Sunday, November 13, 2011

Mr. Ness, everybody knows where the booze is.

A quality-driven MD colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  "I suggested that instead of being embarrassed, maybe we should OWN the data." This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the "the lawyers will not let us do this."  S/he wonders, "Who, exactly, is our primary concern?"

At another meeting, the chief nursing officer asked why there had not been more progress made with regard to central line infections in the ICUs.  It turned out that there had been meetings with  the bedside staff which identified a number of problematic workarounds they had created. However, the team was limited in what they could do because decisions about equipment and kits are made based on cost, away from the bedside. The CNO was upset because the local folks had not shared with her what they had already done and wanted to know why they hadn't told her about these problems – while acknowledging she couldn't do anything about them.

My friend summarized: 

I explained that if she wanted to find out what was going on – she need only walk onto the unit and ask.

This all reminds me of the scene in The Untouchables. Elliot Ness talks about busting Al Capone if only he knew where he was making his booze. Sean Connery's character (Jimmy Malone) takes him to a post office across from the police station.  Ness can't believe the booze is there. Malone says, "Mr. Ness, everybody knows where the booze is. The problem isn't finding it, the problem is who wants to cross Capone."

The problem isn't knowing HOW to fix this problem. It's doing what it takes to accomplish that -- over-ruling the lawyers and accountants and doing the hard-work to change the culture. This can't happen if the C-suite leads from meeting rooms.

These stories exemplify the huge cultural schism in the country between the minority, those institutions that have taken on the quality and safety agenda and internalized it into their decision-making and process improvement efforts, and the majority, the ones that have not.  Each year at the IHI Annual Forum, I hear from nurse managers and young doctors asking, "What can I do to get my CEO/CFO/CNO/Board of Trustees to support us in what we know must be done?"

I want to state this as clearly as possible:  The leaders of academic medical centers and medical schools are failing to be the leaders the country needs at this time. In their failure, they sow the seeds of burdensome governmental and regulatory requirements, for those in policy positions will see the vacuum and will fill it. In their failure, they persist in accepting the view that "these things happen," and are personally -- yes, personally -- responsible for thousands of preventable deaths and injuries each year.  This is the most significant ethical issue facing the profession, and they simply fail to accept responsibility.


Bruce Ramshaw said...

From Facebook:

Again Paul- you get it. We had to start a new academic medical center from scratch because of our lack of ability to do it within established academic medical centers. The study of disruptive innovation makes it clear that creating new disruptive organizations is what is necessary- it cannot happen within the established industry leader organizations. At least, not at this point in history.

Lee Tilson said...

From Facebook:

Saul Alinsky had solutions for circumstances like this.

Chris said...


so if the leadership of these organizations are failing the question is, "what's the next step"?

It would seem that leadership needs to be replaced with one that is more patient-centric and owns its problems, not hides behind them.

But how does any one person or group make the case against a power block like this? It would seem that while dangerous that building the case in the community would be the best way.

Or must the focus be on disrupting them by investing ourselves in new and needed segments?

What do you think?

Paul Levy said...

Hi Chris,

Lee (above) suggests the former, in essence, when he brings up Saul Alinksy, the mentor of all movements.

Others, like Clay Christensen in The Innovators Prescription, suggest the latter.

Let's see what other commenters think about this.

e-Patient Dave said...

When you mentioned the small group of facilities that have taken the lead in quality initiatives, I thought instantly of Cleveland Clinic.

Then I thought, they just STOPPED their most public reporting of their quality shortcomings. (Of course they didn't call it that, but that's what they did.) Clearly for them something is more important. (They cited costs, but if that's their best current opportunity to control costs, they must be really amazing.)

Have you thought of reaching out to Dr. Cosgrove there and asking "What's up???"

wrinkledman said...

The kind of selfishness you describe is endemic to human nature. People don't want to admit mistakes or weaknesses and "leaders" who can cover up, do. Penn State is just the latest high profile example. These people are the disease that will kill us and they populate the boardrooms throughout the country. I have two words "the bastards" I find myself using on a pretty regular basis. Health care should be different, but so should education, religious ministry, banking even. I hate to say it, but the older I get the more resigned I become to corruption in character. The bastards!

Tom Emerick said...

Many employer health plan managers have been aware of the shortcomings at academic med centers for years. A small but increasing number of employer-sponsored plans are using plan design to "steer" certain types of patients away from academic med centers for those reasons. Watch for this to grow significantly going forward.

Anonymous said...

I'm not surprised that data has not made so great a difference as it should. There is no accountability for provider reporting, nor street-level connectivity to make the numbers meaningful to the public.

It isn't data but ideas and beliefs (self-motivated and self-deceptive, among them) that drive what people do. Take a poll down a street, "If you are very sick, what hospital would you go to? Why? What do you know about safety in the hospitals in your community?" The first two questions will contain some element of safety - but ask the source, and it will be a story, not a number. How many can tell where such data exists?

Those who know, know that sparkling lobbies, bustling halls, and engraved lists of donors have no correlation to the complex safety behaviors that happen to a person in bed with lines and machines and layers of medical care. People respond to salient features of the environment that are reassuring - and to the gossip currents in which they live. It is about trust, and disrupting misplaced trust should be as central to patient safety efforts as producing good data itself.

What would Occupy Healthcare look like?

Anonymous said...

I recognize the hospital that your friend practices in - because I and most docs in the country have also practiced there.

Anon 12:12 has it dead on as to why this situation perpetuates itself. Occupy Healthcare - now THERE is a real thought........


Anonymous said...

Like many medical centers, we are undergoing a multi-million dollar expansion. The market surveys suggest we can fill those beds so it is financially advantageous to build it...and we are building it in a manner that will recreate our current inefficient and unsafe processes - just add beds. If we spent 10% of that to improve existing systems, we would save hundreds of lives. Wonder how it might be received for MDs and RNs to protest at the construction site for improved care for our patients...

Beverly said...

From Facebook:
How interesting that you (Lee) should mention Alinsky; a quote from his 'Rules for Radicals" which seems to apply:

"There's another reason for working inside the system. Dostoevski said that taking a new step is what people fear most. Any revolutionary change must be preceded by a passive, affirmative, non-challenging attitude toward change among the mass of our people. They must feel so frustrated, so defeated, so lost, so futureless in the prevailing system that they are willing to let go of the past and change the future. This acceptance is the reformation essential to any revolution.'

Anonymous said...

While we wait for Human Nature 2.0, we can see these kinds of quality problems fixed if the money flow works the right way. Kaiser, the mother of all ACOs, has made dramatic improvements in quality. Why? Because poor quality, e.g. central line infections and the like, is really expensive. If the org is both the provider and the payor, somehow leadership in the Kaiser health plan, care delivery (nursing mgmt), physicians, unions (nurses et al), and companies/orgs with Kaiser health plans see the light and change comes. Academic medical centers have no such combination of financial incentives.

I agree with you that from an ethical standpoint, the failure to act is appalling. I guess it's not appalling enough to academic medical center leadership unless they or their loved ones are lying in the bed when someone comes in to treat them and doesn't wash hands or change gloves...