Hospital CEOs Reveal Their Top Priorities

While reading Paul Levy’s post on hospital rankings, I couldn’t help recall an  American College of Health Care Executives (ACHE) survey that he discussed onNot Running a Hospitalback in March of 2010.  The ACHE asked hospital CEO’s about their top concerns. Below, a table shows the results: “Patient Safety” and “Quality of Care” ranked at the bottom of their list of priorities.

Granted, from 2004 to 2007 these issues moved up in the rankings, but CEOs still were more likely to worry about “financial challenges,” “the cost of caring for the uninsured,” and “Doctor/hospital relations.”  They might as well have been the CEOs of auto companies, who worry about  first about profits, then costs, then labor relations, roughly in that order.  

Maggie2

Even worse, by 2009, Levy notes, “there was a major disappointment.”   The two issues most important to patients appear to have fallen off the chart.   “We can't blame just the CEOs for missing the boat on elevating safety and quality,” Levy commented. “It is the governing bodies of the hospitals, behind and above the CEOs, who should hold them accountable on this front.”

Two months ago, Levy took another peek into the minds of the nation’s hospitals CEOs. This time he pointed to an article in Health, Medical, and Science Updates about a study by the Beryl Institute, entitled "The State of Patient Experience in American Hospitals." As in the prior ACHE survey, 69% of hospital executives rank things other than quality and patient safety as top priorities.

About half of the institutions surveyed were individual hospitals; the other half were hospital groups or systems. They represented was an even mix of urban, suburban, and rural facilities.

Levy comments on the findings. In our medical culture, “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.”

It is hard to imagine nearly any other industry– say the airline industry, taking this attitude. But in hospitals, people are hurt and people die. This is to be expected.  Hospital workers become inured to a suffering, and death.  But preventable harm cannot be expected, or accepted, as the norm.

Once again, Levy blames hospital leadership. 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?’”

                                “Moral Disengagement”                

Hospital CEOs tend to defend hospital errors by saying, “We’re no worse than the average hospital,” Marshall Allen, a health care reporter for the Las Vegas Sun. explains in an outstanding piece published on the April/May issue of Washington Monthly. They explain that “similar problems” exist in other hospitals. “To some degree you can’t eliminate them.” In other words, “these things happen.”

Hospital administrators who track rates of hospital acquired infections and preventable mistakes compare themselves to each other and say, ”We’re not so bad,” Allen writes.

He knows how hospitals react when error rates are exposed because, “Not long ago, my colleague at the Las Vegas Sun, Alex Richards, and I set out to identify these cases of preventable harm and publish them.  Transparency turned out to be “an antidote to complacence”.

Nevertheless, hospitals defended themselves by saying “We’re no worse than average.”  When Allen and his colleagues showed their data about accidental surgical injuries to Dr. Jim Christensen, an allergist who also oversees quality improvement at Spring Valley Hospital in Las Vegas, he was nonplussed. “I see these all the time,” he told me. Asked if he had become inured to the problem, he said that surgery is “like working on the car with the engine going. Sometimes something slips, but they recognize the injury right away and repair it. As long as that doesn’t go beyond the published error rate, I’m fine.”

He quotes another surgeon saying, “We’re like lawyers. We just provide services by the hour and sometimes it works and sometimes it doesn’t.”

“If the airline industry and its regulators had clung to the same attitude, Allen observes, “the average rate of airline fatalities would likely be little better than it was in the 1950s, when flying was at least three times as dangerous, on average, as it is today.”

‘It’s only human nature to call average good enough, particularly when what you are doing is difficult,” he adds. “Moreover, when people are engaged in inherently dangerous activities that they believe bring great benefit to society—whether it is serving their country in combat, or moving passengers at 600 miles an hour in and out of the wild blue yonder—it’s understandable that they tend to overlook or dismiss any avoidable harm caused by their actions. Dr. Thomas Lee, an associate editor at the New England Journal of Medicine and a professor at the Harvard School for Public Health, notes how this same process of moral disengagement affects doctors and hospital administrators. They are reticent to acknowledge patient harm, he says, because they’re too busy highlighting the diseases cured and lives saved.

“To overcome this natural tendency toward moral disengagement—or what safety experts in other fields call “normalized deviance”—we need in health care what the airline and many other industries already have: a process for systematically recording specific errors and near misses and for making them widely known so that everyone can learn from them”

Finally, we know that hospitals can be made far, far safer. Some have created with Levy calls “islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety." The success stories are not limited to well-endowed academic medical centers. Some VA hospitals have reduced hospital acquired infections to nearly zero. What is required is committed leadership—a hospital CEO who understands that a hospital isn’t a business, like any other. Its top  priority should be “First Do No Harm.”

