Most people are familiar with the symptoms of arthritis – pain, decreased mobility, stiffness, swelling, redness, and even warmth in the affected area.  What most people don’t know is that there are numerous types and causes of arthritis.  One medical encyclopedia says there are 100 types of arthritis.

The most common . . . → Read More: Plan for Post-Traumatic Arthritis]]> What is it?

Most people are familiar with the symptoms of arthritis – pain, decreased mobility, stiffness, swelling, redness, and even warmth in the affected area.  What most people don’t know is that there are numerous types and causes of arthritis.  One medical encyclopedia says there are 100 types of arthritis.

The most common cause of arthritis – and the one that readily comes to mind is osteoarthritis. Osteoarthritis is a breakdown of the cushiony cartilage between the bones in a joint.

Previously, osteoarthritis was thought of as a general “wear and tear” of joint cartilage.  This wear and tear would seem to indicate that most osteoarthritis sufferers are elderly; however arthritis patients are getting younger.  Secondary, non-specific, inflammatory changes also affect joints – making the term “degenerative joint disease” technically inaccurate  when referring to osteoarthritis.  There are also subdivisions of primary and secondary arthritis – but most of these technicalities of diagnosis won’t be as relevant to most personal injury cases.

Risk Factors

Modifiable risk factors for arthritis include: obesity, exercise to maintain good muscle strength & tone, repetitive use, and injury prevention.  Non-modifiable risk factors include: advancing age, genetics, inherited or acquired diseases (ex: rheumatoid arthritis, sickle cell disease, female hormones, and bone disorders).

How many get it?

According to info from the Cleveland Clinic, post-traumatic arthritis is responsible for approximately 12% of arthritis cases involving the hip, knee, and ankle (5.6 million patients).

There is no way to prevent post-traumatic arthritis except to prevent injury.  In the event joint injury occurs, restoring the injured joint to as close to normal as possible can help reduce the risk of post-traumatic arthritis.

Development of  trauma related arthritis may occur soon after an injury, or it may not be seen for many years.  The type of injury, as well as the age, lifestyle (active/sedentary), and health status of an individual, can play a part in when post-traumatic arthritis occurs.

Management of pain is the most common reason people seek treatment of arthritis,  although other factors such as loss of function and poor quality of life  can also trigger the need for treatment.

Treatments

Pain management may be handled by a family physician, but a pain management specialist may need to address unrelieved pain.

Medications – narcotics, anti-inflammatories (NSAIDs), topical analgesics, even anti-depressants and anti-convulsant medications— may be used to control pain.  Steroid or hyaluronic acid injections may be helpful to decrease joint pain.

Psychological counseling and other non-pharmaceutical interventions may be a component of a pain management regimen.  Often it will take a combination of various types of medications and other interventions to achieve enough pain relief for a person to be able to function “normally”.

Other healthcare providers may also be needed to manage the effects of arthritis – such as orthopedic surgeons, physiatrists, neurologists and psychiatrists/psychologists.

Surgeries such as arthroplasty (joint replacement) may be needed to restore function and decrease pain.  The younger a patient is when they require a joint replacement, the higher the likelihood that they will need a revision(s) of those joint replacements during their lifetime.  After a joint replacement, there are various requirements for care long-term, like antibiotic prophylaxis for dental procedures (even teeth cleaning) and imaging studies.

A patient undergoing surgery will need “clearance” to ensure they are healthy enough to undergo anesthesia for surgical treatment.  Lab work, EKGs, stress tests, radiology (Xrays,MRIs, CTs,) and even appointments with other specialty physicians may be required before the planned surgery.

Patients on long-term pain medication usually require periodic laboratory testing to monitor for side effects, efficacy, and contraindications.

Physical therapy (PT) can help restore & maintain mobility and function in an arthritis patient as well as help with pain management.  Occupational therapy (OT) and adaptive equipment may be necessary for a person with post-traumatic arthritis to be able to perform every-day activities.

Durable medical equipment (DME) may be necessary for health, safety, and independence

Orthotics and/or custom shoes can improve the pain level, function, safety, and quality of life for arthritis patients.

Plan for the costs

Treatment for trauma related arthritis and the resulting problems is often costly.  The cost of pain medication alone can run into hundreds of thousands of dollars over the lifetime of the injured person.

