Monday, May 09, 2011

Let's just keep killing and maiming them

Old patterns die hard. Back in March 2010, I posted a chart from the ACHE that Jim Conway had sent me showing a decrease in the ranking of quality and safety among priorities reported by hospital executives.

Now comes an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled "The State of Patient Experience in American Hospitals." Of those places surveyed, 51% were individual hospitals and 49% were hospital groups or systems. There was an even mix of urban, suburban, and rural facilities.

As in the prior ACHE survey, 69% of hospital executives rank things other than quality and patient safety as top priorities.

Any way you look at it, this is quite simply a failure of leadership and governance in American hospitals. There is a strange adherence to the view that "these things happen," an apparent belief that a certain level of harm that occurs to patients is just the way things should be. It is as though the medical profession, hospital administrators, and hospital trustees have decided that the current amount of harm is the statistically irreducible level.

In contrast, I quote again from Captain Sullenberger, who notes that such an attitude is impossible to imagine in other fields, like air transport:

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country."

Those of us who have participated in systematic improvements in the way work is done in hospitals understand that America is nowhere near the "statistically irreducible" level of harm. As Sully notes,

"We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

There are thousands of people at lower levels of authority in hospitals who want to improve the situation, but they are stymied. I can't tell you how often nurses, nurse managers, and junior physicians have come to me at conferences and said, "How do I convince my hospital leadership to take an interest in this and support us?"

The leadership for improvement has to come from the top: Hospital CEOs, clinical chiefs of service, and boards of trustees. To date, the American hospital leadership is failing in this regard. Maybe they should be required to say every day, "Let's just keep killing and maiming the patients. After all, they are just statistics, not real people."


Mark Graban said...

The ACHE data has always shocked and disappointed me.

Dr. Deming said "quality starts at the top." Many hospital CEOs apparently believe quality and patient safety are a detail to be delegated.

You, John Toussaint, and a growing list of CEOs believe that the buck stopped with them. Paul O'Neill was a great example of that with his CEO leadership of safety improvement at Alcoa (a concept he brought with him to healthcare and PRHI).

Healthcare leaders, including the CEOs, need to start actively participating and shaping their cultures. We need cultures that support safety and quality (as you were working toward at BIDMC) instead of CEOs just blaming individuals and throwing people under the bus when harm occurs.

RalfLippold said...

Thanks a lot Paul for bringing the word. What applies to hospitals (with very severe consequences in some cases) also applies in general very often. People just treated as numbers in a game of profit.

People are people and we all should treat them in the way we'd like to be treated: honestly, helpful, and authentic.

Remember quite well first learning about your "challenge journey" at BIDMC on MIT World, If it can be done in the healthcare field then it can be done anywhere.

Mark thanks a lot for tweeting about this article on Twitter :-)

Anonymous said...

Pardon the less urbane tone of this comment, but it is ironic that we docs like to quibble over the strength of the evidence for patient treatments in evidence-based medicine. The evidence that there has been no improvement in patient safety is pretty darn clear. There are meetings, speeches, conferences, white papers, workshops, ad nauseum and nothing changes. Earnest people preach to the choir while the rest ignore the obvious.
I have commented before that it's going to take patients utilizing the tactics of the civil rights era to force action on a national scale. Perhaps it is no coincidence that this month is the 50th anniversary of the Freedom Riders. Read the Presidential Proclamation of this event below and see if it doesn't strike a chord. Hospital sit-ins and picketing, anyone?

nonlocal MD

Kathy Day said...

From Facebook:

The quote "these things happen" is exactly what I was told after my father was diagnosed with noscomial MRSA pneumonia, about 3 months before he died (at about half of his usual weight). That quote is condescending and arrogant. Like we pitiful family members can't figure out that it was preventable. There is no acceptable level of medical errors or hospital acquired infections. Zero is the only acceptable number because even at 1, there are is a human being who suffered and loved ones who are hurt by something preventable.

I love the idea of one of the people who commented that it will take something like a civil rights movement of patients to make a difference. I believe I have begun something similar in Miane, but I need a lot more people who are not willing to accept the killing and maiming up here in my corner of the US.

Mark Graban said...

@nonlocal - sign me up for the march. Or I'll help lead one in the Dallas / Fort Worth area.

Keith said...

Why should healthcare CEOs pay attention to quality if it seemingly does not affect their bottom line?

You have pointed out time and again that the dominant provider in Mass. does not have superior quality results, but gets rewarded most handsomely by the insurance middelmen with the highest payment.

In our wonderful capitalist utopia, it is the almighty dollar that speaks. As long as these dominant healthcare systems can make a good buck while not having to spend excess dollars to improve quality of care, they will continue buisiness as usual.

