November 28, 2010
Hospital Quality Study Finds No Improvement
Medical mistake rates in some North Carolina hospitals show no improvements from 2002 to 2007.
STANFORD, Calif. — Despite concerted efforts, no decreases in patient harm were detected at 10 randomly selected North Carolina hospitals between 2002 and 2007, according to a new study from the Stanford University School of Medicine, Harvard Medical School and the Institute for Healthcare Improvement.
Since a 1999 Institute of Medicine report sounded the alarm about high medical error rates, most U.S. hospitals have changed their operations to keep patients safer. The researchers wanted to assess whether these patient-safety efforts reduced harm. They studied hospitals in North Carolina because that state has shown a particularly strong commitment to patient safety.
The US car makers had to improve safety because they were losing customers (lots of customers) to Japanese makers. Well, there's no Consumer Reports or J.D. Powers rating hospitals the way car makers are rated for quality. So the pressures to improve quality have got to be less intense. Can hospital error rates fall substantially? Can this be done with just internal bureaucratic pressure? Or with regulatory pressure? Or are market incentives needed? If so, what form of incentives?
Some best practices were still not being used in 2007. This NY Times article has good coverage.
The findings were a disappointment but not a surprise, Dr. Landrigan said. Many of the problems were caused by the hospitals’ failure to use measures that had been proved to avert mistakes and to prevent infections from devices like urinary catheters, ventilators and lines inserted into veins and arteries.
Why did it take so long from 2007 to 2010 to publish the results? What's needed is a much shorter loop between a measured time and known results. In manufacturing settings the quality measurement results are often known the same day or in even less time.
This suggests to me that lawsuits are not improving the system but are acting as a financial drain on medical services. How about this as an incentitive?
Hospitals, medical facilities and personnel are exempt from lawsuits if their error rate meets or is lower than the national average for identical procedures. If your error rate is higher than the national average than you have one year to remedy the problem or be subject to heavy fines. If after a year there is no improvement you are removed from the medical profession. To avoid gaming the process an independent set of inspectors similar to those the governemnt uses to chack military manufacturing quality would monitor results.
The Japanese use a process called poka yoke - in one translation idiot-proofing. It is part of the continous improvement process. Make a mistake once, understand what caused the mistake and work to prevent its repetition. Or as I tell my folks I'm looking for new, improved errors, not the old ones we have done before.
Yes, it is true: Nature is always producing a better idiot, one who can eventually figure out how to go around all the safe-guards and create disaster. Chernobyl was a perfect example of that. You have to have good people to make any system work. We need to weed out the incompetents and dullards.
Hospitals don't improve. Humans do.
The whole system is corrupted by lack of incentives and bloated bureaucracy. Until we as individuals are directly responsible for our own healthcare costs and payments in some manner, we will continue to see $50 per aspirin and amputation of the wrong limbs lol. Show me any consumer who wouldn't laugh in the face of someone trying to charge the outrageous and extortionate prices routinely paid out by insurance companies and medicare in some twisted Dali-esque 3 card monte charade.
'So the pressures to improve quality have got to be less intense.'
It is worse than that. It is more profitable to make people sicker, to the extent that you can get away with it - i.e. make it 'accidental', or the result of sloppiness that stops short of negligence, or convince your patient that they have a chronic illness that your treatment is at least holding at bay. Patients both need to have enough knowledge to be able to tell good treatment from bad, and enough choice that they can select one provider over another. The first criterion is harder to meet than might be supposed, given that many ailments improve all on their own and that the medical establishment has some pretty good PR going for it. Heck, even without the special status enjoyed by mainstream medicine, there are plenty of alternative practitioners who are able to convince their patients that they are being treated effectively despite the fact that their treatments are ineffective (aromatherapists, foot reflexologists or w/e).
'The whole system is corrupted by lack of incentives'
Oh, there are incentives all right. They're just perverse.
Who is going to measure the error rates?
People are more likely to reveal mistakes if they do not get punished for them. Error rates published internally behind closed doors might do more to improve outcomes. I do not know for sure.
I do not know how to solve this one. I think it is hard. Do we need more automated methods of measuring and detecting errors?
Another problem with error rates: There'll be fluctuations by chance. Smaller hospitals will have bigger fluctuations because they have a smaller number of total patients and events. A single error is a larger percentage of their total errors. Also, hospitals differ greatly in how sick their patients are. A hospital with sicker patients with more treatments will get more total errors than another hospital with the same number of patients who are younger or otherwise healthier.