Even a non-catastrophic injury can result in trauma related arthritis.  With so many variables in injuries, treatments, and patient co-morbidities, careful examination of each individual situation is warranted when evaluating potential future medical needs.

Whether working on a plaintiff or defense case,  post-traumatic arthritis, the effect on the body, and its treatments should be considered.

The legal world usually defines a standard of care (SOC) as the attention and degree of care that a reasonable person in the same circumstances would exercise to prevent an injury.

A standard of care in the medical world is usually considered a written statement describing the rules, . . . → Read More: Standards of Care – What, When, and Should I Care?]]> What Am I Looking For?

The legal world usually defines a standard of care (SOC) as the attention and degree of care that a reasonable person in the same circumstances would exercise to prevent an injury.

A standard of care in the medical world is usually considered a written statement describing the rules, actions, and conditions directing patient care.

Both of these definitions have a weakness – standards of care can be subjective and open for interpretation.  Some standards of care can vary based on a person’s level of education, training, and experience – in addition to the different situations they’re applied to. 

Professionals working with medical-legal issues should remember that written medical standards of care are more appropriately called “guidelines”. 

Because a SOC cannot cover every component of every situation, most SOC are written as recommendations without absolutes.   A guideline gives options for best practice while allowing the practitioner to individualize the treatment to each situation using knowledge & judgment. 

Having a SOC that resembles a rule book instead of a treatment map would be disastrous to patients – not to mention opening up liability issues for the party issuing the standard.

An attorney often wants a SOC that definitively outlines care and supports their case using specific wording.  Often a SOC that has the EXACT wording desired does not exist.

So what do you do?  Find the guidelines that best fit the case you have – even if the standard is not worded exactly as you had hoped. 

Anyone can research and find a SOC, but without medical training, that SOC may not be the right fit for the case. Or the SOC may need further analysis and explanations to draw the proper conclusions when the SOC does not have the exact wording that you want.  This is where medical professionals, such as legal nurse consultants, as well as expert witness testimony, come into play. 

When Should I Worry about SOC?

The well-informed attorney will ideally have a good idea of the SOC for the case BEFORE it is sent to an expert witness for review.   Not only does this assist in deciding whether to further investigate the case and spend time/money on an expert witness, it helps the expert and attorney get on the same page faster.

Because standards of care have a subjective component, it may require reviews from multiple experts before finding one that agrees with the case position – whether plaintiff or defense. 

This Isn’t A Malpractice Case, Should I Still Care About SOC?

Short answer – YES.

Obviously in a medical malpractice case, the standard of care is the main focus, but even in a personal injury case, SOC makes an appearance.  Attorneys may only focus on causation in a PI case, but without knowing the medical SOC for the injury litigated, parts of the picture might still be missing.

Having an idea of the treatment standards can help guide the development and disposition of the case for both sides. 

A personal injury case can actually have a malpractice component. 

A common issue in personal injury cases is pre-existing conditions.  Considering pre-existing conditions is a standard of care for any treatment of injury/illness.  Complications arising from failure to consider these pre-existing problems during treatment of an acute injury can exacerbate the problems, prolonging recovery time or cause further injury.

Sometimes a complication resulting from a deviation in SOC may be attributed to a pre-existing condition when in fact, it is related to the injury being litigated, or vice versa.

Behind-the-scenes legal nurses are usually the ones to pick up on these types of issues in PI cases because expert witnesses generally focus on causation of the main injury being litigated.

Standards of care also play an important role in the development of future medical cost projections and life care plans.

Bottom Line

Be on the lookout for SOC issues in all your medical-legal cases, just in case.     

Areas of the body containing compartments that can be affected by compartment . . . → Read More: The Squeeze of Compartment Syndrome]]> Compartment syndrome is a painful condition caused by the build-up of pressure inside an enclosed anatomic space.  This high pressure cuts off blood flow and constricts nerves, which can lead to loss of function, loss of the involved limb, or even death.

Areas of the body containing compartments that can be affected by compartment syndrome are:

·         hand

·         upper/lower arm

·         abdomen

·         buttock

·          upper/lower legs

·         feet 

Many people think of compartment syndrome as being seen in leg fractures; however, any type of injury to compartmented body parts can cause compartment syndrome.  Internal forces such as bleeding or swelling can cause compartment syndrome.  External forces causing compartment syndrome are splints, casts, and any type of prolonged pressure to the area.

