Wednesday, January 28, 2009

The fear of transparency clouds all

I have been worried lately that I may have adopted radical views on quality and safety in hospitals, that I may be out of the mainstream of American life when I suggest that we should jointly determine to eliminate certain types of infections or engage in protocols to enhance patient safety. I was also worried that my insistence on the importance of transparency with regard to these issues was just too outlandish for people to absorb and accept.

Imagine my relief then, to read this editorial in USA Today. Hardly a radical journal, the editors write:

Too many Americans go into hospitals for treatment and end up getting sicker....

A greater sense of urgency is needed....

Why are infections so widespread? In part, of course, because hospitals are full of sick people and germs. But medical professionals, hospital administrators and government regulators are failing to demand adherence to actions they already know will protect patients....

Secrecy allows the problem to fester. Although 23 states require hospitals to report infections to one of four unlinked federal databases, reporting is so scattershot that there's no way to determine whether the problem has been getting better or worse.

On the comments under the post below, some of the world's experts on quality and safety offer their perspectives on this issue. What is it about the medical community that makes it so hard for these views to be accepted? A close colleague writes to me saying, "I imagine the fear of transparency clouds all."

Look at the numbers in the editorial: Tens of thousands of deaths from often preventable infections. We -- and I mean the academic medical centers in general -- rely too much on our reputations. It is beyond time to hold ourselves to a higher standard. As I have said before, if we fail to do so, it will be done for us and to us by legislative and regulatory action, and such action is bound to be less accurate and helpful than the kind of self-reporting I have advocated here.


WDavidStephenson said...

Paul: my cousin went to hospital that every yr. is honored as best in world for minor back surgery, almost died & impaired for life by infection she got there.

This has to be collaborative effort by all involved, including patients: when wife was patient recently at her own hospital (stone's throw from you) she insisted docs [they're worst], nurses, etc., wash hands in front of her.

Good argument for my "democratizing data" crusade: infection stats should be publicly available, real-time.

Anonymous said...

Strongly agree. It's time for a lot of healthcare organizations and physicians to hold themselves up to any standard at all *other* than their institutional and personal reputations.

The problem is in most organizations physicians are in charge, and they have no motivation to do anything that doesn't improve their reputation, much less something that might hurt it.

Anonymous said...

The adoption of "Universal" precautions in the mid 1980's (as a response to the general hysteria re HIV at the time) was the beginning of the end of mindful technique. The concept of cross-contamination of surfaces went out the window, replaced by an obsession with putting on a pair of gloves to protect oneself.

For example, a clinician may take a set of vitals on a bedridden patient. S/he will have donned gloves to do this, but then s/he will go to the bedside chart and with same gloves on, pick up a pen, handle the chart, and discard the gloves afterwards. Likewise with drawing blood---with the same gloves on, the nurse will bag the blood, so instead of the outside of the bag and the requisition being "clean" surfaces, they are now all the same. The icing on the cake is taking the specimen to the tube station to send it to the lab, pulling a tube out with same gloved hands, and sending the now contaminated tube on its merry way.

If watching the clinical staff is scary, try watching transport and housekeeping for an even more chilling experience. For example, transport will put on gloves to help get a patient onto a stretcher and then with the same gloves on grab the chart from the unit secretary and proceed to the elevator with gloves on, where the elevator buttons will be pushed with the same gloved hands. The confusion about procedure is even scarier when the patient is identified as falling into a precaution category other than universal.

My experience with observing this began when my immunocompromised child was hospitalized in a premier pediatric institution. The housekeeper came in to clean and started in the bathroom. After cleaning the entire bathroom, she then proceeded to clean the room. She did not change her gloves! I watched in horror as she approached my daughter's bedside table. I tried to keep her from touching anything on the table, but she did not understand English. I pointed to her gloves, and she seemed for a second to understand my objection, but then dismayed me by holding up her gloved hands and saying "me protect", which was apparently the only part of her training that she had absorbed. I finally got her to move on (still gloved) and recounted this to the nurse who was mildly concerned but used the language barrier as an excuse not to try to intervene/educate.

Besides my observations as the parent of a chronically ill child, I have worked at several major teaching hospitals, and have not seen any place where proper technique was used.

Anonymous said...

Given half a chance, most physicians will embrace transparency if it improves care. Being a doctor involves adoption of a moral principle that commands the doctor to place the needs of patients before his or her own convenience or interests. The challenge is finding performance markers that truly measures performance and does not create an incentive to act unprofessionally. Take mortality rates following certain types of surgery. These are one of the earlier forms of health care transparency. They’ve had the unfortunate consequence of penalizing surgeons who are willing to do everything to save desperate cases. Operating on emergency patients with high preoperative mortality adversely impacted survival rates and hurts the surgeon’s image. Despite this incentive to first do nothing, the vast majority of surgeons have stood true to their professional ethics and do what it takes to give every possible chance to their patients. Ultimately performance markers will evolve to take into account the specifics of the population that’s care is being measured. But premature posting of markers that do not accurately reflect care can do quite a bit of harm.
Transparency using ill structured markers has left many providers with a distrust of the process and this is where you find physician reluctance, not in the desire to protect image. Trust in physicians in the United States is poorer than in any country in the world, yet health care does not work without patient trust. I agree that we need transparency to trust but verify. But we also need to proceed cautiously to be sure we are measuring true performance and outcomes.

Anonymous said...

Paper from National Bureau of Economic Research:

"We find that the mean valuation of amenities is positive and substantial. From the patient perspective, hospital quality therefore embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital's demand by 38.4% on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality."

Sigh. So much for transparency on quality.


Anonymous said...

Your work at Beth Israel is a model for increasing transparency in medical practice. As the infection issue demonstrates (just as in the recent article in the New England Journal of Medicine on surgical checklists reducing complications), so many complications, illnesses, and death can be prevented. Iatrogenic causes of illness are such a substantial burden on the health care industry and consumers. We need to do everything we can to eliminate and prevent them.

Thank you for your continuing efforts in this department.

Anonymous said...

Ah, we can't consider that the purpose has much or anything to do with patient choice -- although maybe some day it will. It is about holding ourselves accountable to a high standard of care.

Anonymous said...


But that's why our healthcare system is so fundamentally messed up - when these smaller hospitals in Boston of which you speak are desperately trying to compete with Partners, they read an article about amenities increasing demand by over 1/3 (but not mortality) and they have only so much money to spend. Are they going to spend it on quality of care or amenities?
I know - you can only do what you can do and I certainly agree with your trying. But the incentives, as always, are incredibly perverse.


Anonymous said...

Right in so many ways, but we actually find that quality and safety improvements save money. There is a good business case to be made for them.

Anonymous said...

Thank you so much for this post. I wish I could get it in every office and hospital. I'm sorry but in the $$$ driving medical culture, these sorts of things take a back seat to not "doing the right thing" in regards to patient safety and health.