13 thoughts on “Hospital CEOs Reveal Their Top Priorities

  1. “Even worse, by 2009, Levy notes, “there was a major disappointment.” The two issues most important to patients appear to have fallen off the chart.”
    It looks to me like from 2004 to 2007, patient safety and quality were two separate line items on the survey and in 2008 they were combined into one line item. They remained important concerns. It’s not surprising to me that financial issues would be top of mind for hospital CEO’s because without sound finances, the hospital couldn’t stay in business. No margin, no mission.
    I’ve heard doctors on other blogs comment that patient safety and quality are getting much more attention from hospital leadership lately. I suspect that the reason may be new payment models that will no longer pay for avoidable harm. Improving patient safety and quality may be the right thing to do but it often costs time, money and effort in the short run when there are many other demands on the people that have to devise and execute strategies to bring about improvement. If financial carrots and sticks increase the likelihood that hospital leadership will elevate patient safety and quality initiatives to a top priority, as a patient or potential patient, that’s fine by me.

  2. Barry–
    If you look at the table, you will see that both patient safety and quality disappeared.
    This is why Levy calls this “a great disappointment.”
    Until about 18 months ago, Paul Levy was the CEO of a prestigious hospital in Boston. He’s giving us the inside story.
    Yes, some hospital CEOs are paying more attention to safety.
    But as he reports, when he talks to people at hosptails around the country, younger doctors, nurses and others are saying : How do we get our hospital administration to pay attention to quality and safety.”
    Compared to patient quality and safety, “finances” are of no importance. There is no reason for a hospital to stay open if it is not putting quality of care and patient safety first.
    Would you want your child to be in a hospital where the CEO open admittedly: “We’re mostly concerned about profits and costs. Patients–and their safety– are much less important.”
    Yes, some CEO’s are making great strides toward making their hospitals safer. But many (probably most) are not. This is why the stats showing preventable medical errors and infections are rising.
    “No margin, no mission,” is an easy excuse that a great many non-profit hospitals use–wile their
    top administrators are piad millions. (I know this is a small amount in the larger context, but it sets
    a tone for the institution.)
    These same hospitals also have been wasting tens of millions on contruction
    projects that are not needed.
    I would urge you to start reading Levy’s blog. It is
    eye-opening.

  3. Maggie –
    There are 10 lines of data on the chart. Line 9 is patient safety and line 10 is quality. Both have entries for the years 2004-2007. Line 4 is patient safety AND quality with entries for 2008 and 2009. I think it’s clear that line 4 replaced and combined lines 9 and 10 starting in 2008. I have great respect and admiration for Paul Levy and I’ve learned a lot about the healthcare system from him through his blog but I think he made a minor mistake regarding the interpretation of this particular data set. We’re all human and we all make mistakes, even the best among us.
    Of course I want to be in a hospital that takes patient safety seriously. I also want to be in one that is financially strong and viable so it can afford adequate staff and supplies and up to date equipment. I don’t care about the waterfalls, piano players or valet parking, though. If a CEO says patient safety is important but sound finances are even more important, it doesn’t mean that he doesn’t care about patient safety or take it seriously. Even Paul Levy spent a lot of time and effort to take $20 million out of BIDMC’s costs late in his tenure though he tried is best to do it in a way that minimized layoffs and protected the pay of the lowest paid workers. He didn’t ignore the revenue vs. cost issue because he and his hospital couldn’t afford to. It’s that simple.

  4. Very nice post Maggie, the situation is worse than you describe. I have seen it first hand.
    Take the gloves off Maggie and call it like you see it no matter who wants you to support what.
    That’s the Maggie I read in your books.

  5. Barry–
    You may be well be right about the table; I hadn’t noticedhow line 4 changed. I’ll have to ask Paul Levy.
    But the fact he called 2009
    a “great disappointment” still suggests that safety and quality were not moving up on the list of priorities at that point.
    And the fact is that, overall, patient safety has not improved in hospitals in recent years. This is suprising– given the IOM report of 2000, and given the concern about malpractice suits.
    But as the most recent survey that Levy cites indicates, hospital CEOs still don’t see safety & qualtiy as a top priority.
    Many deny that there are any safety problem at their hospitals.
    I totally understand that a hospital needs to stay in the black in order to have adequate staffing, etc.
    But those who consider patient safety & quality a priority will make staffing a priority.
    Those who dont’ will expand their cath lab (a revenue center) before they hire palliative care
    specialists. (Medicare may save money on palliative care but the hospital may well make more money on
    keep the beds in its ICu filled. A Manhtattan doctor at a brand-anem hospital explained to me that his hospital didn’t have pallative care because the CFO was more interested in expanding the cath lab–which would be a “profit center.”
    And what Paul says about younger doctors and mid-level hospital workers being very frustrated that they can’t get hospital administratoin to pay attention to patient safety is very true. Since I’ve began writing the book (in 2003) I’ve been hearing the same thing, over and over.
    But hospitals are very political places. Nurses, residents, younger doctors, mid-level hospital workers — most are afraid of bucking their hospital’s administration.
    And with good reason.
    Hospital CEOs enjoy enormous power. And if you are labeled a “trouble-maker” you will have a very hard time finding another job.

