You may have read that last year, Jack Welch fell victim to a medical error that could have killed him. While in the hospital, the retired General Electric Chairman and CEO contracted what was presumably a preventable spinal infection. It was so serious that some newspapers began polishing Welch’s obituary.
The 73-year-old did recover—but only after spending 91 days in New York’s Columbia Presbyterian hospital battling “discitis.” Welch believes that the infection was caused by “a dirty needle from a cortisone shot he took to help him play golf.” The infection “not only spread through his spine, but also to his artificial right shoulder, which had to be surgically cleaned out.”
Enter GE Healthcare, a $16 billion unit of General Electric. Alarmed by Welch’s close call, GE researchers decided to take a close look at patient safety—and perhaps consider whether the company could develop a new line of business in the process.
GE’s Solution
Their work paid off. Last week GE Healthcare announced that its Smart Patient Room pilot at Bassett Medical Center in Cooperstown, New York has been approved and is ready to being “collecting data.”
What does “collecting data” have to do with preventable infections? The GE press release is rather wordy, so let me sum it up: “Smart Patient Rooms” spy on nurses, doctors, and other health care workers to make sure that they are washing their hands. Over time, the technology will be expanded to check up on them in other ways.
But "the first app — the killer app — is hand hygiene,” Jeff Terry, managing principal at GE Healthcare announced proudly.
Some reporters had an opportunity to view the technology in action in a mock hospital room at the GE research campus. Eric Anderson, Business Editor at the Albany Times Union describes how it works: “sensors and visual detectors . . . track individuals and identify whether they are patients, doctors, nurses, or other staff or visitors,” and “make sure that any staff interacting with the patient washes their hands before and after the visit. Incidents are collected in a Medical Errors Reporting System or MERS.”
Jan De Witte, President & CEO, GE Healthcare Performance Solutions, refers to the electronic records of “incidents” as “actionable data,” which will then be used to “affect the necessary behavioral changes to avoid preventable errors.” GE doesn’t spell out exactly how hospitals will modify behavior, though the press release does say something about “intervening through gentle notification.” This suggests that perhaps the technology is able to communicate with the hospital worker at the moment that he is about to make a mistake. Perhaps he or she is zapped, like a mouse in a cage that is trying to learn a maze? (Very gently, of course.) Or maybe soft lights flash? One wonders: at some point, do notifications become less gentle? Would it matter whether you are a nurse or a “rainmaker” surgeon? That would be up to hospital executives. GE just makes the technology.
The sensors also monitor “whether the patient is being seen regularly by hospital staff” and “whether he or she is getting too close to the edge of the bed.” The goal is to avoid patients’ falling out of bed. (It’s not entirely clear just how often nurses are expected to visit each patient and make sure that he or she is nicely centered on the bed. Some people tend to roll around quite a bit while sleeping.)
There Must Be a Better Way
Call me crazy, but I don’t think any of this is going to be good for hospital morale. Imagine knowing that your boss has monitors set up throughout your work-place—to make sure that you’re doing your job. Any slip-up will be electronically recorded. Imagine, too, that the work you do is extremely demanding, and that your company is understaffed. You are working long hours, and under intense pressure much of the time.
As a health care reformer, I find the whole idea of setting up cameras and sensors to monitor doctors and nurses terrible depressing. If we have to spy on doctors and nurses in order to force them to wash their hands, we might as well throw in the towel. Such surveillance suggests that our health care system is beyond salvation. These people are not convicted felons in a prison block—they are medical professionals. The vast majority are genuinely concerned about patients and work hard to do the right thing.
Let me be clear: I don’t mean to minimize the importance of medical mistakes —or hand-washing. Preventable errors cost the U.S. health care system tens of billions of dollars each year, while causing an estimated 40,000 to 100,000 deaths. GE claims that “Actual hand hygiene compliance is only about 35 to 40 percent.” Let’s assume that’s correct. Still, there must be a better way to protect patients.
A Better Way: Teamwork, and an Administration Focused on Safety
Rather than playing “gotcha” with individuals, Don Berwick, co-founder of the Institute for Healthcare Improvement, argues that hospitals should focus on encouraging health care workers to work as a team to keep patients safe. Finger-pointing only promotes fear, shame and guilt. It doesn’t reduce errors. As Dr. Berwick points out, all humans are fallible, everyone will make mistakes. But health care workers can block errors before they happen by watching out for each other. This is part of what it means to be a “team”—nurses and doctors watch each others’ backs.
