How to Choose a Hospital

When it comes to choosing a hospital, many patients rely on their doctor, who will usually steer them to the facility where he or she has privileges or other affiliations. Asking friends and family for recommendations is also a time-honored solution, and a hospital’s reputation in the community is an important indicator of its quality.

In an emergency, of course, ambulances are usually directed to take patients to the closest hospital. But for elective surgeries and procedures where there is time to plan ahead, there are resources to help judge the quality of hospital care, especially for common procedures such as cardiac bypass surgery. In the push to bring more accountability and transparency to the U.S. health-care system, federal and state government agencies, employer groups, and non-profit foundations are offering a growing range of data on hospital quality.

Much of the information comes from mining Medicare data and state records and surveying hospitals to come up with user-friendly databases to help consumers comparison-shop for care. States are also starting to publish more data on their hospitals, such as infection rates, and information on how well hospitals adhere to recommended guidelines for certain procedures.

So you can find out, for instance, how consistently your local hospital gives heart-attack patients a kind of medication called beta-blockers, or what proportion of surgery patients get antibiotics an hour before surgery. But sites that primarily delve into hospital processes — rather than outcomes — won’t tell you how well patients actually fare. And in some cases the information is too vague to be of much use: Web sites may only indicate whether a given hospital is better, no different or worse than national averages.

It helps to check your state health department and its hospital association, since the scope of information offered to consumers varies widely. In Wisconsin, for example, consumers can visit wicheckpoint.org for information on quality and safety measures at hospitals in the state, and go to wipricepoint.org for access to information on charges for various procedures at different hospitals.

New York’s state health department combines state and federal data to let consumers compare mortality rates for cardiac surgery at all hospitals in the state; at www.hospitals.nyhealth.gov, consumers can compare facilities against one another and against state averages. The site also provides some data on how often a hospital does a particular procedure, as well as some best-practices statistics.

Pennsylvania offers a broad variety of data from hospitals in the state, and publishes quarterly reports on mortality rates, readmissions and complications for some conditions, and average lengths of stay adjusted for how sick patients are, among other details. It also offers reports comparing costs and outcomes for specific procedures, like open-heart surgery, and examining the frequency of patients acquiring new infections while at different facilities.

It is also a good idea to check your health plan’s Web site. Blue Shield of California, for example, categorizes hospitals based on cost and their participation in quality-improvement and patient-experience programs.

How to Have a Safe Hospital Stay

Despite advances in medical care, hospital safety continues to be a serious concern for patients. In 1999, the Institute of Medicine reported that an estimated 90,000 patients die from medical errors each year, a number that by some estimates has not changed and may even have increased. The threat of hospital infections is one key concern for patients; according to the Centers for Disease Control and Prevention healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. The non-profit Institute for Healthcare Improvement calculates that in total, nearly 15 million instances of medical harm occur in the U.S, each year — a rate of over 40,000 per day.

While many hospitals are working with groups like IHI to prevent errors and make hospitals safer, patients and families need to be vigilant about everything, from the moment the hospital stay begins until after discharge — and beyond. For starters, patients need to keep their own detailed records of family health history, past hospitalizations and surgeries, and medications, and make sure that this information is placed in the medical record at admission, or while planning an elective procedure. Although hospitals now have many systems of checks and balances, there are an estimated 1.5 million preventable medication errors annually, such as administering the wrong drug, the wrong dose, or giving the medication to the wrong patient. Likewise, though there are now universal protocols that all hospitals are supposed to follow for avoiding wrong site, or wrong patient, surgery, such events happen all too frequently.

If a patient is incapacitated, a friend, family member, or hospital patient advocate has to be on top of medications and treatment plans. At no time should patients or families have any hesitation about questioning anything that is happening in the hospital. It is even common nowadays to see posters around the hospital that say “Speak Up” to encourage patients and family members to challenge health care professionals if they see something that doesn’t look right, and ask questions if they don’t understand what is being done. Nurses and doctors may now sport buttons that say “Ask Me if I’ve Washed My Hands” which are aimed at making it easier to do just that. While it may seem intimidating if you or a family member are hospitalized, and it is natural to want to avoid antagonizing the people who are taking care of you, it is possible to be your own advocate without alienating hospital staff.

