Sunday, September 23, 2012

Unaccountable

Many of you may have seen the recent article by @DrMartyMD, Marty Makary, in the Wall Street Journal, "How to Stop Hospitals from Killing Us."  The lede:

When there is a plane crash in the U.S., even a minor one, it makes headlines. There is a thorough federal investigation, and the tragedy often yields important lessons for the aviation industry. Pilots and airlines thus learn how to do their jobs more safely.

The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers.

The article is drawn from Marty's recently published book UnaccountableThis trailer will give you a sense of the themes.  He notes:

It does not have to be this way. A new generation of doctors and patients is trying to achieve greater transparency in the health-care system, and new technology makes it more achievable than ever before.

I hope so, but I don't know.  For several years, I have joined Marty, Peter Pronovost, Brent James, David Mayer, Lucian Leape, Jim Conway and others in advocating for changes in medical education, in clinical process improvement, in transparency of clinical outcomes.  Those changes are all necessary conditions for a transformation of this industry, not only in the US but in all developed countries.

Unlike these people, I come to this field with a background in other industries, much more than in health care.  I have seen and participated in the transformation of other sectors, where the hope was that changes in technology would render previous industry patterns unsuitable.  Whether with gentle or forceful steering from the government, it was hoped that the disruption in those industries would result in more customer choices, greater value for each dollar (or pound or peso) spent by consumers, and an overall improvement of efficiency for society.  The results in those other fields have been mixed, as is perhaps inevitable when any major sector with extensive vested interests is perturbed.  But we can often see some change in the hoped-for direction.

But I have yet to encounter a field that is as recalcitrant to change as health care.  While filled with people of the best intentions, intelligence, and extensive training, it is also characterized by self-satisfaction, denial of the underlying problems, and arrogance.  Thus far, too, the patient advocates who have tried to cause improvement have not been unified or effective in purpose and plan.  Thus, there does not yet appear to be a solid, sustained constituency for the result Marty predicts.

Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger:

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

9 comments:

Anonymous said...

A friend recently said, "Repeat something 3 times and most people will get it by then." You have made this point in your blog way more than 3 times. I remain firmly convinced that rapid change will occur only when some 'sentinel event' happens involving a particularly egregious error to a child or a celebrity, or a damning book emerges, which will turn public opinion against the industry and force change. Perhaps this will be the book; I plan to order it.

nonlocal MD

Laura Henze Russell said...

I am with you on this. I am writing a companion piece likely to be called, "How to Stop Dentists from Killing Us."

Last week I went to Minneapolis to attend the International Academy of Oral Medicine & Toxicology Conference. IAOMT's motto is "show me the science."

Show me they did, all the latest 2012 papers from the US and abroad finding definitive links between toxicity from mercury amalgam dental "silver" fillings and chronic diseases across the age spectrum, from Autism to Alzheimer's. Mercury amalgam is particularly toxic for those with the ApoE4 gene, who do not clear mercury well.

Even Woods, the lead author of the Children's Amalgam Trial in Portugal, has retracted his earlier finding that amalgam has no health impacts in children. When the outliers are removed, amalgam is strongly associated with urinary porphyrin damage, en route to its silent but deadly journey as a hidden river of toxins in US.

Meanwhile, the world is still flat at the ADA, FDA, and NIH Dental and Craniofacial Institute, which considers mercury amalgam, that has been proven to off-gas toxic mercury vapors in the presence of heat and abrasion, a "safe" prosthetic device in our teeth.

As a consequence, most dentists don't know. If they do, they keep quiet, because the ADA Code of Ethics has clauses expelling dentists who promote removal of amalgam for health reasons.

Dental plans only pay the cost of putting amalgam back in the back of your mouth, even with medical proof of mercury toxicity, because it is not in your "smile area."

Hidden River Cloud Network/One Challenge is a social innovation enterprise that has launched SafeAMER, asking people to consider and investigate the issues, risks and safer alternatives to mercury amalgam in dentistry in the coming year. Help us prove or disprove the hypothesis that it is a factor or co-factor in about 20 percent of chronic disease, and at least 20 percent of health care and long term care costs in the U.S.

It is time for crowdshifting to focus on health, not disease management. That's how we do it.

See www.oceanriver.org/hiddenriver.php and www.facebook.com/hiddenriver.

fairhavenhorn said...

I'm both more and less optimistic. My first experiences were with the introduction of modern manufacturing and quality methods to the US automobile industry. It took decades, and the resistance was at least as tough as that in the medical sector.

The major difference is that unlike the automobile sector, the US healthcare providers are not directly threatened by a better competitor. This will make it harder and take longer.

John A. Lynch said...

I'm afraid your skepticism is well-placed and your impatience all too appropriate, even essential if we're to ever overcome the industry's lethargy regarding patient safety.

We keep hoping our providers will somehow see the light and make the kind of commitment needed to make significant improvements in patient safety. A relative handful do, but the mainstream of medical practice in America remains largely indifferent - too preoccupied with self-interest to remember their fiduciary duty to put their patients first.