Many of our non profit institutions stopped acting like philanthropic organizations long ago and have morphed into tax exempt corporations that work mainly for the beneift of a select few (hospital CEOs and other key hosptial leaders) Exhibiting the shortsightedness of our financial wonks who brought on our great recession, they will continue their same behavior till the party is over, leaving their institutions morally bankrupt for a secure retirement.

Anonymous said...

This harm - mass experiment, really - on the US poplation deserves a civil rights movement. Does this make medical tort reform the parallel of dissolution of collective bargaining rights? Or Tuskegee, where the interests of almighty medicine would eventually be the hero, if you would just hold your arm still for this minor procedure


In the few corners where 'preventable harm' stimulated real thought a few years ago, there is little peep. Silent boards. Meek administration. Protective medicine.

Rest comfortably, knowing that the consent form was signed.

Barry Carol said...

When the CEO embraces patient and workplace safety and minimizing avoidable harm as a top priority, it can make a positive difference. Transparency and mandatory reporting are also helpful as they would allow both patients and hospital employees to see hospitals’ performance and trends both within the hospital and vs. their peers / competitors. Incentives matter as well. Patient safety metrics should be part of the equation that determines raises and bonus compensation. For physicians, maybe a much higher percentage of them should be hospital employees instead of independent practitioners who have “privileges” to practice at the hospital. It should be a lot easier to get cultural buy-in from employees than from independent contractors, in part, because employees can be fired if they can’t or won’t embrace the culture of continuous improvement in patient safety as well as other hospital priorities intended to improve care quality and mitigate cost growth.

Anonymous said...


As always, you make perfect sense. However, traditional incentive approaches applied to this arena are highly subject to gaming and manipulation. This is too important for that. When an airline pilot with no experience in the field (as well as the owner of this blog with no prior experience in the field) are the ones to observe "we are choosing every day..... how many lives should be lost in this country", or "let's just keep maiming and killing"; then we must conclude that the lack of change within the field is willful and tatamount to bigotry - patients apparently just don't matter. That goes way beyond simple business incentives.


Paul Levy said...

Nonlocal raises an important point. I don't think this is about money or financial incentives. Here are a few other things that turn out to be more important. (Remember, at our hospital we made major advances in quality and safety -- and by the way, cost savings -- with no care-related financial incentives, with doctors who were not employees of the hospital, and under a fee-for-service reimbursement system. In essence, we succeeded because we decided we wanted to. And then we learned together, with help from others, how to.)

To start with, there is something seriously wrong with the underlying culture and pedagogy of medical education -- both undergraduate and graduate. Lucien Leape has talked about this at length and has documented it.

But the problem extends beyond the education system. The failure of governance at many hospitals is so clear: Trustees who do not feel it is their role to hold the staff to a high level of performance with regard to eliminating preventable harm. The executive and medical leadership need to know that they will be both supported and held accountable on this front.

Then there is the recruitment and hiring of chiefs of service. The CEO and selection committee must explicitly call for expertise in process improvement as part of the search process. We did this, and it led to the hiring of academically superb people who viewed process improvement as part of their mandate.

This is not an all-inclusive list, but you get the point. Senior governance, administrative, and clinical leadership has to set the tone and the pace.

Anonymous said...

Board member responsibility as community representatives should be demanded for non-profit status. Do they have the knowledge base to make specific, timely and visionary contributions to the health of patients? Who among them has any clue about how - and how much - harm happens? Accounting is EASY compared to care. And assurances are easy compared to real change.

But so it goes. The titans will make decisions independent of any ambition on the part of patient health. And the more skilled among trustees will tire of hearing platitudes around the table, and dissipate to put their energies where they might be better used.

Ben Geisler said...

I disagree: quality and safety issues need to be promoted top-down AND bottom-up.

Robin said...

The descriptions of cultures raised here (silent boards, meek administration) are embarrassing to healthcare, but unfortunately, very real. Those reading this blog are the ones that understand how ridiculous it is to continue with the status quo thinking that "things just happen." As noted, it will probably take a civil rights movement to get the attention of those still on the sideline. What actions or steps would readers recommend that an interested, concerned community member do to hold healthcare leadership accountable to eliminating preventable harm? It sounds like Kathy has started something in Maine; it would be so helpful to have concrete ideas about what we can do within our own communities to move the needle.

Keith said...

Who feeds the information to boards and trustees? CEOs and mangement of the hospital! How do you expect unbiased information to bo obtained by these boards. Why are tey largely populated by individuals with accumulated wealth?

Answer: because they are selected for their ability to contribute to hospital coffers and not for their insight into what constitutes good health care for a community. They are often hand picked by the mangement of the hospital, again creating some conflict of interest.

