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Federal Hospital Inspectors Miss True Dangers, Focus On Documentation Minutiae

In an effort to promote transparency in healthcare, the Association of Health Care Journalists (AHCJ) has published a database of recent hospital deficiencies discovered by Medicare and Medicaid  inspectors. They then highlighted 168 reports containing the phrase “immediate jeopardy.” This, of course, piqued my interest as I presumed that hospitals who were putting putting patients in “immediate jeopardy” must be some pretty bad actors.

After sifting through the hospital names, I saw no record of ones who should probably be on the list based on my personal experiences. I did find some surprises, including well respected academic centers (including Stanford, UCSD, and Intermountain Health). I did a “deep dive” on a hospital for which I have a good deal of respect and some familiarity. What I discovered was both funny and sad.

In the case of the hospital that I knew, the very grave concerns expressed by the inspectors turned out to revolve around patient signatures on HIPAA documentation, and physicians refreshing their electronic restraint orders on patients with traumatic brain injuries. These documentation mishaps had landed the hospital on the ominous list of institutions who are “putting patients lives in immediate jeopardy.”

What a waste of inspector time and hospital resources! Apparently, a hospital who passes CMS muster simply means that they are providing documentation correctness to patients. Forget the real sources of life-threatening dangers – medication errors, poor physician handoffs, unnecessary testing and treatment, and unsanitary conditions. What the safety police are focused upon is whether or not the sick and delirious signed their health information privacy paperwork.

Now don’t get me wrong, I think it’s important to let patients know their rights, etc. But I’ve yet to see more than 10% of patients even read the HIPAA-related documentation that they sign.  Surely an absent signature or two shouldn’t land a hospital on a humiliating federal watch list.

True patient safety cannot be regulated. It is far too complex and nuanced, requiring collaboration between all members of a hospital’s staff. From frequent nursing surveillance, to careful medication review, to laboratory critical value alerts, to conscientious sanitation practices – hospital culture dictates whether or not a patient receives excellent care. Watch lists would be far more accurate if they were simply based on hospital employee questionnaires. As Dr. Marty Makary has discovered, complicated care quality algorithms are no more accurate at predicting hospital excellence than simply asking staff if they’d recommend the place to family members.

So next time you see your hospital flagged by the feds, don’t assume that there is a serious problem going on – better to ask someone who works there if it’s a safe place for care.


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6 Responses to “Federal Hospital Inspectors Miss True Dangers, Focus On Documentation Minutiae”

  1. edwin leap says:

    Val, awesome post and excellent work! It’s about control, busy-work and job security. Period.

  2. Ben says:

    Great post! I’ve found that this basic flaw is true (maybe inevitable) when trying to measure the performance of virtually any large, complex system. The measure of whether an organization is doing a “good job” is so complicated and includes so many key factors that cannot be controlled for (i.e. patient demographics), that inspectors are forced to rely on small number of objective heuristics (“did paperwork X get filed”,”have doctors spoken to patients about smoking and documented it”, etc). These heuristics can be measured, and they’re sometimes correlated with quality, but more often than not they’re weak stand-ins for a more subjective analysis… which of course carries its own pitfalls. I’m not sure what the solution is, exactly, but I suspect that this type of “checklist” review is more misleading than it is illuminating.

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  6. Steve O' says:

    The language of such things is, of course, the language of propaganda.

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