My belief is we'll only make progress by refocusing on patients themselves. If patients were taught to fear the dangers from their medical interventions as much as they fear disease, we'd begin to see some demand side changes in how medical care is so clumsily delivered.

Dr Stephen E Muething said...

Paul,
Thank you as always for your thoughtful prodding. I share your impatience as we continue to focus on the harm occurring in children's hospitals. With that said, I'll share that I am more optimistic now than I was a year ago. In the last year, 25 children's hospitals have joined the 8 Ohio children's hospitals with a shared goal of reducing serious harm across our organizations by 40% by the end of 2013. This is part of a hospital engagement network though Partnership for Patients. For the first time these organizations are sharing data on harm with each other, sharing best practices and learning real-time from those that seem to be doing better. We have a long ways to go, but our CEO's have committed to this shared goal and the transparency that is allowing us to accelerate the learning. And now leaders are agreeing to take on culture by adopting common error prevention behaviors and leadership methods across our hospitals.
Healthy skepticism is reasonable, but we also have some healthy optimism as we can start to see a method to change our course. I'll keep you informed as we move forward.
Dr Steve Muething
VP for Safety
Cincinnati Children's Hospital

Anonymous said...

Medical errors occur at many levels, from the unsupervised technician, to the overburdened nurse assistant,the under-staffed RNs to overworked physicians.

I work now in the acute care setting as a "mid-level"provider but worked for over 15 years in nursing. This is what I see: care-givers at all levels, show up wanting to do a good job, but the staffing (determined by administrators)often makes truly "good care", which is also safe care, virtually impossible.

High nurse-to-patient ratios leave patients at risk for adverse events like falls, development of pressure ulcers, development of catheter associated infections, and development of central line infections. As you know these are the reasonably avoidable, so-called "never events" or serious reportable events.

So why do they occur? Human limitations. There are only so many tasks a person can effectively complete in 8 hours. It does not take a research study to figure this out; better staffing among housekeeping, nursing assistants, nurses, nurse practitioners and physicians would make for better care.

We all talk a lot about patient safety, but when budget time rolls around, do administrators care what the nurse-to-patient ratio is? When you are a patient (and we all will be) do you want your bedside nurse to have 4 patients or 8? How do you think patients get hospital acquired pressure ulcers? If a patient cannot effectively move on their own, someone else must move them, clean them, and see to their nutritional and medical needs.If a nurse has 5 or 6 patients and even one needs this sort of "complete care" and, there is only one nursing assistant for 30 patients, does the immobile patient receive the level of attention required to avoid a pressure ulcer? Most of the time, they do. But when they do not, a painful costly wound develops. A goal of having a nurse-patient ratio that does not exceed 1:4 and adding more nursing assistants would make a difference.

I know adding staff is expensive but surely in the end, if one stage III pressure ulcer is prevented,(or one CAUTI,or one fall etc.) a couple of those staff members will have, in effect, paid for themselves--By preventing just one " never event". It makes sense to me--but I am a clinician, not an administrator.

If the public knew which hospitals had lower nurse-patient ratios, the beds would always be filled.
DD

Paul Levy said...

Thanks, DD, for this perspective. I appreciate the point of view but disagree. I do not think the issue is nurse-to-patient ratios, but rather the manner in which work is organized in most hospitals, which is to say, highly inefficiently. HBS' Anita Tucker has shown that nurses spend, on average, 20% of their time with patients. The rest--not because of them, but because of a poorly designed work environment--is spent fetching and in other non-productive activities, along with some compulsory ones.

So before we can decide what is the "right" nurse-to-patient ratio, we need to engage in a real assessment of how the work environment can be improved. On that front, the nurses themselves often have the best ideas. Management has to learn how to listen to them and empower them to help make the changes necessary.

Judy said...

From a quality and safety chat room:

Until we have protected, mandated error reporting, like aviation, we will really not know the dimension of the problem, or the possible solutions. I’m not convinced the problem is getting worse or better – we simply don’t know. It is certain that there IS a problem with harming patients, but that’s about the only conclusion we can safely reach.

It is disheartening to chase this undefined dog’s tail. There are so many contributors to lack of standardization in American healthcare, and that lack of standardization contributes to error. There are also huge gaps in understanding error sources when we have a peer review system that keeps physician-specific errors behind closed doors while publicly reported measures put hospitals out in the public eye. Then, of course, there is tort law and its influence on transparency and learning from error.

One more book for us all to read that shames American healthcare. I’m not sure that’s what we need to shift the movement to accountability and eliminating preventable harm.

Anonymous said...

I have to agree with Paul that hiring more people, be they nurses or other providers, is not the ultimate solution. Aside from his well-stated remarks that poor process design is the real culprit, the brutal fact is that we simply cannot afford it. Health care already is one of the most labor-intensive industries in the country (world), and labor is of course THE biggest expense for any endeavor. That's why those 'unfair' administrators are paying so much attention to nurse/patient ratios.
Until the industry learns to do its work more efficiently AND effectively with less people, we will continue to kill patients and throw money away which could be used to save more lives.

nonlocal MD