Berwick, who is now director of the Centers for Medicare Medicaid explains: “In the medical culture at large, there still is too much focus on turf issues between doctors and nurses. In the long run new safety initiatives will be fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries. He also stresses that hospital administrations must take the lead: “the finger should point to the executive suite. .. . There’s more and more evidence that safety does not improve without the clear commitment of leaders.”
I recently looked at data on medical errors at hospitals in New York State, and noted a very high rate of infections at a much-esteemed Manhattan hospital. I asked a physician who has worked there for many years what he thought was causing the problem. He replied: “It’s the –physicians-run-amok culture. The hospital is hesitant to impose restrictions on physician behavior. That’s why we don’t use checklists.”
In the case of hand-washing, hospital administrators might just announce a simple rule: if nurses, doctors or other health care workers—whatever their rank—notice anyone approaching a patient without scrubbing, he or she has an obligation to speak up and say, “Excuse me doctor, but I think you forgot to wash your hands.” In a medical culture that acknowledges all humans are fallible, no one should be embarrassed. Ideally, the physician would respond matter-of-factly: “You’re right—thank you.” That is professionalism in action.
GE’s spy system, on the other hand, is designed to humiliate the culprit. The person responsible for the “incident,” is the only one who knows. No one else is told—reinforcing the feeling that he or she has done something shameful and is in need of behavior modification. (In the bad old days in the Soviet Union, they called it “re-education.”)
The GE press release assures us that the “actionable data” is kept confidential. By contrast, Berwick, like other healthcare reformers, believes in shedding light on medical errors, without blame and shame, so that everyone can learn from them. GE claims that their new system is modeled on airline safety. But in fact, pilots report their own “near-misses” without fear of repercussion, so that they can be discussed openly, and systems improved.
If a hospital CEO makes it clear that hospital workers should speak up, he is saying: “These things happen. We don’t need to hide the fact that humans make mistakes. We don’t need to cover it up. It’s fine if a patient hears you remind someone else that they forgot a step. What is important is that, if at all possible, you intervene—before the patient is exposed to risk.”
If I were a patient, and heard a nurse ask an attending—or another nurse—“Are you sure that needle’s clean?” I would feel safer. If, on the other hand, I noticed sensors on the ceiling, asked “What are these?” and was told, “Oh, the hospital uses them to monitor us, and collect evidence when a nurse or doctor does something that might endanger a patient,” I would be alarmed.
Hiking the Cost of Care While Boosting GE’s Bottom Line
I also have to wonder what an integrated system of sensors and tracking devices –one in each and every room—will cost. GE hasn’t indicated how much it thinks its new technology will fetch. Probably the answer is: whatever the market will bear.
Lisa McGiffert, Director of Consumers Union’s Safe Patient Project shares my concerns. When I e-mailed her a description of GE’s “Smart Room,” she replied: “Technology can be a good thing, but reliance on it to completely solve what ultimately is a human problem is probably going to lead to disappointment – expensive disappointment. Certainly new ideas are good, but nothing works like peer pressure and a culture that refuses to accept certain behavior (like allowing doctors to touch patients without washing their hands).
“You can add all of those bells and whistles and still infect patients,” she added. “The hospitals are always hollering about lack of resources, but often invest in technology that is less necessary than other initiatives.”
We know that there are low-tech solutions. If hospitals are concerned about preventable infections and other errors, how about using checklists? Oh, I forgot—there is not a lot of money to be made on a piece of paper and a pencil.
Low-Tech Solutions
When the New Yorker published “The Checklist,” an essay by Dr. Atul Gawande in 20007, it was widely read. In 2009, Gawande came out with a book: The Checklist Manifesto. It caused a stir. Yet as of the beginning of 2010, only about 20 percent of U.S. hospitals used surgical checklists, even though we know that checklists can reduce complications following surgery by roughly one-third.
Gawande points out that, in the U.S. more than 150,000 patients die each year following surgery—more than three times the number who die annually in traffic accidents. Research consistently shows that at least half of these deaths and major complications are avoidable. . . “The knowledge exists,” says Gawande. “But however supremely specialized and trained we may have become, steps are still missed.” Like Berwick, he believes that if we want to protect the patient, teamwork is essential: "Man is fallible,” says Gawande, “maybe men are less so.”
This is why the checklist is meant to be read aloud before each operation, to make sure that each member of the team agrees that they are ready to proceed. Everyone in the room is responsible: “Did we get the blood ready? Did we get antibiotics in? Also, does everybody in the room know each other’s name, so we’re working as a team?” This last question is something that Gawande and his investigators learned from health care systems in other parts of the world.
