By PAUL LEVY
Old patterns die hard. Back in March 2010, I posted a chart from the ACHE that Jim Conway had sent me showing a decrease in the ranking of quality and safety among priorities reported by hospital executives.
Now comes an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled “The State of Patient Experience in American Hospitals.” Of those places surveyed, 51% were individual hospitals and 49% were hospital groups or systems. There was an even mix of urban, suburban, and rural facilities.
As in the prior ACHE survey, 69% of hospital executives rank things other than quality and patient safety as top priorities.
Any way you look at it, this is quite simply a failure of leadership and governance in American hospitals. There is a strange adherence to the view that “these things happen,” an apparent belief that a certain level of harm that occurs to patients is just the way things should be. It is as though the medical profession, hospital administrators, and hospital trustees have decided that the current amount of harm is the statistically irreducible level.
In contrast, I quote again from Captain Sullenberger, who notes that such an attitude is impossible to imagine in other fields, like air transport:
“I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country.”
Those of us who have participated in systematic improvements in the way work is done in hospitals understand that America is nowhere near the “statistically irreducible” level of harm. As Sully notes,
“We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety.”
There are thousands of people at lower levels of authority in hospitals who want to improve the situation, but they are stymied. I can’t tell you how often nurses, nurse managers, and junior physicians have come to me at conferences and said, “How do I convince my hospital leadership to take an interest in this and support us?”
The leadership for improvement has to come from the top: Hospital CEOs, clinical chiefs of service, and boards of trustees. To date, the American hospital leadership is failing in this regard. Maybe they should be required to say every day, “Let’s just keep killing and maiming the patients. After all, they are just statistics, not real people.”
Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.
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A dangerous assumption — especially in an academic medical center. You can only achieve what people in the organization want to achieve. With luck, you can help focus the debate and encourage people to work well together. But it is important to remember that the MDs in that environment are not employees of the hospital. The CEO has no say over who gets hired, promoted, and fired; how much they get paid; and how they spend their time. Even among the hospital’s employees, real authority is highly diffuse in a big organization. Any CEO who think s/he is actually running the place is delusional.
” President and CEO” usually includes power.
Dear MD as Hell,
Was your comment about power directed to me? It confuses me, as I never had any power!
Hell,
You of all people need to read this book. Educate yourself before you, once again, shoot your mouth off.
For more education on Paul’s comments about process improvement, read the book about Gary Kaplan, M.D., CEO of Virginia Mason hospital in Seattle, “Transforming Health Care” by Charles Kenney. I found astounding some of the things they were able to accomplish by a relentless and complete 10+ year commitment to process improvement – solving problems that all of us in medicine just accept as an intractable part of our work lives. It also illuminates how they solved issues like docs’ perception of loss of autonomy.
I suspect it is not so much the $$ that bothers these other CEO’s, but the sheer effort and commitment involved when their priorities are focused elsewhere – and yet Gary and Paul have shown it CAN be done – as well as why it MUST be done.
This is like “do you often beat your wife?”
“No?”
“Well, how often do you beat her?”
I notice you don’t have any power anymore.
I second Paul’s comment that there has to be someone in power who unrelentingly supports such efforts, which may at first fail as we learn how to do it. Rather than abandoning the idea (how many of us docs have seen this happen repeatedly in hospitals?), learning from others and then trying again, and again, is the key. Read Gary Kaplan’s experience at Seattle’s Virginia Mason hospital in “Transforming Health Care”.
A living example of this occurred at my hospital where a gifted and eloquent anesthesiologist, who ‘got it’, chaired our Performance Improvement Council and really converted me and other docs. A real movement was starting. Administration was at first supportive but then became embroiled in other internal issues leading to a change at the top,and the entire effort fell apart, never to be seen again. The anesthesiologist left the institution in disgust. Again, does this sound familiar to anyone?
We need a different, more nationally comprehensive idea.
