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 on “Not Running a Hospital” back 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.
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?’”
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.”