  6. Joe Says–
    Thank you very much.
    But at the end of the day, I don’t need to be encouraged to “call it like I see it.” That is what I have been doing my entire life. (For better and for worse. Doesn’t always work out well, but this is who I am.)
    No one at The Century Foudation, except Naomi, reads my posts before they are pubished. (Naomi puts them online and and embeds the links)
    No one in management at TCF has ever suggested that I shouldn’t say X or Y, or that I should promote Z.
    I choose the topics and write the posts. I know that I can write anything that I can back up with evidence.
    That is what makes this a wonderful job. And this is what inspires me to work as hard as I do.

  7. Maggie –
    I have no doubt that some hospitals don’t focus as much on patient safety issues as they should. Every institution has is own culture and leadership or lack thereof at the top can make a difference both positive and negative.
    Regarding the table, though, I noticed that the scores received by both financial challenges and care for the uninsured fell within a very narrow range across the entire 2004-209 time period. In 2009, great uncertainty surrounding the impact of health reform was mentioned as a top 3 concern by 53% of survey respondents whereas it wasn’t even an issue in prior years. The fact that it pushed the patient safety and quality score down to 32% from 43% the prior year does not suggest to me that hospital executives as a group cared any less about safety and quality than they did previously.
    The company I work for is involved in heavy manufacturing with parts of the workplace potentially very dangerous. Our industry still has workplace fatalities and serious injuries though not nearly as many as in years past. While our CEO leads a private company and has a responsibility to shareholders, he embraced workplace safety as a core priority when he became CEO several years ago. He pounds on it constantly. It’s incorporated into senior management performance goals. The Board is updated regularly on our progress. His leadership made a positive difference. Whether or not it would make his top 3 list of concerns on a survey I have no idea.
    Separately, whether a hospital CEO chooses to build a new cath lab rather than introduce or expand a palliative care program is probably more of a financial choice than anything else. Experts have told me that hospitals make most of their money on inpatient care from surgical procedures and cancer treatment. They lose money on trauma and don’t make all that much on mental health, childbirth, and low to moderate acuity medical (as opposed to surgical) cases.
    To evaluate patient safety efforts, show me what they’re doing to reduce infections and how their results stack up against their competitors. Show me whether or not they do a root cause analysis when there is a wrong site surgery or other serious mistake in the OR and whether they follow through with process improvements to ensure that it doesn’t happen again. These are the actions that drive quality and safety improvement, not whether or not the CEO ranked them as top 3 concerns on a survey.

  8. Maggie – I’m with you – I think the health care culture that “dumbs deviancy down” or engages in the “bigotry of low expectations” (to use some analogies) is a big part of the quality and safety problem.
    I think one of Don Berwick and IHI’s main contributions has been to change the conversation from “complications” (inevitable and just part of doing business) to “errors and harm,” which can and should be reduced. See http://www.jhartfound.org/blog/?p=434
    Another part of the problem I feel is a more or less explicit trade off in the minds of health care workers, that to do a really good job for one patient would mean that they won’t be able to serve others. The argument goes, what we do is good enough now, if we were to allocate more resources to make it better, we’d have to take them away from other needy people.
    On an all cost/societal cost level, I very much doubt that it is true, but on a micro level it may have some validity. E.g., if a hospital allocated enough nursing staff to its beds to improve care, it might not be able to have as many beds open. If a primary care visit was long enough to really address all the issues, there would be fewer slots in the day.
    Systemic redesign is what we critics usually argue is the solution to permit a higher quality system at the same or even lower cost, but the upfront costs and the uncertainty of reaching that new performance plateau are still barriers.