"Just ticking boxes is not the ultimate goal here," Gawande writes. "Embracing a culture of teamwork and discipline is.” In that sense, the function of the checklist is as much psychological as practical. “It is a first step toward learning to live with our fallibility — a kind of gateway drug to humility,” says Karthryn Schulz, author of Being Wrong: Adventures in the Margin of Error.
Nevertheless, in the U.S., this simple, inexpensive tool has run into what Gawande terms “cultural resistance.” Other health care systems have embraced the idea. In 2009, France went live in all 8,000 of the nation’s operating rooms, with surgeons using the checklist to reduce harm in care.
But in the U.S. many physicians believe that they don’t need a checklist. It can seem demeaning to call out the obvious things that everyone knows that they are supposed to do. Here’s my question: would these surgeons rather be tracked by GE’s electronic eyes? In the second stage of its “healthyimagination initiative” that’s just what GE hopes to do, installing its technology in hospital operating rooms across the nation.
What’s really scary is a lot of hospitals will race to jump onto this technology. They will use it as a PR piece on patient safety.
As you correctly note, it will devastate the morale of nurses and other health care workers, especially if physicians are not held to the same standard.
On the other hand, the teamwork approach can and DOES work. Moses Cone Health Care System implemented a “gel in gel out” program a couple of years ago. Gel stations are placed at the entry and within each patient room. All staff, including physicians, are expected to gel before going in, and either gel or wash hands at the sink coming out. Staff are expected to remind one another to gel in gel out if they see someone forget hand hygiene.
It works. I don’t have exact statistics, but their infection rate dropped dramatically.
OTOH, I remember working at a hospical in the early 90’s that took a punative approach to med errors. Give a med late, and you got a write up. Two write ups and you didn’t get a raise. Three write ups and you got fired.
No one self reported med errors. Falsification of the MAR was rampant. Med errors continued unabated. This attitude didn’t change until the release of “To Err is Human” from the IOM.
If hospitals are really serious about reducing errors of all kinds the solution is really quite simple.
Hire more nurses and decrease the nurse to patient ratio. One nurse responsible for the care of 10 patients, who have to share a single CNA with two other nurses, are going to make mistakes. They’re going to skip hand hygiene. They’re pressured to get too much done without the resources to do it. They expected to do 16 hours of work in 12, and to hell with lunch or bathroom breaks.
But hospitals don’t like to increase the pesky staff. They cost more than capital improvements, and don’t generate the media buzz of tech toys.
*sigh*
Panacea–
Anyone who has spent time in a hospital sees how hard most nurses are working.
They are mutli-tasking, and I would add that some of the things they are asked to do could be done by someone who hasn’t been trained as a nurse. Other tasks just aren’t that important–i.e., tending to technology that isn’t very effective in helping patients.
Too often, hospital administrators really don’t understand what is important to patient care–they have no experience, They are not nurses or doctors; they are MBAsa and they don’t try to get the experience they need by spending hours on the wards.
Inevitably, hospital care is labor intensive. We may need a different mix of workers–For instance, more young assistants who can easily move
very heavy patients who are at high risk for bedsores so that older, experienced nurses who can’t move a big patient by themselves can do other things. That’s just one example.
But the bottom line is that hospitals need more nurses and others who can assist nurses and doctors.
By and large, more equipment and techology is not the answer to increasing patietn safety.
More caring, well-trained. hospital workers, who actually have the time to do their jobs, is.
This is not nearly enough….
First, they should also put sensors and cameras in staff bathrooms and prevent anybody from leaving without washing their hands because they may touch equipment that may eventually come in contact with a patient.
Second, the sensors in the spy room cannot detect if clinicians actually use soap or just water, which is not good enough. So, my high-tech suggestion would be to erect a force field around the patient, which can only be deactivated by special ionized chemicals added to hospital soap or gel.
Assuming the patient doesn’t wash in his/her sleep, the force field should prevent falling out of bed too, which is an added bonus free of charge.
Margalit–
Yes, that’s exactly what we need. Bravo!
Again, Maggie, your instincts are ahead of this new technology. Having spent a career in the food business as I read about this Big Brother approach to what is in reality a cultural issue I recalled how tough it was to get cooks to keep the doors to walk-in coolers closed when they started their work day. After the first hour or two it was easy, but at the start of the day propping the door open saves a lot of hassle, especially if both hands are full. But temperature controls for potentially hazardous products is the point (not to mention energy conservation).
Cutting to the chase, really good operations don’t have the problem because their people are properly trained and there are enough on schedule to get the job done without dangerous, wasteful work habits. The rest are trying to get good results (read profits) from bad practices (read poor training and scheduling).
