Wednesday, November 16, 2011

Tell us the lessons, UPMC

Way back in May, I suggested that a botched kidney transplant at UPMC, for which a nurse and doctor were blamed, was "not totally a person problem," but more likely reflected systemic issues in that hospital.  After more information came out, I suggested that UPMC should "attack the problem, not the people." 

Well, the Pittsburgh Post-Dispatch now reports:

[A] federal agency on Tuesday put UPMC's transplant program on probation, a rarely used form of discipline handed down for some of the most serious transplant errors.

The federal Organ Procurement Transplant Network (OPTN) said it meted out the discipline not only because of the kidney transplant error, but because UPMC's transplant program was found to have problems in its communication and documentation procedures before.

And look at this,

OPTN's president John Lake said in a statement Tuesday after an OPTN board meeting in Atlanta, where the decision to discipline UPMC was reached. "The University of Pittsburgh Medical Center has identified a need for process improvement in communicating key clinical information among transplant staff members."
Hmm, so what happens to that doctor who was demoted and the nurse who was suspended?  Do they remain scapegoats for an institutional failure? If this was an institutional failure, shouldn't the Chief of Service, the Chief Medical Officer, or the CEO of the hospital suffer some form of sanctions?
The answer, obviously, is that none of them should have been or should be punished:  This should be viewed as a learning opportunity for all, both inside UPMC and more widely.  Early on, I said, "It will . . . be revealing to see if UPMC shares the results of what they learn more broadly with the transplantation community."
The question remains as to whether UPMC will broadly and helpfully explain to other transplant programs around the country what they learned from all of this. Perhaps OPTN should make that a requirement of getting off probation.


Josh said...

Why not punish the C-suite administrators that are responsible for systems development and administration? If they are always found blameless, how is there any impetus on their side for improving their performance and, more importantly, listening to those below them who are aware of the systemic problems?

Anonymous said...

Without knowing how egregious individual behavior was in this case, I'm reluctant to judge that punishment is not appropriate. The word is wrong - but consequences for ignoring safety protocols is what is missing in most of medical care. Rarely are internal leaders held accountable at ANY level of organization for safety. There are no systematic reviews of individual safety performance, no incentives for reporting, and no recalibration of power relationships in care settings that allow subordinates to challenge providers without risk.

Accountability is what we need from everybody. What would be fair, probably, is if that x% of the organization who put safety below other interests to be fired alongside. But who would run the hospital? My vote is for social workers and providers who pass a Institute of Healthcare Improvement stamp of approval.

Has it escaped anyone that communication failure was a root cause? Now that is where we need an improvement revolution.

Anonymous said...

I want to say first I wholeheartedly agree (once again) with Paul's point in his last paragraph. But to the specifics, it is my understanding that a positive donor lab test for hepatitis C was missed in the record. Missed lab/pathology abnormalities are a glaring system problem crying out for a systemic solution - as a pathologist, I was involved in myriad examples, some even fatal. There are innumerable variations - presurgical results, post-discharge results, critical values not called, or called but not acted upon, etc.

Paul's point about an earnest collaborative effort to solve this problem in a transplant program, if successful, would help thousands of patients way beyond transplants. Why are we still trying to solve problems in silos???? Once again, what will it take?????

nonlocal MD

Anonymous said...

Everyone knows when the proverbial feces hits the fan it flows downhill.

Right now there is a great turmoil in the Pittsburgh market in healthcare. UPMC's only major competitor is West Penn Allegheny Health System, who had gone through bankruptcy and reorganization from extremely poor management and bad decisions.

Highmark BCBS has formed a "Partnership" with WPAHS to help maintain the system.

UPMC now refuses to renegotiate with Highmark for its own hospitals. There reason is that an entity should not be in the health care business (which UPMC does with its own UPMC insurance) This leaves thousands of Highmark customers without access to many specialty hospitals in June 2012.

UPMC actually building a hospital one half a mile from an established hospital in Monroeville PA.

I actually have to post this anonymously because of fear of retribution.

Paul Levy said...

Dear Anon,

Thanks for your comment. I excerpted out your comments about individuals, which I do not permit here.

Barry Carol said...

I think too many hospital managements view everything from their cost structure to their care systems as proprietary information. If they’re really good at something, they view it as a competitive advantage that shouldn’t be shared. If they make a mistake and learn how to fix it, they don’t think they need to share that information either regardless of how much the broader healthcare system might benefit from the lessons learned. Perhaps what’s needed is something akin to the National Transportation Safety Board that investigates airline crashes and serious accidents and communicates its findings to the rest of the industry as well as the public.

Anonymous said...

I second Barry's astute (as always) comment. There is always an excuse for hiding the information, most recently HIPAA.
The one thing an injured patient wants MOST is for this never to happen to anyone else. All of us who have had experience with such patients know that. There should be mandatory disclosure of errors and all the intelligence of our medical community should collaborate to fix them. The problems are exactly the same in every hospital; anyone who's worked in one can tell you that.
Why make this so hard? As Barry implies, one begins to suspect business motives prevail, rather than the reason why we are all in this profession.

nonlocal MD

Anonymous said...

It is of course a great idea to share learned experiences from our mistakes. However, confidentiality issues will be an issue.

Paul Levy said...

Whoa, see nonlocal's comment.

It should be quite possible to tell the story of the root cause here without violating anyone's confidentiality, especially when you consider what has already been disclosed and printed in the press. If there is some sensitivity about some details, perhaps the patient/family would be willing to sign a waiver, for the good of future patients. It would sure be worth asking, as many patients who have suffered harm feel that they can have a role in helping to prevent it in the future.

Let's not go into this assuming that it CAN'T be done; rather go into it deciding that it MUST, for the sake of future patients.