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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety, the potential contribution of checklists to reducing medical errors, and his upcoming book about the need for more transparency in the healthcare system. Marty was well dressed and soft spoken – sincere, and human. We exchanged business cards and wished each other luck in changing the healthcare system for the better. We were two doctors tilting at windmills.

Just two months ago my fiancé sent me a “must read” article from the Wall Street Journal. It was Marty’s provocative piece, “How To Stop Hospitals From Killing Us.” The article was an excellent primer for his book, “Unaccountable: What Hospitals Won’t Tell You And How Transparency Can Revolutionize Health Care” which I highly recommend (holiday gifts, anyone?)

Unaccountable is both horrifying and oddly optimistic. Marty describes case after case of medical errors, lapses in judgment, and near misses in the surgical suite. He exposes the cultural foibles of the medical and hospital hierarchy, leaving no dirty stone unturned. Surgical delinquents such as Dr. Hodad (“hands-of-death-and-destruction”) are presented with detached accuracy, along with a clear list of reasons why the system fails to prevent the Hodads of the world from operating.

From the micro (individual physician mistakes) to the macro (trends in hospital safety breakdowns), Marty turns to survey data to make sense of the shortcomings. Interestingly, hospital “culture” (rated by its own employees) is the most predictive of overall hospital safety performance. Detailed record keeping of surgical complication rates correlates strongly with how employees rate their hospital on three simple questions:

1. Would you have your operation at the hospital in which you work?

2. Do you feel comfortable speaking up when you have a safety concern?

3. Does the teamwork here promote doing what’s right for the patient?

Marty’s conclusion that culture is the defining factor in patient safety and satisfaction ratings is both accurate and squishy. It’s difficult to create a reproducible template for a healthy work culture, and yet good culture is the basis for the success of hospitals such as the Mayo Clinic. Individual hospitals, like individual surgeons, have different personalities and temperaments. Raising them to be upstanding citizens involves a combination of good parenting and good luck.

Because I think Marty is absolutely right about culture as the foundation for safe and effective care, I think he’s also overly optimistic about the potential success of strategies to reproduce caring hospital cultures. By his own admission, not even the Mayo Clinic “mother ship” in Rochester, MN, has been able to create the exact level of quality care in its sister hospitals in Scottsdale, AZ, and Jacksonville, FL. So how can we dramatically improve patient care on a national level? Marty suggests that we need to find ways to force hospitals to become more transparent in order to revolutionize healthcare. His ideas include:

1. Mandatory hospital public reporting of patient re-admissions, complication rates, and never events.

2. Adoption of check lists by surgical teams to reduce errors.

3. Installation of video cameras throughout hospital floors and surgical suites so that staff behaviors can be monitored more effectively (e.g. to enforce hand washing or identify surgeons who have high error rates).

4. Accessible and transferable medical records that put patients at the center of their documentation.

While these ideas have merit, I believe they will fall short of achieving our ultimate goals. In my view, a culture of accountability is not the same as a culture of caring. Adopting certain “Big Brother” (cf. #3 above) strategies to pressure staff to behave/perform appropriately is only going to force the Hodads underground. We need staff to genuinely care enough about their patients to gang up on the Hodads and kick them out of the hospital for good. Caring doesn’t happen at a national level, it is personal and local. That’s why individual hospitals must develop their unique cultures for themselves, with progress measured by responses to those staff questions about whether or not they’d want to be cared for at their own institution.

I agree with Marty that hospital data transparency might be the best antiseptic we have to scrub the underbelly of medicine, though the ultimate success of our procedures will always be culture and surgeon-dependent. And that’s something you can’t regulate from Washington.

***

Marty’s book is available for purchase at Amazon.com.

Check out your local hospital safety scores from LeapFrogGroup.

How A Patient Who Asks For Salt For His Eggs Could Cost A Hospital $2.5 Million

This was a classic moment of comical clarity that only comes along once a week.  As you may or may not know, starting in 2013, The Medicare National Bank has promised to take back 1% of all  of a hospital’s total Medicare revenue (to increase in future years) if the hospital has a higher 30 day readmission rate for  congestive heart failure, acute myocardial infarction or pneumonia than an as yet undefined acceptable 30 day rate of readmission.

What does this mean?  It means if the government decides that 20% is an acceptable rate for congestive heart failure 30 day readmission, and the hospital has a readmission rate of 25%, the hospital will be told to return 1% of all Medicare revenue for the year, not just their heart failure revenue.

Let’s use some hypothetical numbers, shall we?  If a hospital generates $250 million dollars in a year on 25,000 Medicare discharge diagnosis related groups (DRGs)  but only 100 of those discharge DRGs (or $1,000,000) were heart failure in 2013, what would happen if 21 CHF patients returned for readmission  (a 21% thirty day readmission rate) within 30 days for heart failure instead of allowable 20%? The hospital would have to return 2.5 million dollars (1% of their total revenue on all Medicare admissions).
That one patient that took them from 20% to 21% will cost them 2.5 million dollars.  The hospital would generate one million dollars in CHF  revenue for the year and pay back 2.5 million dollars in penalty.  That’s a pretty hefty price to pay considering that hospital profit margins from Medicare have been negative, on average, for most of the last decade. Read more »

*This blog post was originally published at The Happy Hospitalist*

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