I think the problem here is largely cultural and organizational. There are still too many arrogant doctors who don’t react well to having a nurse or other lower paid hospital employee tell them that they forgot to wash their hands or follow an operating room procedures. If the doctor is not a hospital employee but has privileges to practice there instead and generates a lot of revenue (surgeons), management may be reluctant to confront him about the issue because of fear of lost revenue if the doctor leaves and takes his patients elsewhere. In theory, the issue should be easier for management to deal with if the doctor is an employee of the hospital, but even then, if there is a lot of revenue at stake, it’s not so easy to ask him or her to leave.
This spying / monitoring technology is potentially useful if violations are communicated privately saving the offender embarrassment in front of other staff. Lots of employees in other fields have their phone calls routinely recorded (call centers, insurance claims departments, Wall Street trading desks, etc.), many of us are fingerprinted as a condition of employment and virtually all large companies tell employees that e-mails sent and received on corporate accounts should never be considered completely private. My advice to medical people is: Big brother is watching and/or listening in many other fields. Get used to it.
Back in the 80’s, I worked at a nursing home that had a “turn team”: 2 CNAs who went around turning every resident every 2 hours.
Then administration thought a turn team was too expensive and eliminated it. Turning became the job of the regular staff . . . on top of everything else we had to do. Skin breakdown became rampant; 1 LPN, 1 med aide, and 2 CNAs could not keep 50 residents turned every two hours, clean, dry plus feed patients, bathe patients, pass meds, do dressing changes, manage feeding tubes, do trach care and other things done in a skilled nursing facility.
Some hospitals now use specialized equipment installed in each room for turning patients safely (for both patient and staff member). That technology is great. It improves patient safety while improving worker safety.
Repeated studies have shown that outcomes are better with fewer patients per RN, and that RN care is key to good outcomes.
Truth is, I really don’t want more CNAs at the bedside. I want more RNs. I want RNs doing the bed baths, because that’s how a good skin assessment is done. That’s when range of motion is done. That’s how muscle tone is assessed. And so on and so on. That’s how we work on increasing patient independence. It’s really not a task I want to delegate any more than I have to.
I do want to spend less time charting. Easy to use, efficient EMR can’t come soon enough . . . but it needs to come with input from RNs. I want to spend less time on paperwork that is designed to prove to JCHACO that hospitals deserve to be recertified. In short, I want to spend less time at the nurse’s station and more time at the bedside.
If it’s technology that makes my job easier while improving patient safety, then I’m all for it. But no amount of technology can replace common sense and commitment.
And monitoring technology only works if someone is actually monitoring it.
I fail to see the downside of Welch croaking
I’m often asked “How do we change a physician’s behavior” and I reply “You don’t, they have to decide to change”. Compliance based solutions never worked in the past and they won’t here either. The concept of a “team” does work. Providing paths of least resistance work best. Make it easy to do the correct thing. Change happens from within and not without.
Want to bet how many months after these systems are installed they’re still in use?
the question isn’t whether folks are hard working and dedicated. rather it is whether they are cutting corners and endangering patient health. and while it would be nice and much cheaper if everyone adopted checklists, it is clear that’s not about to happen anytime soon. hovering in the background is the aviation culture where there are protocols that are enforced. as a result they tend not to make the same mistake more than once. call that a punitive culture, but it makes the skies a lot safer
@brucefryer
Reminds me of the old joke, “How many psychiatrists does it take to change a light bulb?”
Answer: Only one, but the light bulb has to WANT to change.
Bruce, John, robertsgt40
Bruce–
I totally agree. People change if they want to change.
That’s why positive reinforcment tends to work in behavoior modfication, and negative reinforcement doesn’t work as well.
Team-work–and being reinforced by the people you are working with every day–works best of all.
John–
Good joke & spot on. As Bruce suggests, positive reinforcement is what is likely to make doctors Want to change.
Robert-
I can’t say that I’m sorry someone didn’t die. (Though I know enough about Jack Welch that I wasn’t as sorry as I might have been to hear about his bad luck).
But I can say that anyone who goes into a hospital for a cortizone shot “to improve his golf game”– a person who is not a professional athelete but just an older amateur– made a vain and foolish decision.
.
Bruce, John, robertsgt40
Bruce–
I totally agree. People change if they want to change.
That’s why positive reinforcment tends to work in behavoior modfication, and negative reinforcement doesn’t work as well.
Team-work–and being reinforced by the people you are working with every day–works best of all.
John–
Good joke & spot on. As Bruce suggests, positive reinforcement is what is likely to make doctors Want to change.
Robert-
I can’t say that I’m sorry someone didn’t die. (Though I know enough about Jack Welch that I wasn’t as sorry as I might have been to hear about his bad luck).
