Big administrator is watching you

Last week, came the announcement that Suzanne Delbanco, founding director of the Leapfrog Group, has assumed the presidency of a company that tracks compliance with safety and quality practices via remote video. Big Brother, meet the Joint Commission.

The report, in Modern Healthcare, describes the process this way:

Video auditing refers to a system in which cameras are mounted in targeted locations to continuously capture specific clinical processes, such as observing handwashing and hand-sanitizing stations. [Using video] fed through a Web-based link, independent, third-party observers audit the recordings and provider reports on safety incidents.

Did you ever doubt this was coming? Virtually every other industry with compliance standards has long used video to monitor compliance and to goose workers into following the rules. If video surveillance is good enough for Vegas croupiers and Kansas meat packers, why wouldn’t it be good enough for neonatal nurses and ER docs?

Consider hand hygiene. Until a few years ago, low hand hygiene rates were just accepted as inevitable and unfixable – “we can’t control what the docs and nurses do,” lamented many infection control practitioners. But now that infection rates are being measured and reported (and soon tied to payments), hospitals are doing backflips to promote hand hygiene. With this focus, many hospitals, including my own, have seen hand cleansing rates skyrocket, from previously mortifying levels of 20-30% to merely embarrassing rates of 60-80%. But even with all the attention we’re lavishing on preventing nosocomial infections, we can’t seem to get to 100% (for a nice discussion why, see Gawande’s insightful essay).

Hospitals everywhere, under tremendous pressure to get these rates up, now conduct spot audits – with infection preventionists hiding in dark corners of ICUs and wards, recording whether providers cleaned their hands. Everybody accepts this kind of monitoring as the cost of doing business in the Patient Safety Era.

Several years ago, at one of our medical center quality meetings, I suggested that we should consider remote video monitoring of key clinical areas like ICUs. It seemed to me that – as long as we were going to go through the trouble of deploying people to snoop on their colleagues – why not just bite the bullet and put up cameras, which would be less intrusive over time, less game-able (folks putting forth their best behavior in response to an auditor’s visit) and ultimately less expensive than human observers. “We can’t do that,” came the shocked reply. I never got an answer to the “why not?” question.

Of course, it is natural to be slightly repelled by this concept. Companies like Delbanco’s (called Arrowsight Medical) are generating the predictable concerns about patient and provider privacy, and these creeping willies are likely to crescendo, particularly once the first nurse or doctor is reprimanded after being caught with dirty hands. (Perhaps this will ultimately be like those automatic traffic video systems that send drivers tickets after running red lights – in this case, the camera will notice that you didn’t wash your hands and submit an incident report on you.)

Just as predictably, Delbanco and others coo that these systems won’t be used punitively:

…the concept is meant to bolster individual control over patient safety practices, not give a hospital any control over providers, according to Delbanco. Video monitoring contributes to a culture of safety; “part of the team culture is measuring performance,” she said. When team members see their collective performance increase, there is “enormous pride. That was a feature that sold me,” she said.

Yeah, sure.

You can see where this is going. Now that safety practices are being publicly reported, required by accreditors and even legislators, subjected to media scrutiny, and even paid for (or payment withheld when they are absent), the pressure to measure these practices is escalating faster than the cost of a Wall Street bailout. Unlike quality measures that can be captured through chart review (did the patient receive aspirin and beta blockers?), many safety measures rely on provider self-reports or the observations of others. Was the head of the bed elevated? Did the surgeon conduct a time out before the first incision? Did the patient receive full barrier precautions before central line insertion? Did the nurse come running when the bed alarm went off? Did providers clean their hands? All these practices can be monitored easily and relatively inexpensively via remote video.

Although the privacy concerns are real and the concept does give me a bit of the heebie jeebies, I predict that video surveillance of safety practices is here to stay.

So get used to it. Who knows, it might even save a few lives.

4 replies »

  1. Interesting and insightful comments, other than the gratuitous sarcasm directed at Suzanne’s comments about team building. These sorts of comments and the silly “blog-squabble” over the past few days are immature and unhelpful. Given the enormous challenges that this industry faces in the sudden disastrous economy, perhaps we can have a more civil discussion about the downside of ideas that have the potential to improve the product.

  2. Good example, but I meant professionals, so I wondered about examples concerning lawyers, engineers etc.

  3. “This may sound elitist, but I just wonder whether there is any other professional group that allows video monitoring of their activities.”
    Cameras on police patrol cars are becoming common. When a cop pulls a driver over, there are increasing odds that the entire encounter is filmed. This can catch both actual abuses of authority and provide a measure of safety to the the officer if a false claim of abuse is filed.

  4. Very interesting.
    I agree with Dr. Wachter’s attitude. This may sound elitist, but I just wonder whether there is any other professional group that allows video monitoring of their activities. In other words, is that something physicians may be able to boycott (e.g. by not working at institutions doing that)?
    Moreover, could the surveillance tape (data) be used for litigation purposes? Did Dr. XY really thoroughly examine patient Z before she expired that same day? There is already a high degree of both reasonable fear and litigation paranoia in US hospitals (which I do believe results in wasteful and ultimately destructive defensive medicine) … video surveillance could exacerbate this problem further.