Once agin, don't expect change in our money driven culture till you change the incentives and align what you expect from hospitals to be incentivised with greater financial reward. Until you do, you will have health care institutions that build gleaming palaces and market their fancy new gizmos and will be buying minimal improvements in measureable health while spending ever more money. All current CEOs are bought into this model because it works financially for them!

Anonymous said...


I have zero actual experience with the phenomenon of grass roots organizing, but I bet if one studies the history of AIDS/gay rights activists, civil rights activists, the 'pink' breast cancer campaign, etc., there would be commonalities of method. It would seem that engagement of the public and the media would be necessary elements. Trying to engage with individual hospital administrations alone would probably result in defensiveness and frustration. And, since young people seem to often carry the torch, engagement of medical students through such vehicles as the IHI's Open School (see may be productive.

There are enough patient safety advocates across the country now that I can imagine some sort of simultaneous demonstrations across several cities, with prior notification of the media, as a start. Most of these things start slowly and then gain momentum over time.

I do know that hearing/reading some of these heartrending stories arouses outrage in me, and no doubt the public would feel the same way.

And yes, I would also love to hear details from Kathy in Maine.


Robin Eichert said...

Thanks, nonlocal. As always, good insight, I appreciate it.

Mark Graban said...

I don't think it's online, but the new issue of HealthLeaders has a piece with survey data called "Who Owns Patient Safety?"

"Where on your organization's list of financial priorities does patient safety rank?"

#1: 43%
#2 to 5: 48%
#6 to 10: 7%
Out of top ten: 2%

Surveys like this are surprising... who would actually SAY that safety is NOT a top 10 priority? It's just a survey.... I'd expect people would at least lie and say safety is a top concern, much as I'm surprised the ACHE survey doesn't have more people saying safety is a top priority.

Anonymous said...

Among the reasons that patient safety has not received broad outrage is that (1) preventable harm is routinely covered up (whereas breast cancer eventually makes itself known), and (2) when you do have to think about care, you are highly vulnerable to the goodwill of those who practice it (on you).

What we haven't seen is the numerator of patients informed that harm occurred. Of the 588 of 2341 occurrences of harm identified by Landrigan et al. 2010 (North Carolina record reviews) or the 393 of 795 harm events identified by Classen et al. 2011 (Utah record review), how many patients or families were contacted? And did they have the opportunity to learn that they are not alone? Were any of them sent the publication that their medical record participated in? While issues of specificity and sensitivity exist, there are certainly a large subset of records where harm is clear and preventability is certain.

A Civil Rights-style campaign is more appropriate than the 'Pink' campaign for two reasons: (1) The breast cancer foundations have done a very good job at raising massive amounts of money for medical research, but a very paltry job of pushing investigation of preventability. Very few monies address known environmental contaminants (e.g. hormone disruptors, mimics, and carcinogens). My hospital would love these millions to create a 'Quality and Safety Research Institute'. But I am skeptical that new labs and careers would actually create internal pressures necessary to change medicine at its roots. (2) Because of the lack of monies to investigate cancer's environmental etiology (v. treatment), it looks like no one's responsibility, just the poor fate of the person who gets it. The Civil Rights movement, on the other hand, clearly identified the structural, political, and financial interests that assaulted the humanity of populations within society. It did not raise millions to give to sociologists to study the problem of race relations. It was driven by the very real experiences and barriers of its victims. Patients and families may not know if they are getting the right kind of care. But they often know when they are not.

Anonymous said...

Anon 8:59, the last part of your comment, beginning with "The civil rights movement" is brilliantly stated.
I also agree with you that requiring harm to be disclosed , at the very least to the patient/family, would be an excellent starting point toward rapidly raising the consciousness of those within the field who seem so willfully ignorant. In addition it would provide another measuring stick of harm, as well as serving to publicize and humanize the problem.
Perhaps this is where the 'movement' should start.


Anonymous said...

The Establishment (aka saw fit to delete my comment when it went down a few days ago, so here is a re-send of the meat of it, for the record:

Should there be a federal law requiring disclosure of all incidents of harm in health care facilities to the patient-victims and/or families?


Ben Tilly said...

If you want perspective on why hospital CEOs don't care about patients, I highly recommend The Buyout of America. The short version of it is that hospitals are a prime target for private equity. Whenever private equity moves into an industry, they saddle companies with debt, cut any corners that they can, and then try to flip the company to someone else based on the (usually unsustainable) increase in profit margins. Which is exactly what they have done to hospitals, without any regard for the injury and loss of life that they cause.

Note: I do not recommend that book to anyone with a tendency towards high blood pressure.