The Joint Commission, which accredits hospitals, and is behind the “Speak Up” campaign, urges patients not to be worried if they don’t understand something that a doctor, nurse or health professional says; if they speak another language they should ask for an interpreter, and have the right for free help from someone who does speak their language. Through its website, jointcommission.org, the group offers several consumer-friendly brochures on how to prevent medical errors and have a safe hospital stay.

If a family member or friend is able, it can be an advantage to have that person stay overnight with you in the hospital if need be. Make sure he or she knows what you want done about life support and other life-saving efforts if you are unconscious and not likely to get better. Tell this person if you have signed documents such as a living will, organ donation form and do-not-resuscitate order.

Here are some important strategies for a safe hospital stay.

At Admission: List all medications you are currently taking, including herbal supplements and over the counter use. Be honest about any recreational drugs or narcotics you may be taking, or have taken in the past. Fill out a complete medical history, and read all of the documents having to do with informed consent that you are provided before signing them. If you don’t understand something or have a concern, say so.

Before Surgery: Ask the doctor to mark the area that is to be operated on, and ask if the hospital has the policy of calling a “time out” just before your surgery to make sure they are doing the right surgery on the right body part on the right person. In addition, ask what steps will be taken to prevent an infection at the surgical site, such as antibiotics before or after surgery. Discuss the anesthesia that will be used, who will be monitoring you, and what steps will be taken in the event of an emergency or unanticipated event. If light sources such as lasers or electrocautery devices are being used, ask if measures are in place to prevent a fire.

During Medication Administration: Tell a nurse or doctor if you are concerned that you or your hospitalized family member is about to get the wrong medicine or if you think they may have confused you with another patient. Often, medications are bar-coded, and nurses should scan a patient’s wrist band to make sure the proper medication is being administered. Nurses should also ask you your name, and check it against the name on the medication.

During Exams and Treatment: Hand washing is the most important way to prevent infections. Soap and water or antibacterial gels, which are now in dispensers in most hospital rooms and corridors, are both effective. Notice whether caregivers have washed their hands and do not be afraid to remind a doctor or nurse to do so. Ask hospitals what measures are in place to prevent the spread of infections, and whether the hospital currently has an infection problem in any of its units.

At Discharge: Make sure you have instructions for recuperating at home, such as how to care for wounds or stitches, and ask for phone numbers for on-call doctors or nurses who you can call if something goes wrong or seems unusual after you leave the hospital. If your regular medications were discontinued during your stay, make sure you know whether to resume them; if you have been given new medicines, make sure you know what they are for, how they are to be taken, and whether there are any side effects or possible interactions with your other medications. Ask when you can resume activities like work, sports, and travel. Make sure you have an appointment for a follow-up visit before you leave the hospital.

How to Have a Digital Doctor Visit

Doctors are increasingly communicating with their patients online. Here are some tips for making the best use of the technology.

Generally, the most common digital doctor services are the simplest ones, like paying bills, sending lab results and scheduling appointments, and you will likely find these digital tools convenient once you start using them to avoid phone calls.

But patients are also using computers to deal with issues that usually require a trip to the doctor’s office, and the practice of online care has grown as more health insurers begin paying doctors for treating patients online.

There are a number of technologies that doctors are using for digital visits, and your insurer may require a particular format – typically not traditional email, which may not meet federal privacy requirements.

One version requires patients to fill out interactive questionnaires that automatically generate follow-up queries based on the symptoms patients describe. The answers go to the patient’s doctor, who typically responds within a day.

Another type of digital doctor visit is more like secure email, with patients typing up a free-form message, often sent through a special Web site. Physicians often follow up with questions and then a written response within 24 hours.

