks, to penalize hospitals with poor performance and reward those with better outcomes.

However laudable the intent, reliance on 30-day mortality as a surgical report card has also generated growing controversy. Some experts believe pressures for superior 30-day statistics can cause unacknowledged harm, discouraging surgery for patients who could benefit and sentencing others to long stays in I.C.U.s and nursing homes.

“Thirty days is a game-able number,” said Dr. Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison and co-author of an editorial on the metric in JAMA Surgery. Last fall, she led a session about the ethics of 30-day mortality reporting at an American College of Surgeons conference.

“Surgeons in the audience stood up and said, ‘I can’t operate on some people because it’s going to hurt our 30-day mortality statistics,’” she recalled. The debate is particularly urgent for older adults, who are more likely to undergo surgery and to have complications.

Those questioning the 30-day metric point to potential dilemmas at both ends of the surgical spectrum. Surgeons may decline to operate on high-risk patients, even those who understand and accept the trade-offs, because of fears (conscious or not) that deaths could hurt their 30-day results.

At a hospital in Pennsylvania, for instance, a cardiothoracic surgeon declined to operate on a man who urgently needed a mitral valve replacement. He wasn’t elderly, at 53, but he was an alcoholic whose liver damage increased his risk of dying.

Dr. Douglas White, the director of ethics and decision-making in critical illness at the University of Pittsburgh School of Medicine, was asked to consult. According to Dr. White, the surgeon explained that “we have been told that our publicly reported numbers are bad, and we have to take fewer high-risk patients.”

Other surgeons at the hospital, under similar pressure, also refused. A helicopter flew the patient to another hospital for surgery.

An outlier case? A study in JAMA in 2012 compared three states that require public reporting of coronary stenting results to seven nearby states that didn’t report. Older-adult patients having acute heart attacks had substantially lower rates of the stenting in the reporting states. Doctors’ concerns about disclosure of poor outcomes might have led them to perform fewer procedures, the authors speculated; they might also have weeded out poorer candidates for surgery.

Perhaps as important for older people, when things go wrong, surgical teams concerned about their 30-day metrics may delay important conversations about palliative care or hospice, or even override advance directives.

“There are no good published studies on this, but it’s something we see,” Dr. White said. “Surgeons are reluctant to withdraw life support before 30 days, and less reluctant after 30 days.”

That may have been what happened to Ms. S. Or perhaps her aggressive treatment resulted from a surgical ethos that has little to do with mortality reports.

“We want to cure patients and help them live, and we consider it a failure if they don’t,” said Dr. Anne Mosenthal, who heads the American College of Surgeons committee on surgical palliative care.

With surgeons already prone to optimism and disinclined to withdraw life support, the effect of reporting failures, if there is one, is subtle. Surgeons tell themselves, “Maybe if we wait a little longer, he’ll improve; there’s always a chance,” Dr. Mosenthal said.

But many older patients, and their families, have different ideas about what makes life worth sustaining and might welcome a frank discussion before a month passes.

“The 30-day mortality statistic creates a conflict of interests,” said Dr. Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School. “It can lead to the violation of a physician’s duty to put patients’ interests first.”

Leaders at the nonprofit National Quality Forum, which just endorsed 30-day mortality as a measure for coronary bypass surgery, find such fears overblown. The forum evaluates quality measures for Medicare and other insurers, and went ahead with its endorsement despite some physicians’ objections.

“There is some concern,” said Dr. Helen Burstin, the chief scientific officer of the forum, but “certainly no evidence” that the metric is unduly influencing patient care.

“Is it better not to measure and compare, just because we can’t get it perfect?” added Dr. Lee Fleisher, a co-chairman of the forum’s surgery standing committee.

But critics think other quality measures might serve better. Perhaps the benchmark should be 60- or 90-day mortality. Perhaps patients having palliative surgery to relieve symptoms should be tracked separately, because comfort is their goal, not survival.

Maybe quality should include days spent in an I.C.U. or on a ventilator, Dr. Schwarze said.

“Medicine isn’t just about keeping people alive,” she said. “Some of it is about relieving suffering. Some of it is about helping people die.”

Source: www.nytimes.com