HealthInsight Blog

Over the past 20 years at HealthInsight, I've had the opportunity to work with health care providers and organizations on root cause analysis to learn from sentinel events, patient harms and other negative, unwanted and unexpected events. Seeking to prevent future harms, we've learned that the most important answers to the question "why did this happen?" – the root causes – are often far removed in time and space from the events that occasioned the review.

Cause and effect analysis is a technique employed in root cause analysis that pushes you to consider all possible causes of a problem, rather than just the ones that are proximal and obvious. Forms of cause and effect analysis include the "5 Whys" and causal tree analysis. Analyses using these techniques produce cause-effect chains, with each identified cause itself becoming the effect of preceding causes. When learning and applying either of these analysis techniques, it's not always clear when the analysis stops, because one can always propose a preceding cause – even if you have to go back to the "big bang."

On Nov. 3, 2016, the Centers for Medicare & Medicaid Services (CMS) published the final rule updating the Medicare Physician Fee Schedule (PFS) for calendar year 2017. With all of the attention that the Quality Payment Program (QPP) established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), there is some risk that meaningful changes may have escaped notice.

There is also a risk that the implications of these payment policy changes, and the opportunities they may create, will not be fully realized or that they will only slowly create positive change in care delivery.

The 2017 PFS update is nearly 400 pages – too much to summarize in this forum. But I'll highlight a couple of changes:

Imagine you are in a position where you are expected to help people change unhealthy habits or otherwise maladaptive behavior. You're not expected to be a miracle worker, but you want to make a difference. Finding effective ways to help these people is important to you. Now, let's make the problem a little harder: the people you're expected to help know that it's in their best interest to change; they've known for some time. Many have made prior attempts to change and have been discouraged by their results.

You are not in an enviable position. It may be even worse than it seems. The very people you are expected to help might see you or what you have to say as being threatening to their sense of self-worth and become defensive. What can you do to help them change?

A recent study points to a simple and inexpensive technique that you might consider. In the field of positive psychology it is called self-affirmation. It works like this:

This week is National Immunization Awareness Week for Adults. Influenza and pneumonia are vaccine-preventable diseases, yet these two diseases combined were the eighth leading cause of death in the United States in 2012, and 90 percent of the influenza deaths occurred in adults 65 and older. Nearly one in three people in the United States will develop shingles (herpes zoster) in their lifetime and there are an estimated 1 million cases each year. The risk of shingles increases as a person ages.

The HealthInsight team is working with office-based practitioners, home health agencies and hospitals in our region to improve influenza, pneumonia and shingles vaccinations among Medicare patients and those with both Medicare and Medicaid insurance. We are currently recruiting providers to join this effort. Our website contains information and the benefits to participating. We need you to help us improve immunization rates and prevent these diseases.

I came across an interesting study on retirement savings behavior recently. The investigators were exploring the phenomenon of "discounting future benefits." Put simply, the idea is that we tend to prioritize a short-term benefit over a long-term benefit, even when the short-term benefit is a luxury and the long-term benefit may be a future necessity.

The lure of immediate rewards is widely recognized. In the context of retirement savings, these investigators were interested in a curious aspect of our decision-making and behavior: in general, we don't seem to care very much about our future selves. Or, more properly, we apparently contemplate our future self, more or less, as we would a stranger. As usual in describing population characteristics, we see variability. Some individuals have a greater connection to their future selves; those who do tend to save more. But discounting future benefits is broadly enough observed to provide meaningful insight into the behavior and potential ways to change it.

We have the opportunity to work with health care improvement and innovations initiatives throughout the country focused on a broad range of clinical topics, care settings and target populations. In this, we often end up working with teams on developing an explicit "theory of change" for their initiative. In spite of growing emphasis on the use of logic models, driver diagrams or other related tools, this remains an underdeveloped area in the field of health systems improvement—but that's a topic for another blog.