Another option is live online visits, using technology that allows for real-time interaction between doctors and patients, using Web video, live chat or a phone conversation connected through a secure computer system.

Doctors who offer digital visits say they generally are most effective for treating mild, simple conditions, often when patients are too busy or too far away to come to the office. Another advantage for some patients is that doctors charge far less for digital visits than for the in-person version. Often the fee is around $20 to $35. If you are uninsured or have a high-deductible health plan, you may want to consider a digital doctor visit.

Ailments most frequently treated online include sinus problems, cold and flu symptoms, urinary infections and coughs. Other common conditions are back pain and sleep issues.

Doctors also use digital communication to track patients with chronic conditions like diabetes who can regularly send in their blood-sugar readings. If you have high blood pressure or heart failure, for instance, you might be a good candidate for such online monitoring. Some doctors even use digital tools to stay in touch with patients taking psychiatric drugs such as antidepressants, tweaking their doses based on the patient’s description of his or her status.

But there are certain conditions that physicians typically won’t treat through online advice, particularly chest pain or other symptoms that may signal an emergency. Some state medical boards have rules that limit the use of digital visits, including requiring that doctors see patients in person before prescribing drugs. Even with minor ailments, many physicians will offer digital advice only to regular patients, for liability reasons and also because they feel that in-person visits are important to discuss broader health issues.

Conditions that may be ambiguous don’t lend themselves to online diagnosis. Some doctors say they won’t diagnose complaints such as vertigo and ear aches without an exam. Another no-no for some physicians is abdominal pain, which could be a sign of anything from appendicitis to an aneurysm.

Of course, patients can’t always tell what’s urgent. Doctors say that a good rule of thumb is that if you would have gone to the emergency room in the pre-digital world, you should still go to the emergency room.

How to Find a Doctor

For decades, patients have found doctors by asking neighbors and co-workers, and getting referrals from doctors they already know. Barring that, many simply pick a physician from their health plan who happens to be nearby — and hope for the best.

But today, patients have an expanding array of referral resources, fee-based services and free online tools to find the right doctor — from insurance companies, government agencies and private companies.

Here are ways for patients to mine the growing pool of data to help make their choice:

Start With Your Health Plan
Long a source of basic details — contact information, gender, schooling and maybe language proficiency — health-plan networks now include some physicians tagged with performance labels, essentially recommendations that patients use these doctors over others in the networks. Aetna Inc., for example, denotes favored doctors with an “Aexcel” designation. Aetna says its label indicates that doctors have met quality and cost thresholds, and that criteria are tailored for different specialists.

Give the Doctor a Check-Up
Health plans may ensure that their doctors meet minimal licensing standards, but it doesn’t hurt to check for yourself. You can look up a doctor’s license status free with each state’s regulator; find a list from the Federation of State Medical Boards.

Medical boards typically can also tell you if a doctor has been disciplined, and many provide online searches. Some states don’t make it easy, however. New York, for example, has separate Web sites to search licensing and disciplinary records; Illinois simply notes whether a doctor has been disciplined with minimal details. For $10, the Federation of State Medical Boards will let you search all U.S. records at once, plus those of several foreign jurisdictions, at the FSMB’s DocInfo.org site.

Many doctors are also certified in one or more specialties, a process governed by the American Board of Medical Specialties and other groups. Advocates call it a good indication that the doctor keeps up with the field; to get certified, doctors must pass a written exam and go through a fellowship program for specialty training. Health-plan lists often note board certification, as do reports from the DocInfo site, or search the American Board of Medical Specialties directly.

Check With the Watchdogs
Some measures of physician quality are available from nonprofits and professional groups.

Diabetics and heart and stroke patients as well as those with back pain can search for nearby doctors who meet the standards of the Recognized Physician program from not-for-profit National Committee for Quality Assurance. Some areas with plenty of doctors, however, have no listings, and doctors must apply for the recognition, which costs a solo practitioner about $500 (though some insurers provide incentives). If doctors flunked or didn’t apply you won’t know — they just won’t be listed.