  9. Chris,Barry
    Chris: Thank you.
    You write:”I think one of Don Berwick and IHI’s main contributions has been to change the conversation from ‘complications’ (inevitable and just part of doing business) to ‘errors and harm,’ which can and should be reduced. See http://www.jhartfound.org/blog/?p=434
    Exactly.And I urge readers to go to the Hartfound Foundation link.
    Calling an
    “adverse event” a “complication” makes it
    sound as if it cannot be prevented (an act of Nature)
    . But as some hospitals have shown many
    adverse events can be avoided–by improving the “systems” that hospitals use.
    It is very important, I think, that Berwick and other reformers want to move away from the “shame and blame” culture of trying to blame one (or a few)individuals.
    I’ve been trying to point
    toward that solution in
    Parts 1 and 2 of my recent malpractice posts. I’ll be expanding on the theme in Part3.
    Barry–
    It’s good that your CEO is concerned about workers’ safety. But … he isn’t running a hospital.
    Also,in his company, if workers are injured, they call in sick– and are not as productive. His company loses money.
    By contrast,a hospital doesn’tlose money if a patient is injured. Worst care scenario–the patient sues. But only a tiny percentage of patients injured by adverse events sue. Andif they do, the hospital’s insurer pays.
    For a hospital, patient injury doesn’t hit the bottom line the way a high rate of worker injury does in heavy manufacturing.
    The hospital business is one of the few businesses, where you can botch the service you promised to provide, and still get paid. Moreover, your customer has to pay you to repair the damage..
    What is important is that minority of hospital
    CEOs list “safety”as one of their major concerns.
    As Levy points out,
    doctors,nurses and other
    health care workers in many hospitals are frustrated that they can’t get the administration to
    back safety programs.
    At many hospitals, the administration refuses to back nurses who speak up when they see a doctor ignoring safety standards (i.e. “Excuse me,doctor, but we really should have a “time-out” before beginning surgery.)
    If the CEO doesn’t back them up,nurses won’t dare speak up.And many CEOs won’t speak up because
    these doctors are “rainmakers”who bring in many lucrative cases.
    (This is what doctors and nurses tell me.)
    Of course, as you say, deciding to choose expanding a cath lab over palliative care is a financial decision.That’s preicsely the problem: the decision is money-driven. It isn’t based on what would be best for patients.
    By expanding the cath lab,
    a CEO can expand the number of angioplasties that his hospital does.
    The fact that medical evidence shows that 50% of angioplasties are unncessary doesn’t bother him.
    The fact that palliative care makes dying much easier doesn’t really interest him. (As doctors have explained to me) And,if he’s an MBA, (rather than someone with a medical background) he probably doesn’t read the studies which show that,in fact,
    palliative care can save
    hospitals money.
    More importantly, palliative care saves all of us money.
    Too many hospital CEO’s engage in “silo-thinking”–“How can I make money for my hospital– and thus hike my bonus for next year?”
    Of course, over the past two decades a great many U.S.CEOs have made decisions based on what would please Wall Street on a short-term basis, and thus lift the value of their stock options while boosting their bonuses.
    If you don’tbelieve me, ask Warren Buffet about this.
    This short-term thinking is terrible for any corporation, but when the institution is a hospital, it is both tragic and criminal.
    People die.

  10. It would be interesting to know what the top priorities are in countries that have single payer healthcare systems. Of course, in our “capitalist” healthcare system, our hospitals will be concerned about finances first; most are private corporations responsible to their stockholders rather than to their patients. CEOs who do not have this mindset are not going to be CEOs for very long. In fact, if they don’t maximize “profits” they are considered to be financially irresponsible. I’m not saying that this is right, just that it is the reality in our dysfunctional healthcare system.

  11. And where do you think employee safety is on the chart? Healthcare has the highest injury rate of any industry (NASI). IHC (the golden child of healthcare) has high incidence rates of back injuires and needle sticks. Which is sad, because with the right equipment and training they should have no needle sticks and with patient lifting systems greatly reduced back injuries. But those are not priorities.
    I would be curious to see if there are any studies relating employee statisfaction with patient care including patient quality and safety.

  12. Sara–
    Actually, the vast majority of U.S. hospitals are not-for-profits. They do not have shareholders,
    though they do borrow money from the public by issuing bonds.
    Unfortunately, in our money-driven system, non-profit hospitals behave very much like for-profits– huge salaries for CEOs,
    much emphasis on construction and hotel-like amenities to attract well-heeled and well-insured patients.
    More attention is paid to patient safety in many European countries, not because they have single payer (no country in Western Europe has straight single-payer, only Canada and the U.K.)
    but because doctors are trained differently (less high-tech medicine and less overtreatment); hospitals are less hectic; greater use of nurse-practioners (they deliver the majority of babies– much lower rate of C-sections & complications) and greater use of electronic medical records which can reduce medication mix-ups and patient mix-ups.
    Also, in countries like Germany, hospitals are quite Spartan. Few single rooms, not much money spent on decorating, carpeting, atriums, etc.
    The hospital is not seen as a hotel or a resort. It focuses on medical care–period.

  13. Bruce Fryer–
    You make a very good point.
    My guess is that the accident rate is high for
    hospital workers in part because our hospitals are so chaotic– too much going on at once as people are over-treated and
    over-tested.
    Also, as you suggest, hospitals are not investing in the equipment that would keep employees safe.
    I don’t know of any studies of employee satisfaction, but I do know that, in general, morale is pretty low among workers at most hospitals.
    And many nurses are terrified by the likelihood of a medical mistake– they’re being asked to do too much, multi-tasking, tending to the technologly as well as the patients.