Examples of types of conditions contributing to compartment syndrome are;

·         fractures – both open & closed

·         blunt trauma

·         penetrating trauma – gunshots, stabbings, etc.

·         burns

·         snake bite

·         infiltrated IV lines

·         pressure from splints/casts

·         prolonged pressure on a body part – ex: lying on an extremity, positioning aids used in surgery

·         crush injuries

·         conditions causing edema

·         trauma to blood vessels – including venipuncture to draw blood/start IVs

·         exercise

Chronic compartment syndrome usually manifests as muscle pain that occurs with exertion and subsides after exercise is stopped.  A feeling of fullness, numbness, tingling, weakness of the affected limb, and muscle swelling/bulging can also occur with chronic compartment syndrome.  Although chronic compartment syndrome is not considered to be life-threatening, left untreated, continuing to exercise with symptoms can lead to damage of the nerves, blood vessels, and the affected muscle.  Exercise can cause both acute and chronic compartment syndrome. 

Acute compartment syndrome is a true emergency.  The pain associated with acute compartment syndrome is not relieved with rest and may be disproportionate to the injury.  Pain with passive stretching of the muscles is often the only indicator of rising compartment pressure.  Pale skin to the area, diminished/lost pulses, numbness/tingling, and paralysis are considered late signs.  When these late signs appear, cell death has already begun and efforts to decrease compartmental pressure may not restore full functioning.  Irreversible damage begins after approximately 6 hours of increased compartmental pressure.

When compartment syndrome is suspected, measuring the pressure of the compartments should be a top priority.  Blood testing, radiological testing and ultrasound may help with differential diagnoses but will not definitively diagnose rising compartmental pressures.

Measurement of the pressure inside a compartment involves placing a needle inside the space.  There are commercial available pressure devices and should be used to achieve more reliable results than home-made measuring devices.  Measurements may be difficult to obtain in the small compartments of the hands/feet.

Persons with acute compartment syndrome should receive supplemental oxygen.  Affected extremities should not be elevated as this can decrease blood flow to the area.  IV fluids to maintain normal blood pressure and volume are needed.

The primary treatment is to relieve the pressure.  If external forces such as a cast is the cause of the increased pressure, the cast should be removed. 

Fasciotomy is the definitive treatment to relieve the internal pressure.  Medical personnel continue to debate at which pressure fasciotomy should be performed. 

After 24-48 hours of a missed diagnosis of compartment syndrome, fasciotomy is generally considered to be contraindicated.

A fasciotomy increases the risk of infection that may not have been present with the original injury.  Scarring, need for skin grafting, swollen limbs, chronic pain, and sensory loss are a few of the complications that may be associated with a fasciotomy.

Failure to measure compartment pressures are common in medical negligence cases.  Failure to consider potential errors in measuring – such as faulty equipment, needles in the wrong place, failure to interpret measurements in context with clinical condition, are areas of concern as well.

Both personal injury and medical negligence cases may deal with the long-term effects of compartment syndrome – particularly with loss of function and chronic pain issues.

I was reading through a nursing journal today and was struck (again) with annoyance at a letter to the editor.  A nurse wrote the editor expressing their support for mandated nurse:patient ratios.  Now normally this would not have annoyed me, except the end of the letter was signed “name . . . → Read More: The Cost of Anonymity]]>

Take off the mask!

I was reading through a nursing journal today and was struck (again) with annoyance at a letter to the editor.  A nurse wrote the editor expressing their support for mandated nurse:patient ratios.  Now normally this would not have annoyed me, except the end of the letter was signed “name withheld upon request”.

Why would the writer want to remain anonymous?  I’m guessing they decided they needed to do some CYA.  It seems that to support the writer’s position, they mentioned specific problems in their healthcare facility, including the fact that a sentinel event occurred due to inadequate staffing.  Actually, I doubt that the nurse really needed to add those facts into the letter to support their position as much as they needed to vent about issues at work and they chose the venue of writing a letter to the editor of a magazine.

ANONYMOUS CRIMINALS?

