Saturday, December 27, 2008

The Knitting Must Stop!

A friend of mine had a baby in August. She credits me as her inspiration for studying nursing; now she's working on her PhD, studying hormonal aberrations in elite female athletes. So my baby gift had to be good. To purchase it, instead of patronizing Babies R Us or Target, I took the elevator to the 13th floor of a local hospital. There (not in the hospital's gift shop) I chose a fuzzy, pale yellow, hand-knit angora hat from among pumpkin-colored, flower-embellished, cable-knit, and striped varieties. It was hard to reject the pastel one with sweet little ears on top, but it wasn't gender-neutral. Darn.

The 13th floor is the mother-baby ward. The post-partum nurses sell these lovingly knit hats there for $20 each. The tiny hats are not made by good-hearted retirees, volunteers or hospital auxiliary ladies. They are knit by registered nurses who volunteer their time and money (and yarn can be expensive) and donate all the proceeds to the Lactation Support Program. Without nurse knitters, and limited grant money, there would be no Lacation Support Program for mothers who need help with breastfeeding.

Breastfeeding, to the uninformed, seems "natural", and thus, in the reasoning of the clueless, is assumed to occur effortlessly. As is often the folly of the ignorant, that which they do not understand is assumed to be simple. You may count the administrators of the hospital among the uninformed. In truth, mothers need coaching, support, resources and education to successfully breastfeed their infants. Many mothers who leave the hospital breastfeeding will give it up in a few months for lack of support. Support means time away from other responsibilities, a quiet & comfortable place, and education from an informed, caring individual, among other things. Many lacation consultants are nurses, professionals who have the requisite knowledge of growth and development, a dash of anatomy and physiology, and very strong interpersonal skills.

In addition to nursing skills, post-partum nurses have the dedication it takes to buy yarn and knit tiny hats in support of women, babies and health when their employr refuses to do so.

This is a common story. We nurses are lauded for selfless commitment to improving health when the health care system and our employers fail at the task. Today by e-mail I read of Michelle Battistelli, a nurse at Morris Hospital and Healthcare Centers in suburban Chicago. Michelle makes embroidered pillows that reduce pain for abdominal surgery patients. The American Nurses Association news brief said, "The ICU nurse and [her] colleagues wanted to do something to make it less painful for surgery patients when they cough, and holding the pillow against their stomach helps."

Why are nurses knitting and sewing? With patient safety, patient satisfaction, and other indicators of hospital quality under close scrutiny, why are hospitals not supporting programs that are known to improve patient outcomes?

Part of the reason is that health promotion doesn't "count" - literally - in our disease care system (it's not really a health care system; it runs on disease.) Hospitals are reimbursed on the basis of medical diagnoses, and breastfeeding success is not among them. Neither is pressure ulcer prevention, functional improvement, effective coping with loss, post-operative pneumonia avoidance or a host of other desirable health outcomes. Because there is no line item on the spreadsheets, the accountants miss all the dollars gained by prevention and health enhancement, work often done by nurses. Because there is no billable code for lactation consultants' services, nurses must knit.

If the accountants had access to a larger view, they'd notice that breastfed infants have fewer pediatrician visits as toddlers and do better in school, and the value of these outcomes would show up in support for breastfeeding consultations. If they could see a few steps beyond the immediate, they'd endorse the cost-effectiveness of buying pillows for people after abdominal surgery. But health care accounting systems, like all systems, see what they are built to see. And the nurses go on knitting and sewing.

What are implications of this situation for health care reform? In the current system, Hospital A competes against Hospital B, spending dollars on advertising and fancy machinery that add little or no value in terms of health outcomes. The disciples of Milton Friedman would say that costs are controlled through competition and open markets, but they are not referring to health care; they are referring to purchases of consumer goods where one purchase is not dependent upon another, as followup care depends upon the outcome of a hospitalization. They also are not referring to a system where costs are usually unknown to the consumer, as in health care. Health care as a market is also drastically different from consumer goods in that its availability is necessary for societal productivity: the sick use resources, but cannot work. Getting your hypertension under control is in no way analogous to buying a new Toyota. Thus my contention that multiple competing providers and insurers cannot work in health care, and the present crisis is evidence of that.

What will work is cooperation and transparency. We must have a single payer system where better coughing among abdominal surgery patients in the ICU translates into measurable, "countable" efficiencies that are shared across health care venues. Rather than paying for more procedures and more doctor visits after the surgery, let's pay for better coughing to prevent all that. Because of the interrelatedness of human health, because breastfeeding support produces kids who spend less time at the pediatrician's office later, we must have a single system that takes advantage of, rather than fights, this interrelatedness.

Human beings and our individual and collective health are interdependent, like strands of yarn knit into tiny baby hats; our health care system must also be.

No comments: