How to combat the 'July effect' to maintain care quality in a season with high hospital turnover

Not everyone believes in the so-called "July effect." Studies have examined the phenomenon, but for every one that seems to confirm it, another purports to debunk it. To be fair, it's a hard thing to measure. If true, the July effect can have an adverse impact on care, threatening patient engagement and negatively impacting costs.

The July effect goes something like this: Hospital turnover, already higher in the summer, reaches a peak this month, and as employees leave and new graduates fill up internship spots, there's a discernible change in quality and outcomes, at least for a period of time. 

There's no contention over statistics that show higher turnover for the month of July. What is debated is whether this leads to a lower quality of care.

Peter Bonis, MD, chief medical officer at Wolters Kluwer Health and a gastroenterologist by training, is a believer. He's seen it firsthand, and he attributes it to two main factors, both intertwined. One is the high turnover in the care delivery labor force. The other is a sudden dilution of institutional knowledge.

"There are certain ways you have to get things done that are institution-specific," said Bonis. "You might have a new electronic health record. There are people you trust and know, or who have areas of expertise you have relationships with, and you know the areas in which they're deficient, so you send patients to this person or that person based on that. All of those things require some experience in working with the teams in that environment. Those are components of institutional knowledge."

And it's not a phenomenon limited solely to trainees. Bonis described it as a pervasive and global problem, worse in some geographic areas than in others. The differences can result in inconsistent patient experiences and cost, and span many divergent conditions.

Bonis sees technology as key to the solution. Wolters Kluwer uses its own proprietary software, Up to Date, to combat the problem. Medical students are exposed to the program and are already familiar with it by the time they become a trainee, so they're already versed in how to retrieve information. When they arrive as house staff, they have access to a resource, with which they're already familiar lays out evidence-based care guidelines for a number of different conditions.

"It has good face value that when you have staff who has access to a knowledge resource to have the best care for your patients … that's going to help reduce unwanted variability in patient care," Bonis said. "You're admitting a patient with a particular condition, you can very easily look that condition up, and you don't have to rely on a senior doctor and can make a confident decision. It has attenuated this onboarding problem."

Another big piece of the puzzle is the use of electronic health records. When Bonis was an intern he didn't have access to an EHR system that could write orders, so he had to do it all by hand. That occasionally led to issues. People were not always able to read the clinician's handwriting, but even if they could it was often unknown whether the recommended treatment would interact with certain drugs. It was sometimes possible to ascertain that through conversations with the patient, but the patient wouldn't always know. This was a measure of uncertainty when it came to certain aspects of care.

Staff often changes in July, but the patients don't. Most patients have a decent grasp of the level of care they should be receiving, and when they don't get it, they know it.

That's where clinical tools can help maintain consistency. Oftentimes, using these technological solutions will cause a clinician to change or reconsider his or her initial instinct, usually resulting in better and more consistent care.

"A large percentage of the time that query leads them to do something differently, and what they end up doing changes -- about 18 percent of the time, which is extraordinarily high," said Bonis. "Imagine that you have lots of these changed decisions, all of them leading to potentially better and safer patient care. Could those in fact lead to better health outcomes? And the answer is yes."

Financial incentives for hospitals are changing. If a hospital is still in a fee-for-service system and there's a bad health outcome, it can still be reimbursed by payers. Under a value-based arrangement -- which is becoming the norm -- reimbursement is tied to outcomes. The financial impact of care quality varies depending on the mixture of payment models at any given time, but it's safe to say that outcomes matter, and not just for the patients.

"The journey is still continuing," Bonis said. "The systems have not yet been optimized for clinical workflow and bettering patient care and patient safety. Many of these systems were built tobe data warehouses of medical records, and they're helpful for optimizing billing processes. But the impact in clinical care and workflow is still forthcoming. We have made some strides with respect to the July effect.

"In think in the future, all signs point to the better use of digitized health information and workflow tools to assist patients and care for them safely and effectively," he said, "and I think we'll see more of that in the coming years."

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com