Over the past year, I’ve followed the circus involved in the cases of two Texas RNs who were indicted on criminal charges after they reported a physician to the Medical Board for questionable behavior and medical practices.  They too chose to remain anonymous when they made their report.  But the physician had a lot at stake – he discovered the identity of the nurses and had them arrested.  Fortunately, wisdom prevailed and the nurses were vindicated.  (the doctor now must answer to the board)

FEAR AS A MOTIVATOR

Before last year,  nurses remained anonymous for fear of job retaliation, not because they could become felons.  Now, nurses are afraid to end up down the path that Anne Mitchell & Vicki Galle found themselves this past year. 

I cannot blame nurses for wanting to protect themselves. I’ve been there.  But I am saddened (and angered) to see a profession that I’ve put so much work into, become so powerless while claiming that nurses are powerful because of poll results that say people trust us. 

We have become Powerless to perform our duties.  Powerless to fix the problems so prevalent in today’s healthcare system that are well within a nurse’s scope of practice.

CONCERNS

Nurses have spent decades citing problems with inadequate training, inadequate/inappropriate staffing, lack of supplies, inadequate ancillary support, abuse from doctors (and even each other), and unrealistic expectations that a nurse-is a nurse-is a nurse no matter what their education/experience. 

Finally in the 21st century, there are people out there who have researched these issues and concluded that these issues are not only valid, but that they are contributing factors in skyrocketing healthcare costs & the injury and death of patients.

It’s great that our concerns have finally been verified by scientific research, but little has been done to fix the problem – we just keep studying things to death instead of taking action.  Nurses are so afraid that they either just gripe about their concerns in the nurse’s lounge, or they send anonymous letters to the editors of nursing magazines.

JUST WHINING

In my opinion, sending an anonymous letter to the editor of a nursing magazine is just break room griping on a bigger scale.  You’re preaching to the choir when you complain to other nurses about the crummy things going on in healthcare today.  Nearly every nurse reading that nursing journal has experienced the same unsafe conditions going on in healthcare today. 

I can’t count the number of times I have seen online postings from anonymous nurses that have been commented on by the public with things like “nurses are just trying to get rich at the expense of patients”, or “nurses don’t care about the patients, they just want to do less work for more money – that’s why they gripe about staffing and wages”.

If nurses are truly interested in fixing the problems in healthcare, they MUST stop hiding behind Anonymous. 

Anonymous is not taken seriously.  Anonymous is a red flag.  Anonymous implies powerlessness.

The Meaning of Anonymous

A few synonyms for Anonymous that I found, include: undistinguished, ordinary, run of the mill, unmemorable, dull. 

Don’t know about you, but I don’t like to think that nurses are ordinary or unmemorable.  

Why should anyone take stock in what a nurse says if he/she is afraid to put their name to it?  If a person truly believes that what they are saying is important, then they will sign their name to it.

Yes I know, you might lose your job.  How many times do I have to repeat myself?  They can fire a few people, but they cannot fire everyone!  Nurses need to quit being so darn afraid.  There IS strength in numbers people. 

THE COST OF ANONYMITY

The cost of anonymity is high. 

Anonymity has cost the profession dearly.  Nursings schools are cranking out new grads on an assembly line but those newbies are tripping over themselves to get out of nursing because the working conditions are horrendous. 

Nursing Anonymity has cost the public.  People are dying because nurses have failed to stand together and become recognized as leaders who have legitimate concerns and solutions to the dangerous conditions in healthcare. 

Nurses cannot continue to remain anonymous if they want to be effective patient advocates. 

Nurses cannot continue to remain anonymous if they want to be healthcare leaders. 

SOLUTION

To all my nurse colleagues out there:

STAND UP. 

BE HEARD.

USE YOUR CREDENTIALS TO GARNER ATTENTION TO YOUR CAUSE. 

DO NOT BE INTIMIDATED.

GET INVOLVED.

Stop cowering in fear hoping anonymous will keep you safe - it won’t. 

PS – Don’t wait until you’re the one in the hospital critically injured from a mistake made because the staffing was lousy  - all because you failed to take a stand and work toward a solution to the problems in healthcare that affect us all.

Check out what others say about nurses as leaders

The author of the article pointed out that the causes behind the patient’s perceptions . . . → Read More: Satisfaction Survey Results and Litigation]]> A few days after I posted about patient satisfaction surveys, a nurse in Oregon wrote an editorial on this very subject.  I enjoyed seeing her views in print – mainly because I have found them to be true in my own experience.  

