Logistics of US health care and hospitals

This article discusses some of the challenges unique to practicing medicine in the US. It introduces the concept of health care quality improvement and highlights ways in which this is relevant to you as a resident. It also reviews which logistical issues are the most important to familiarize yourself with at the start of residency.

While practicing medicine in the US may equip you with some of the most advanced technologies and treatments available, there are a number of barriers that render these advances inaccessible to many. The US health care system is a costly, complex apparatus in which care is often highly dependent on insurance coverage and geographic region. The following summarizes some of the most essential aspects of health care in the US:

• High cost but poor value ^[1]
  • The US spends a much higher percentage of its gross domestic product (GDP) on health care than other wealthy countries.
  • The US performs poorly on many quality measures compared to other countries, including avoidable hospitalizations and deaths.
• High complexity: Different groups of people receive funding coverage from different sources (see “Health insurance funding” in “Health care system”). These include:
  • Public insurance funded by the government (Medicare, Medicaid, Veterans Affairs)
  • Various private insurers
• Significant variation by region: Health care access, quality, cost, and outcomes vary between different regions and states within the US. ^[2]
  • 12 states did not expand their Medicaid coverage under the Affordable Care Act of 2010, creating a coverage gap for people in these states who do not qualify for either Medicaid or subsidies with the purchase of private health insurance. ^[3]
  • Prices for an identical health care service can vary dramatically by region. ^[4]
• Insufficient access
  • Around 30 million people in the US remain uninsured. ^[5]
  • Many more are underinsured, with half of US adults reporting having delayed or skipped medical care due to costs. ^[6]
    • The average cost of an inpatient admission was $25,000 in 2018. ^[7]
    • Common and essential drugs, such as insulin and epinephrine autoinjectors, can cost hundreds of dollars.
  • See “Health care access” in “Health care system.”
• High chronic disease burden: 28% of US adults report having been diagnosed with two or more chronic diseases (e.g., hypertension, diabetes) in their life, compared to an average of 18% of adults in other wealthy countries. ^[1]

• The National Academy of Medicine (formerly the Institute of Medicine) has divided health care quality into 6 domains (see “Health care quality” in “Quality improvement”).
• Health care quality and safety is included as one of the six core competencies (referred to as systems-based practice) established for residents by the Accreditation Council for Graduate Medical Education (ACGME).
• You will hear about these domains frequently during residency, from both clinicians and administrators.

Safety

See “Patient safety” for further details.

• Goal: Avoid harm to patients during the course of care.
• Examples of metrics
  • Nurse-to-patient staffing ratios
  • Rates of nosocomial infections
  • Rates of inpatient DVTs
  • Rates of medication errors
• Relevance to residents
  • Be aware of the staffing ratios at your hospital (in general); understand that low nurse-to-patient ratios may be a reason for delay in orders being completed.
  • Know which lines and catheters a patient has and for how long they have been inserted. Attendings will ask about this, especially in the ICU!
  • Pharmacists are invaluable in helping to prevent medication errors; expect to be paged with questions about doses and interactions.
  • Keep track of how long a patient has been receiving steroids or antibiotics and ensure orders have not been discontinued or continued inappropriately.
  • Remember to order prophylaxis (e.g., DVT, GI) and precautions (e.g., falls, bleeding) for patients as appropriate.

Efficacy

• Goal
  • Practice evidence-based medicine.
  • Provide services to patients who are likely to benefit from them; don't provide services to those unlikely to benefit.
• Examples of metrics
  • Rate of readmissions within 30 days
  • Percentage of hypertensive patients with controlled BP, or diabetic patients with controlled Hb A1c
  • Percentage of patients who receive certain preventive services (e.g., mammograms, flu vaccine)
• Relevance to residents
  • Avoid unnecessary care by being aware of interventions that are not evidence-based or recommended.
  • Know the grade A and B recommendations from the USPSTF.
  • Use the discharge process as an opportunity to prevent readmission.
    • Write a clear and succinct discharge summary to which the next provider can refer.
    • Ensure that any important information about medication changes are communicated verbally and understood (use the teach back method).
    • Ideally, provide patients with some means of contacting the inpatient team in case of any questions or issues related to the discharge plan (e.g., a problem with their electronic prescriptions).