This is another reason to live in an area where the smart fraction of the population is high. Smart nurses make fewer mistakes than dumb nurses.
As a practicing Registered Nurse, I can tell you that there are many reasons behind medical errors and many reasons behind them being underreported. Working environments, threats of lawsuits, hostile patients and families, understaffing, fears of retribution are all factors that influence the commission and reporting of errors. As for the person who believes that health care providers want to keep their patients sick, I am disgusted. Nurses and doctors (the vast majority anyway) would NEVER intentionally harm a patient in order to charge for additional hospital days. Most hospitals are working at or near capacity with barely enought staff-extra patients who don't need to be there only increase the risk of errors and take resources away from a patient who may really need them. Medicare rules have become more stringent over the last decade and they will not reimburse hospitals for many of these infections, such as catheter related urinary tract infections and ventilatory acquired pneumonia. Independent insurance companies are very likely to follow suit, especially with the passage of the horrible health care legislation that is going to further stifle the free market.
As for Dave Gore who believes that smart nurses make fewer mistakes than dumb nurses, that is a ridiculous tautalogical argument. There are plenty of nurses with years and years of experience who have made huge, even fatal errors despite being considered smart. See this story about Josie King http://www.josieking.org/page.cfm?pageID=10
Most errors are process issues, not intelligence issues. Hospitals have internal error reporting systems and look at ways to prevent errors from occuring again. But unfortunately no one knows there is a problem with a process until a bad outcome occurs. Negligence or outright reckless behavior is grounds for dismissal in any hospital.
Please talk to health care professionals and do some research before you berate the people who are genuinely trying to help you.
The techniques of continuous improvement continue to not be well-understood, probably especially so in an industry like hospitals. The article notes that proven measures known to cause improvements remain under-utilized or not used at all. This is true in many organizations, in my experience. I think it's because we cling to bad measurements, bad incentives, and the "conformance to requirements" model of improvement. This may be particularly true in health care which has become insulated from market forces.
American managment is just lousy at quality control. Always has been.
In fact, American managemnet is just lousy, period. Don't blame nurses, blame CEO's.
Perhaps I am over-influenced by my manufacturing experiences. I have only been in a hosptial a few times; mainly for my kids' births. While my knowledge of medical processes is - chartiably, speaking - small, I think the principles of continuous improvement could be implemented in hospitals.
I assume that we would start with the current error reporting system as flawed as it may be. The system would be improved as we understand it better. Why not have the insurance companies produce inspectors same as the Government does for military contractors? Reporting errors to the inspectors would be on a non-judgement basis and so long as corrective action was taken the error would not count UNLESS it re-occurred.
Punishment would not be imposed on any individual unless the number of errors significantly exceeds the norm. Incompetent personnel must be eliminated from the system, despite the myth that all medical personnel are above average.
I agree that variances would occur for a multitude of reasons but continous improvement mandates that we locate the causes of variance and eliminate them. I agree that sicker patients will have poorer outcomes than healthier ones and that more ecperienced personnel will perform better. In the latter case why not use simulations to hone skills or employ telemedicene techniques to spread talent?
I don't think everything I have said here will work. Don't expect much will but we need to start somewhere.
Reporting errors, particularly in something as vital as health care, is hard and without accurate information improving the system is impossible. Rather than try for the perfect system now, which would be impossible, let us start with what we have then seek improvements, as the process matures.
To improve we need to measure. I wonder whether better methods of measure, more automated methods, should be the first priority. Do we need electronic medical records, constant electronic patient monitoring, and electronic gadgets that deliver drugs in order to create a better history of medical care per patient?
I'm a RN and agree with everything Jen wrote. The process is almost always the problem when errors occur. As to why processes remain bad I feel the main issue is the Mandatory Happy Face Environment present in the modern workplace is the main issue. In the book "Bright-sided, How Positive Thinking is Undermining America" by Barbara Ehrenreich this issue is addressed. An employee in nearly any industry who dares to point out something in a process is not quite right is subject to loss of future job opportunities, dismissal, etc. Consider the BP blowout. Do any of us really believe there was not a single employee who saw problems ahead of time? Of course there were. But facing their career being wrecked by being anything less than happy face enthusiastic they remained silent.