How the veterans are winning the war

At a seminar last night at the Center for Public Leadership at Harvard's Kennedy School, one of the students asked a question along the lines of, "How do you know when you have done too much with regard to transparency?" My answer was that the question presupposed the wrong approach to transparency, that it was being driven by the CEO without proper attention to the efficacy and appropriateness of what was being measured and disclosed. Instead, I suggested that it should be driven by the leadership of the organization, but based on metrics that were viewed as useful and appropriate by the clinical staff. In such an instance, transparency serves the function laid out by IHI's Jim Conway, as summarized here in an article discussing the BIDMC experience:

[P]ublic reporting created what management guru Peter Senge calls creative tension, a key in getting an organization to change. Announcing a daring vision — the elimination of patient harm — combined with honestly publicizing the problems, fuels improvement, he said.

I expressed the concern last night that the general recalcitrance of the medical profession about engaging transparency will inevitably lead to fiats about disclosure from government regulatory agencies. The problem with those fiats is that they will be grossly constructed and force hospitals and doctors to focus on the wrong things, in a manner not consistent with widely established principles of process improvement. (See, for example, this approach in Maryland.)

Now comes the Veterans Administration, proving the case with panache! You may recall my complimentary post on the VA back in January. Thomas Burton's article this week in the Wall Street Journal -- "Data Spur Changes in VA Care" -- documents this in more detail. Some excerpts:

Hospitals serving U.S. military veterans are moving fast to improve care after the government opened a trove of performance data—including surgical death rates—to the public.

The information was released at the urging of VA Secretary Eric K. Shinseki. Among other things, it presents hospitals' rates of infection from the use of ventilators and intravenous lines, and of readmissions due to medical complications. The details have been adjusted to account for patients' ages and relative frailty.

"Why would we not want our performance to be public? It's good for VA's leaders and managers, good for our work force, and most importantly, it is good for the veterans we serve," Mr. Shinseki said in an emailed statement.

At VA hospitals in Oklahoma City and Salem, Va., the rate of pneumonia acquired by patients on ventilators was shown last fall to be significantly higher than the national VA average. The Salem hospital says a relatively low number of patients on ventilators skewed its infection rate higher, but staff members at both facilities say the numbers prompted action.

Seeing the data helped, says the Salem hospital's chief of surgery, Gary Collin, because "you can become kind of complacent."

In contrast, notes the article:

This unusually comprehensive sort of consumer information on medical outcomes remains largely hidden from the tens of millions of Americans outside the VA system, including many of those in the federal Medicare system.

And, as I reported last month,

A November 2010 report from the Health and Human Services inspector general concluded that one in seven Medicare patients is harmed by medical care, nearly half of those avoidably.

Conway is right. Senge is right. The veterans have figured out how to start winning the war for patient safety and quality and process improvement. The rest of the profession is in retreat and is letting the wrong people design the battle plan.