Patient-centeredness

• Goal: Provide care consistent with the preferences, needs, and values of patients.
• Examples of metrics
  • Survey data on patient experience of care
  • Standardized questionnaires on patient-reported outcome measures (PROMs), such as quality of life and functional status
• Relevance to residents
  • Use a patient-centered approach when talking to patients.
  • Routinely ask patients about their living situation, financial situation, jobs, relationships, and sources of support in order to identify unmet needs and provide care appropriate to their situation.
  • Use shared decision-making to incorporate patients' values and preferences into management plans.
  • Both inpatients and outpatients may receive surveys asking about the care they received.
  • Hospitals have a patient relations (sometimes called patient experience or patient advocacy) department that patients can contact with concerns; this can be a helpful resource for patients and families.

Timeliness

• Goal: Reduce waiting times and harmful delays in care.
• Examples of metrics
  • Average time spent in the ER
  • Time from sepsis diagnosis to antibiotic administration
  • Time from presentation with stroke symptoms to imaging.
• Relevance to residents
  • Ensuring timely care can be stressful, since this can often depend on systemic factors outside your control. Do the best you can!
  • Always follow up to make sure urgent tests and orders are completed.
  • Communicate! Let your senior resident know sooner rather than later if you are experiencing difficulties making something important happen (e.g., an imaging test, reaching a consulting service).

Efficiency

• Goal
  • Avoid waste.
  • Provide cost-effective, high-value care.
• Examples of metrics
  • Length of stay for inpatients
  • Bed occupancy rate
  • Cost per discharge
• Relevance to residents
  • Use good judgment to minimize costs associated with repeating a workup that may have been previously done.
  • Talk to your senior resident or team before requesting consults (unless it's an emergency).
  • Follow guidance from the American College of Physicians (ACP) regarding how to make effective outpatient referrals to specialists to avoid wasted time.
  • When possible, prescribe medications preferred by a patient's insurance.
  • Follow ACP guidance to identify patients with difficulty affording care, and provide them with cost-saving resources.

Equity

• Goal: Provide care that does not differ in quality based on social determinants of health such as gender, race, ethnicity, or socioeconomic status.
• Examples of metrics
  • Stratification of data on quality metrics and health outcomes by sociodemographic data
  • Diversity in hiring
• Relevance to residents
  • While this is a systemic problem requiring systemic solutions, you have an opportunity and responsibility to influence equity of care on an individual level.
  • Be aware of disparities in health care access, quality, and outcomes based on sociodemographic characteristics.
  • Understand the history of racism in medicine. Recognize that past negative experiences with health care providers and systems may impact patient attitudes and behaviors.
  • Similar to the general population, most health care providers have implicit bias against people of color. Examine your own unconscious bias and notice whether you make assumptions about patients or provide care differently based on sociodemographic characteristics. ^[8]

Overview

• You will get a lot of logistical information during your first few days of residency (often in the form of lengthy handbooks).
• It can be overwhelming, and not all of it may seem immediately applicable or relevant.
• To help you sift through it all, here is an overview of some of the most important aspects you should focus on looking up or finding out about initially.
• Much of this information should be stated explicitly in the materials you are given at orientation, but some (such as cutoff times for placing certain orders or consults, and weekend availability of certain diagnostic tests) may be more easily and accurately answered by your senior resident.

Do not hesitate to ask your senior resident if you have any logistical questions in your first few months!

Forms/paperwork

You should be able to locate and complete required forms for the following situations:

• Obtaining informed consent for basic procedures, including blood transfusions, lumbar punctures, thoracentesis, paracentesis, and central line placement
• Ordering a CT or MRI (e.g., informed consent for IV contrast and metal screening sheets)
• Signing a patient out against medical advice (AMA)
• Placing a DNR or DNI order for a patient
• Documenting advance care planning forms brought in by patients (e.g., health care proxy form or a MOLST or POLST form)

Orders

Find out about:

• Cutoff times for placing certain orders or calling certain consults in order for them be done the same day
• Cutoff times for placing routine lab orders for phlebotomy
• Availability of support staff (e.g., phlebotomists or nurses) for obtaining blood cultures
• Analysis and reporting of blood cultures
• Tests which may be unavailable or minimally available at night or on weekends (e.g., abdominal ultrasounds or DVT ultrasound studies)

Rules and regulations

Find out about:

• Dress code for the ICU, inpatient floors, and clinic
• Deadlines for completion of inpatient and outpatient notes
• Abbreviations acceptable for use in patient notes
• Process for completion of death certificates
• Minimum interval time (e.g., 48 hours) between the first negative blood culture and central line placement
• Maximum interval time between a type and screen and a blood transfusion

Discharge procedures

Find out about:

• Requirements for preliminary discharge summaries for certain patients
• Process for scheduling follow-up appointments for patients being discharged

Safety

Find out about:

• Actions following an accidental needlestick
• Contact information for hospital security
• Procedures for reporting a medical error or safety concern