We had had plans to expand our ICU, at a very high cost for capital and additional staff. This was avoided. Meanwhile, yes, we attracted additional patients, too. Maybe they would have gone somewhere else, but the result for us was an improvement in our bottom line — as a direct result of enhanced quality and safety improvement.
Paul, is there a shortage of capacity? I mean, are there non-patients who would become patients if there were more empty beds available?
Yes, it is cost-effective. Please see here for an example: http://runningahospital.blogspot.com/2010/01/progress-in-icus.html
Avoiding capital costs, decreasing length of stay and thereby creating new capacity to handle more patients are documented in this post.
It is time to get rid of this myth that it does not help a hospital financially to reduce the amount of harm to patients, even in a fee-for-service environment. And, that is even without penalties from Medicare.
Paul,
I’m not sure it is cost effective for the hospital to invest money in improving quality. If patients die or are injured due to poor quality, the hospital benefits financially. (A good example of this is the case with elective induction of labor leading to higher use of neonatal intensive care and, of course, profit.)
There is probably a net savings from quality improvement if you consider the cost to patients and insurers but hospitals don’t reap those savings so they consider only their costs. The Medicare quality initiative (won’t pay for certain avoidable complications) has the potential to cost the hospital money and thereby hopefully get their attention.
Dear rbaer,
The point is that there is a virtuous connection between quality/safety enhancement and financial results. Avoiding harm best occurs when waste is driven out of the system. This saves money and produces financial benefit both to the hospital and to the payers (not even including the societal benefit.)
We are nowhere near the point of diminishing returns, where you have to ask what else we would give up for another increment of quality/safety improvement.
Dear Dave,
Correct. Process improvement is a widespread concept that does not focus exclusively on the most visible forms of waste and harm.
Dear Stefan,
I agree, but if senior leadership is not supportive, it is very difficult for those working beneath to make progress.
The US health care system is about profit (even the “non-profits”). Safety and quality cost money (and don’t generate profit). As long as they can get away with killing and maiming (the tort system doesn’t seem to be an effective deterrent), they will continue to focus on profit.
I agree that there has been a difficult to understand complacency about patient safety in healthcare generally and hospitals in particular that has struck me as the most important barrier to improvement.
Part of the complacency seems to me to be a constructed ignorance about the size of the issue. Even among many of those who mount safety improvement programs, there seems to me to be a practice of picking only the most terrible negative outcomes (death, dismemberment) as the exclusive focus and then using less than the best techniques to detect instances of these outcomes. In this vein, I commend to you a recent study in April’s Health Affairs (‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured)
that gives one example of the both the size of the patient safety problem and the low rate of detection now in place.
The study found there to be at least ten times more serious confirmed events than events detected by existing methods. Perhaps, part of breaking the mindset that refuses to prioritize this issue is to start with a measurment method that does a much better job of detection than current methods in general use.
I read this torn between agreement and protest.
On the one hand, IMHO there are more important things in HC than increasing the level of patient safety, at least when safety and safety measures are not well defined. I would say thatworking on coverage issues and spreading a healthy lifestyle are far more worthy of a major effort. Overtreatment is another more important issue – the unneeded surgery that does not happen is still safer than the safest improper surgery.
OTOH, Mr. Levy is a former hospital administrator, and administrators should be concerned about safety – as should be physicians, who should be advocates for the other issues I mentioned, too.
But one question is, when talking about safety, how much bang you get for the buck. We don’t do everything in society to prevent any possible injury if there is a mismatch between magnitude of investment and risk averted.
Amen, amen. I would just qualify one thing, however – the responsibility is not only with hospital and other leaders – it is shared by physicians, nurses, and others who see the insides of how American healthcare is done, and turn a deaf ear and a blind eye rather than demanding the system be reformed. It not only starts at the top, as the article suggests…but in each clinic, every small or large hospital. None of us is excused for tacitly accepting this unacceptable status quo. The airline industry proves pristine safety can occur on a grand scale; it’s high time we demand the same standard of excellence in healthcare.