The author of the article pointed out that the causes behind the patient’s perceptions of quality care must be uncovered in order for these surveys to be more than just reviews of customer service. 

MEANINGFUL OR NOT?

So what exactly does this survey information mean? 

For the public relying on these surveys to find a good healthcare provider/facility, the information may not mean a lot.  While it is hoped and expected that good customer service equals good products, this is not always true. 

I’ve been in a hospital that was modern and well maintained.  The staff were all smiles & friendly.  However, the healthcare was lousy underneath the pretty façade and I did not leave my family unattended in that facility.  Meanwhile, my non-medical family had no idea that there was any problem. 

On the other hand, you may find a hospital that has terrible satisfaction scores due to the a number of respondents that were looking for a place to vent frustrations.  Perhaps the facility is older and seems “dirty”.  Maybe the nurse was grumpy, or the hospital was asking to be reimbursed for services rendered and the survey respondent couldn’t pay.  In reality, the standard of care at that facility may be adequate if not excellent, with good patient outcomes. 

Perception is the basis for these surveys and not everyone has the same perceptions or expectations.

If you’re involved in medical-legal litigation, these surveys might mean something to your case.  

You’ll need to dig deeper than just the superficial scores to determine if the scores – high or low – represent a consistently high standard of care, a consistently low standard of care, or misconceptions of survey respondents.

WHERE DID IT COME FROM?

You’ll want to know where the survey results came from.  Were the results from actual answers from patients, or were they from self-reported information?  Or were the results from review of documentation on outcomes that were sent to government entities?  Was there an adequate number of surveys returned to ensure a good cross-section of patients?

SURVEY CONTENT & HEALTHCARE ENCOUNTER SPECIFICS

You’ll also want to know what questions were asked on the survey and how they were worded.  Did the questions focus on actual medical care/treatments and physical outcome of the patient?  Or did the questions ask about friendliness and staff personalities,  taste/temp/selection of food choices, or how quickly someone came to the room after the call light was pushed?  Did the questions (and survey results) include whether the patients were critically ill or whether they were in for an elective procedure?  If there was a negative outcome such as death, did the survey ask about the diagnosis of the patient and if the illness/injury had a high likelihood of death?

TIME AND OTHER INFLUENCES

What dates does the survey include?  Is the data more than 6 months old?  Were there changes in management, mass employee exodus, or an influx of new graduate professionals at the time covered by the survey?  Were there outside forces (utility outage, hurricane, multi-vehicle car crash, gang war) that occurred during the survey period? 

SOCIOECONOMICS

Where is the facility located?  Is it in a wealthy part of town or the poorer part of town?  Is it the only facility in the area?  What is the educational level and the health literacy level of the respondents?  What is the age of the respondents and the typical age of the patients at the facility? 

ANSWERS

So many factors play into these surveys and the perceptions of the people that fill out the surveys that I could spend days on this subject. 

You probably won’t be able to get an answer to all of these questions about satisfaction survey results from the healthcare provider.   But if you have a case and want to use the survey results to bolster your position (or fix problems), having a nurse on the litigation team can help. 

Nurses know what goes on in healthcare.  They can look at survey results to identify background situations that influence the particular area of concern on the survey results.  That nursing knowledge can assist in formulating questions that may shed light on the behind-the-scenes factors that influenced the survey results. 

It’s the answers to the background questions sparked by the survey results that can become crucial to a legal case.

http://www.asnc.org/content_10111.cfm

Do these surveys accurately reflect the medical treatment received?  Or . . . → Read More: Quality healthcare or customer service?]]> I’ve had several colleagues recently discuss patient satisfaction scores at their hospitals.  The usual scenario goes something like this:  We had a meeting at work and were yelled at because our Press-Ganey scores were low.  You wouldn’t believe what they are making us do now…..

Do these surveys accurately reflect the medical treatment received?  Or are the survey answers based on the patient’s perceptions of what did/should happen based on their personal preferences (which may have nothing to do with medical care)?

It’s funny, while researching this topic, I found most sites touting the correlation of patient satisfaction surveys and quality healthcare were either from groups that get paid to administer patient surveys or from healthcare organizations trying to market themselves by telling the public they had high satisfaction scores. 

