Wachter: Three Stories

In my travels, I frequently hear short stories that help illuminate my work and world. Here are three recent examples; think of them as little health policy tapas.

I recently spoke in a session with Peter Pronovost, the Johns Hopkins intensivist who is the world’s top researcher in safety and quality. We were talking about why engaging physicians in this work – so called “adaptive change” – is sometimes so difficult. Peter recalled a story about his son, who at age 6 came home and told his parents that he was terrified to enter the school bathroom. “There are monsters in there,” he said. His parents reassured him that there weren’t, but the next day he returned, wide-eyed and still panicked. Peter called the school to see if they had any explanation for his son’s sudden bathroom phobia. “Oh, we put in automatic flush toilets last week, and I guess we didn’t explain it to the kids,” said the teacher.

Peter’s point was that we often ask physicians (and others in healthcare) to absorb a tremendous amount of change without giving them the background and tools they need to understand these “monsters.” It’s a lesson worth remembering.

At the same conference, I went to a terrific session given by one of my UCSF colleagues, Adams Dudley, another critical care physician and one of the nation’s experts on the impact of transparency and pay-for-performance strategies on quality. Adams was discussing his observation that physicians often feel that they – unlike every other soul on the planet – are not influenced by monetary incentives. He told this story:

Last year, Adams was asked by the American Academy of Neurology to speak at a special meeting on pay-for-performance and public reporting. His specific charge was to address the following question: “Do professionals respond to incentives?” As he described his invitation, Adams made it a point to highlight the term “professionals” – a carefully chosen word that was clearly meant to be distinct from “human beings,” “physicians,” or even “neurologists.” It is one of those terms that has its answer embedded within it: if one were truly a professional, it seems to say, his or her clinical judgment would not be influenced by something as crass as money.

As Adams was mulling over what he was going to say to this august audience of brain experts, his eyes were drawn to another document in his speakers’ packet, a lawyerly form entitled, “Syllabus Contribution Policy.” The AAN, like many conference hosts, wants speakers to hand in their PowerPoint slides early so they can be printed in the syllabus or posted on-line. Getting the speakers to do this is, to be kind, a challenge – one generally addressed with plaintive, and later frantic, e-mail reminders, topped off by out-and-out begging.

The AAN, though, had adopted a different tack. Reading on, Adams learned that…

… Faculty who meet the syllabus deadline will receive an additional $100 [over their usual honorarium]…. Faculty not contributing to the program syllabus without pre-approval will NOT receive an honorarium.

In other words, the world’s leading society for the study of the brain – the one that was asking Adams to address whether monetary incentives could influence the behavior of “professionals” – was offering a $100 bonus payment for good behavior and exacting a 100% penalty for underperformance when it came to syllabus submission. I believe the ancient Romans had a term for this: res ipsa loquitur.

Finally, a few months ago I was speaking about quality improvement and patient safety to the staff of a large health system, and went on a riff about the kinds of support caregivers should get from their hospital to improve performance. I made the point that ultimately hospitals would need to put more resources – both human and IT – into helping to educate and support their caregivers at the bedside.

One of the physicians, an invasive cardiologist, stopped me in my tracks. “Actually, our hospital already provides a tremendous amount of support and feedback,” he said. “When I perform a catherization or angioplasty, a hospital staff member watches the entire procedure, she sometimes suggests mid-course corrections, and as soon as I’m done she provides me detailed feedback on whether I met all the best practice standards.”

“Wow,” I said. “Your hospital is really taking quality seriously!”

“Oh,” he replied, mischievous smile on his face, “she’s not from the quality department. She’s from the billing department.”

The point, of course, is that hospitals have traditionally enjoyed a large return on their investments in improved billing. However, the business case to put similar energy into improving quality and safety has been sadly absent. This is beginning to change, but not enough to make the idea that this cardiologist’s shadow could have been from the quality department seem anything but absurd. We’ll know that we’ve made it when such a scenario no longer seems impossible.

* * *

I am constantly impressed by the power of a good story to illustrate the essential truths in our crazy world. Although data and graphs can be powerful tools, I find that nothing can match a great anecdote in memorably promoting deep understanding.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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