Chasing the Rabbit: Official Blog by Author Steven Spear

Incident Reporting Systems (IRSs) have been energetically engaged by hospitals seeking to emulate the aviation industry’s record of safety.  According to safety expert, Dr. Bob Wachter, they cost too much and accomplish too little.  His complaint is backed by sound systems thinking.  IRSs gather and process data that is delayed and aggregated.  While useful for seeing trends and identifying hotspots, such data is not useful for diagnosis and treatment.  By the time there is a response, the conditions that caused the problems may have disappeared.  What is needed is real time, nested problem seeing and problems solving so systems can maintain their stability and responsiveness without overloading some central safety function.

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Laura Landro, writing the “Informed Patient” column at the Wall Street Journal, explains that  hospitals are admitting when a patient is grievously harmed. (”Hospitals Owning Up to Errors,” Wall Street Journal, August 25, 2009).  This is good news, but if it ends there, greater opportunities are lost.

Complications occur with staggering frequency.  Very few hospitals identify and investigate small as well as large ones immediately–not on a delay, to find the root causes of inefficiency and ineffectiveness that compromise affordability and quality.  Some have achieved near perfection in eliminating patient harm as an occurrence.

Until all hospitals do the same to improve, public transparency about ill events–large and small–should be required.  Now, patients largely source care blindly, inadvertently trusting institutions too often that are dangerous and too infrequently to those that are remarkably safe.  With informed choice, average quality would be driven higher and average cost progressively lower.

Gawande, Berwick, Fisher, and McCellen (”10 Steps to Better Health Care,” NYTimes, August 13, 2009) document what many of us already felt: For the same service some health care organizations deliver great care affordably while others provide compromised care that is still costly.  If we all got care from the best, they suggest, there would be no crisis.

The irrefutable conclusion is that with such range in quality and cost, you have a right to know who will help you and who will cause you harm.  In service to that right, the necessary policy is clear: Mandatory reporting–first of avoidable complications like medication error and falls, building to ever better measures about efficiency and effectiveness.  With reliable information, you can choose wisely, and every informed choice will raise quality, reduce cost, and keep bureaucrats from having to make our decisions for us.

When my daughter was hurt, I picked a hospital knowing there was a 24 hour coffee shop opened that night.  Am I so reckless?  Hardly.  The problem is, finding out where the care is great and where it is poor is wickedly hard.  Not knowing matters.  If you want evidence, check out the great Hearst Newspapers report by Cathleen Crowley and Eric Nadler, “Dead by Mistake.”  Patients at ‘name brand’ hospitals, one who drowned in his own blood, another with a feeding tube stuck in his lung, another who got a lethal cocktail of pain killers and sedatives.  And this is ten years after the Institute of Medicine’s To Err is Human warned people of the horrific risk to patients.

The New York Times featured two distinctly different understandings of what ails health care.  According to an editorial (”Financing Health Care Reform,” July 6, 2009) the problem is lack of financing, so the problem is shifting costs — do you or don’t you tax health care benefits and if you do, at what threshold?  Do you or don’t you tax behaviors that contribute to ill health — not just smoking by consumption of sugared foods?  Is lack of exercise next? Do you tax other things to subsidize health care?  The obvious downfall of this approach is that it demands trade offs, more cost for more care, or more cost for you to get less cost for me.  It doesn’t drive more, better care for both of us at less cost for each.

According to Paul O’Neill (”Health Care’s Infectious Losses,” July 5, 2009) the problem is in the delivery of care.  An intolerable number of people get needlessly hurt–mis medication, patient falls, surgical site infections, ventilator pneumonia–driving quality down and driving up costs — in terms of human suffering and in terms of treating avoidable complications.  The solution to this is transparency–where do delivery inefficiency and ineffective exist? — and better management — achieve ever better access and outcomes with ever less effort and investment.

Given the overwhelming evidence that O’Neill is right — that better management leads to better outcomes, more access, and less cost, why is it that so called reformers focus only on cost shifting as their remedy?