But I can say that anyone who goes into a hospital for a cortizone shot “to improve his golf game”– a person who is not a professional athelete but just an older amateur– made a vain and foolish decision.
.
Hi Maggie,
I think you might be surprised to learn just how much we agree with some of your concerns.
I lead GE’s efforts to help health systems improve patient safety and capacity management. A big part of that is to first understand and then mitigate the risks of patient harm. As you know, those risks are complex and multi-faceted…and constant. The idea behind the smart room is to monitor the precursors to risk in order to 1) better understand them, and 2) help providers to better care for patients. Many of those precursors – like hand hygiene or medication dosage – are easy to manage in a single instance but very difficult to manage 24×7.
We agree that caregivers need a guardian angel and not a spy. Our goal is to inspire and assist, not monitor or henpeck. Our research and development has been guided by that thinking. Today, we’re learning the most effective ways to help.
Culture change is a major part of how we’re approaching patient safety. We’re working with providers across the country to really understand how just cultures, reporting cultures, safe cultures, etc. are created and sustained.
I should also note that the sensors are not recording raw video. Instead, they gather data that can be interpreted to provide staff and unit leadership the information they need to create a safer patient environment.
Thanks for your post. I look forward to continuing the discussion,
Jeff Terry
GE Healthcare
Jeff Terry,
I appreciate your comment.
But I’m afraid I’m not convinced that health care providers need “a guardian angel.”
They need a team of human beings who frankly acknowledge that we all are fallible, and who watch each other’s backs–not an invisible presence whispering in an individual’s ear.
The money spent on this technology–and money spent training “unit leadership” to use it could be used to hire more caregivers to do things like move patients every two hours (to prevent bedsores), do paperwork (so that nurses can spend more time bedside), etc.
Healthcare is labor intensive. We don’t need more technology, we need more caring, willing hands.
Finally, I’d urge you to talk to people at the Institute for Healthcare Improvment about caregiver morale. I think they’ll tell you how important morale is, and how you undermine a professional’s morale with carrots and sticks like P4P and “guardian angels”
(Don Berwick and someone from GE had a good dialogue about this in Health Affairs a few years ago.)
In the current Hospital environment, I think patients are more in need of old fashioned “guardian angels” than providers. And certainly neither one is need of a high tech facsimile of an angel.
Here is one quick suggestion for the medication dosage risk: fix the EHR/CPOE user interface. No angels required.
Margalit–
I agree. If anyone needs guardian angels, its patients.
And the whole idea of hi-tech guardian angels represents a contradiction in terms.
Hi Maggie:
I would support the logic of a camera watching operations, being major or minor, as a review of techniques and procedures occurring might reveal sooner what exactly happened and promote quicker proper care to coorect the error. Being spied upon is not something new to the work place as most people must log into their places of work via sign-in clocks, computers, and are also under survelance. Your computer messages back and forth are closely watched by the IT department and the quality of work is also critiqued closely. Travel on highways is now monitored by camaeras. Run a light and you may get a ticket in the mail. As predicted, “Big Bro” is taking an active interest in our lives not only to correct errors, reduce crime, eliminate costs (such as this); but, it is being done to increase the revenue stream by applying penalties according to what you did. Go to the mall or shop in a store and look to those little glass bubbles on the ceilings and wave. Being watched is a thing of the present and the future. So why not doctors also?
I believe you know as well as I do, many malpractice lawsuits are the result of preventable error at the hospital. The tic list is a good tool but what does it do when the checkmark is there and the checked procedure not accomplished? And to those doctors who are consistently breaking the rules, why should they escape consequences? As it now stands, the AMA does little to rein in doctors who frequently incur malpractice lawsuits. ~5% of all doctors between 1990 and 2005 are responsible for 57% of all malpractice payments (2 or more); ~3% having 3 or more malpractice payments are responsible for ~32% of all payments; and ~1% of all doctors were responsible for ~20% of all payments (page 12-13).
The Public Citizen’s Congress Watch group doing an analysis of the malpractice data, “Public Citizen’s analysis of malpractice payments as reported in the National Practitioner Data Bank Public Use File for the years 1990 to 2005”, found 2/3rds of those doctors having made 10 or more malpractice payments never were disciplined (page 13). http://www.citizen.org/documents/NPDB%20Report_Final.pdf “Medical Malpractice Trends 1991-2005.”
If the AMA doesn’t investigate the root cause of doctor error, than why not the hospital? And Welch? He is certainly not the one to be held up as an eample of what occurred for the average Joe six pack who lives at the Median Household income.
what about patient privacy fools