In a few parts of the country, you can dig deeper. The not-for-profit Massachusetts Health Quality Partners, for example, lets patients compare medical groups — but not individual physicians — around the state on various clinical measures in a several kinds of care (including women’s health, pediatric care, diabetes, depression, and asthma). The group also compares doctors’ offices on measures of patient experience.

Look at the Hospitals
Picking a good hospital may give you a leg up on picking a doctor. That’s because health-plan lists often include hospital affiliations, and doctors at a given hospital often follow many of the same practices.

The U.S. Department of Health and Human Services lets you look up a host of statistics on hospitals’ care practices.

Leapfrog Group, a not-for-profit consortium of big health-care buyers, also offers hospital ratings. You can search by ZIP Code or hospital name to see if nearby hospitals participate.

Hire an Expert
A growing variety of services are springing up to make finding a doctor easier — sometimes at a price.

Health Grades Inc., based in Golden, Colo., offers reports combining licensing, medical training, board certification, recent state and federal disciplinary records and local hospital ratings, starting at about $13 per doctor. For an added fee, you can search medical-malpractice lawsuit settlements from some states. The reports include extras as well, including a list of issues to consider when picking a doctor.

Consumers’ Checkbook surveys doctors in the 53 biggest metropolitan areas, asking which one or two specialists, in 35 fields, they would recommend to a loved one. The top 5% to 10% end up on its online list. In seven metro areas — Boston, Chicago, Philadelphia, Minneapolis-St. Paul, San Francisco Bay, Seattle-Tacoma and Washington, where the group rates everything from auto shops to veterinarians — the results can be cross-referenced with its patient-satisfaction surveys. Access for a year costs $25 (or $34 to get access to the group’s patient survey ratings and other results too).

Other Web Sources
Sometimes, a simple online search can yield helpful information. Marsha Hurst, director of a master’s program in health advocacy at Sarah Lawrence College in Bronxville, N.Y., says that when her son moved to a new city, he had narrowed down a list of doctors to two or three, and searched their names on the Internet. He settled on one with affiliations with mentoring and teaching programs that struck a chord. With a basic search engine, “you might find something that means something to you,” Ms. Hurst says.

How to Have a Safe Trip Home from the Hospital

Patients are being discharged from the hospital “quicker and sicker” than ever, as insurance companies and Medicare seek to limit costly hospital stays. The number of patients who needed home health care after being discharged grew 53% between 1997 and 2006, according to the U.S. Agency for Healthcare Research and Quality.

The burdens that fall on family members caring for recently hospitalized patients can be heavy. The best time to learn about what the patient will need is during the hospital stay, before you get home. Here are a few tips.

Be prepared. In some hospitals, discharge planners begin assessing conditions at home as soon as a patient is admitted. If that doesn’t happen at your hospital, ask when the patient is likely to be discharged, what kind of help the patient will need, and for how long. If the patient will have difficulty walking, you may need to move furniture and pick up rugs.

Know your rights. Discharge decisions are often dictated by insurers or Medicare. But you have the right to appeal if you think the patient isn’t ready. By law, the hospital must tell you how to go about that. Enlist the doctor’s help and act quickly. Hospitals try to avoid readmitting patients.

Learn as much as you can. Ask the nurses to demonstrate any tasks a family member will have to take on at home. Be sure to ask what symptoms to watch out for — like pain, fever, shortness of breath — and what to do if they occur. There should be written instructions for everything.

Understand home care. If a doctor orders “skilled care” — from a visiting nurse or physical therapist — it’s generally for just a few hours a week. A home-care agency will assess whether the patient needs “custodial care,” such as help with bathing or dressing. That may or may not be covered by insurance. Either way, home care is usually very limited. Most day-to-day care will likely fall to the family.

Organize the family. Designate a primary contact so hospital personnel don’t get mixed signals. Plan in advance who’ll help the patient and where. Recognize that old family roles have changed, tension is common and patients may be frightened and loath to be a burden.