Is health care in America getting safer? This is a question that we all think about as doctors and patients. The answer seems to be not really.
A new report found that hospitals have been gaming the system to make their re-admission numbers look good by putting patients who return in a special observation area instead of counting them as readmission. Independently, another report from the Agency for Healthcare Research and Quality shows that nationwide reductions in patient complications have plateaued. Furthermore, part of the reductions was due to creative ways that hospitals code or report complications.
Many of us who take care of patients know that health care continues to struggle with endemic variations in quality stemming from poor coordination, misdiagnoses and inappropriate care. While state-of-the-art care is there, delivering it can be messy.
There certainly have been real success stories in pockets of health care. I’ve seen some of them. But they occur among the 1% of patients in America who have their outcome tracked. For 99% of patients, the outcome of the surgery or treatment is never tracked. The only reason a small percentage of patients even get their results tracked is because a few doctor groups have had the vision to disrupt medicine’s black box. Already, open heart and transplant procedures have seen improvements with data transparency. But most patients go home after treatment with no tracking of result.
Moreover, data extracted from crude medical bills capture only a small fraction of the overall harm in health care. Mediocre metrics sometimes ignore the patient and focus on parameters that make us feel good that we are measuring quality, sort of like a pill that lowers a cholesterol number on a lab test, but doesn’t actually extend the life of the patient.
The things that matter for patients — a doctor’s skill and sound judgment, and staff teamwork — are unmeasured by the business stakeholders in health care.
As a country, we’ve chosen to spend billions on medical technology and new drugs, but we’ve been cheap when it comes to measuring performance accurately and fairly. As a consequence, the field of health care has focused on what’s easy to measure, rather than things that are important to patients.
For example, we measure knee surgery readmission rates using billing data but not a patient’s ability to walk three months later. We measure patient satisfaction, but not the appropriateness of medical care.
Moreover, there is one metric that tells you more about hospital quality than anything Medicare tracks. It’s the culture. Culture is the teamwork that is essential in delivering safe medical care.
Using a validated survey of hospital employees, my research colleagues and I at Johns Hopkins in partnership with Duke University and the Minnesota Hospital Association conducted a study of hospital safety and teamwork culture and patient outcomes. Specifically, the survey asked a hospital’s doctors, nurses and other staff if they feel comfortable speaking up when they have a safety concern, if communication breakdowns are common, and if management is responsive to their needs.
The study, published recently in the Journal of the American College of Surgeons, found what many doctors and nurses have long known to be true, that a hospital’s culture is a powerful factor in a patient’s surgical outcome.
When hospital employees feel that patient care is well-coordinated and their ideas are valued, patients receive safer care. Conversely, when the teamwork is poor and management is distant, bad things are more likely to happen.
In medical organizations around the country, increasingly, doctors describe working within one of two types of organizational cultures. One where staff are happy, turnover rates are low, and clinicians feel a sense of ownership over the entire delivery of care.
The other is a workplace where doctors believe they know how to make care safer, but feel their management is out-of-touch. As corporate medicine and new technology threaten to depersonalize the doctor-patient relationship, a serious risk to our nation’s health care system is an organizational culture that takes a back seat to the frenzy to collect data to look good on regulatory requirements.
Without meaningful metrics of hospital culture and patient outcomes, we are all flying blind. Health care reform becomes a discussion about how to finance the broken system, not how to fix it.
Creating a great and affordable health care system should begin with supporting the work of doctor groups and patient registries to create ways to measure outcomes accurately and fairly. We should be cautious in celebrating health care’s triumphs as long as medical error is the third leading cause of death in the United States and some patients tell us they can’t afford the surgery we offer them.
Traditional studies in medicine have asked whether there is an incremental benefit associated with a new medication and surgical technique, but we could do more to evaluate the benefit of the nontechnical (behavioral) skills that result in great medical care.
Improving patient safety and quality is an endeavor that requires both human factors and an organizational approach. An organization’s culture also influences our professional fulfillment and workplace happiness at a time when outside burdens are piling on. Improving hospital culture has implications for the important problem of burnout in the medical profession, a well-known safety issue that affect patients.
Health care harm is common, real and costly. As scholars of health care work to improve measurement of health care quality, we should remember that when physicians are looking for medical care, we do not look up a hospital’s readmission rate — we go to a place with a great culture.
