Monday, May 12, 2014

Transparency is not about competition

Cheryl Clark at HealthLeaders Media has an excellent story about how making hospital clinical outcome data public affects providers. It speaks positively about the efforts of my former hospital in this regard and quotes the hospital's chief quality officer:

"But transparent reporting's strongest impact has been internal. There's the overall message that we're confident enough in our performance to share information publicly, and the accountability that it signals. It's generated a series of conversations about what we want to make sure we're doing well at, that we're tracking it."

This point echoes a theme I stated back in 2008, based in great measure on something I learned from Jim Conway, which he picked up from the work of Peter Senge in The Fifth Discipline:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

I do have to correct some misstatements in the article, though.  It suggested that our early forays into transparency of clinical outcomes began in 2003, and that the impetus was the following:

Commercial reputation seemed to suggest BIDMC's competitors were better hospitals, "but when we looked at the data, it didn't look that way to us; it looked like we were the same or better. So we felt there was nothing to lose by creating a more level playing field, by making the data available."

Not at all the case.  First of all, the year was 2006, and not 2003, when I began posting real-time central line infection rates on this blog, followed by other metrics, based on great work by our clinical leaders.  And this had nothing to do with competition.  I wrote these pieces because I was really proud of our progress on these clinical issues.  Also, consistent with the points made above, our Chief of Medicine, VP for Healthcare Quality, and I felt that transparency would lead our staff to hold themselves accountable to a higher standard of care.  Our staff had few or no objections, as they felt comfortable that the data were accurate and were not being used to blame anyone for lapses in performance.  The mantra became, "Let's be hard on the problem and soft on the people."

Our Board of Directors, again with advice from Jim Conway but also from Lee Carter, then chair of the board of Cincinnati Children's Hospital, and MIT's Steven Spear, soon got on board and made a huge commitment to the elimination of preventable harm and to the publication of quarterly figures summarizing harm on the corporate website.

That's how it happened.  It required no governmental mandate, just a commitment from the administrative and clinical leadership, supported by the governing body of the hospital.


Anonymous said...

I remember your reporting back then; it was an important advance. Kudos on your efforts.
Doctors in particular have always had a horror of this sort of transparency; thinking the numbers will be misunderstood, and sometimes they can be. But isn't it better to present the data yourself so you have the opportunity to explain its nuances, than to have it presented by someone else?
As for the comment in the article that hospital websites get few hits, perhaps that is because they present advertising rather than data.

nonlocal MD

Anonymous said...

For me, a trainee at the time, the most important effect was that it underlined a shared sense of mission and purpose around quality improvement. The reporting didn't have a big direct effect on my practice--I just tried to learn how to put in central lines the right way, while my elders had already defined what the "right way" was. The indirect effect was as part of a sense of purpose, though. The absence of a sense of purpose of this kind is toxic. For instance, if you have an advertising campaign that emphasizes our kindness or humanity, but we have no policies or practices that distinguish our kindness or goodness from anyone else's, it may be persuasive to our market as a branding tactic, but it's actively alienating to those of us who work within this system. Conversely, if we walk the walk more than talk the talk, it's inspiring. Posting the data probably influenced very few patients one way or another--but it definitely made many of us feel like we were walking the walk.

Paul Levy said...

Oh, wow, so elegantly put. Thank you!!