I was unable to find many anecdotes from bedside clinical healthcare providers (ones that actually do the patient care) that correlated major improvements in health care (meaning people were healthier) with patient satisfaction surveys.  Some said they had seen some good changes where certain processes had been changed – but it didn’t necessarily correlate with better patient health.  

Most improvements as a result of surveys were “niceties” – efficiency, friendliness of providers, homey environment etc.  While niceties are important to patient comfort, to the doc and nurse in the trenches, keeping people alive is far more important than if the patient wants to be friends with their nurse or if cable tv is available.

One of the ways that organizations have tried to deal with poor satisfaction scores is with scripting.  Here’s an example that I found:  ”We are scripted to say “I hope your care has been EXCELLENT today,” so the patients will mark excellent care on the survey. I feel like a Stepford Nurse.”

Hmmmm, so basically we are supposed to tell the patient what they want to hear, implant in them that they are happy, and then it’s all going to be ok?  And exactly how does that work if what the patient wants is contrary to the standard of care?   

Here’s some things I don’t usually see addressed  by patients or organizations on these satisfaction surveys:

1. Did we fix the ailment the patient came in with?
2. If the ailment isn’t fixable, did we explain this to the patient and give them the tools to manage the ailment as best as possible for as long as possible?
3. Did we care for the patient without screwing up and causing harm?
4. Was the patient compliant with treatment or did they do whatever they wanted in the hospital and at home? 
5. Are the staffing levels and education levels of the staff appropriate to meet the needs of the patients? (who decides what is safe staffing – someone in an office or someone who actually provides patient care)
6. Are the right tools available  to deliver quality care? (facilities need to be honest on this on)
7. Do the patients have a realistic perception of healthcare and the limits of modern medicine? (a negative outcome in healthcare doesn’t necessarily mean negligence was involved)

Here’s some definitions that I found for Quality Health Care:

1.  Quality healthcare can be more exactly described as striving for and reaching excellent standards of care. It involves assessing the appropriateness of medical tests and treatments and measures to continually improve personal health care in all fields of medicine, from the aides that help you eat to the surgeon who removes a tumor from your brain.    (http://www.ehow.com/about_5085075_definition-quality-health-care.html) 

2.  The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.         (http://www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx)

And a definition for Good Customer Service:

A customer defines good customer service as how she perceives that an organization has delighted her, by exceeding to meet her needs.   (http://www.customerservicepoint.com/customer-service-definition.html)

While intertwined, good customer service and quality healthcare are separate entities.  Good customer service is subjective based on personal preference.  You can’t please everyone all the the time.  So why does it seem that organizations are trying to turn heatlhcare providers into personal valets in order to make people happy and then calling that quality care?

Shouldn’t treating a person’s ailment so that they can continue to live be enough to satisfy patients?  It stands to reason that if the medical care is high quality, the patients should be happy –  without resorting to specialty chefs in the hospital kitchen and concierge services at the desk in the lobby.

Perhaps there are some organizations out there that use these surveys correctly - asking the right questions and interpreting the results in the correct context.  In those cases, the surveys might actually improve healthcare outcomes.  Unfortunately, I don’t see these surveys used in this way.  Instead, they are used punitively against staff as bandaid fixes for larger problems.

Healthcare organizations need to realize that meeting the standards of care means ensuring they have competent, well-educated people who are provided  the right tools to give high-quality care.  Even when those tools cost more money than the organizations want to spend. 

Giving patients the illusion of quality by using scripted conversations and “kissing up” to patients, is not the same as actually providing safe care with appropriate staffing and the tools needed to make people healthier than when they came to us.

Healthcare isn’t a vacation at a 5 star resort.  It’s dirty, it’s invasive, it’s personal.  It’s a quest to keep someone alive because they came to us for help.

Somehow, we have to find a middle ground between resources available, patients needs vs wants, and individual personalities in our quest for quality healthcare and the patient’s perception of that care. 

Some interesting insights on satisfaction surveys:

http://drbrenner.blogspot.com/2009/07/culture-shock-why-sociologists-need-to.html

http://drwes.blogspot.com/2010/03/do-patient-satisfaction-surveys.html

http://allbleedingstops.blogspot.com/2009/08/in-defense-of-press-ganey.html