By Mark Crockett, Digital Health CEO
April 2021– In the excellent book “The Hard Thing about Hard Things” by Ben Horowitz, he extolls the virtue of communicating bad news. Culturally, after the first few times bad news is delivered, people stop worrying about disclosure and get in a cadence of fixing.
So, I’ll start: the bad news is healthcare is still not good enough at keeping patients safe.
Missed or inaccurate diagnosis, procedural error (wrong patient, wrong site) and many other opportunities to improve still affect as many as 1 in 10 patients. Since the famous 1999 IOM report “To Err is Human,” U.S. hospitals have made significant improvements in patient safety, and there have been noticeable declines in certain areas of focus, but there are still far too many adverse events in health systems nationally and internationally.
In addition to practicing medicine in an excellent organization, as the CEO of a software company focused on patient safety, I had the privilege of working with great health systems reducing patient safety risks. It probably won’t surprise you that organizations that are leading in patient safety are also leading in patient experience and have better outcomes. In my experience, they are universally taking a systems approach to reducing harm and have used root cause analysis to look deeply for the usually multiple factors contributing to harm. Although there are many examples of how this is being done, two lessons stand out: honest communication internally and externally (Ben Horowitz would be proud), and keeping fixed things fixed.
First, there cannot be enough communication internally about solving for patient safety. An excellent article from last year tied scores on the Safety Attitudes Questionnaire (SAQ) to statistical decreases in all patient harm across multiple harm types and across an entire system.
Not all staff appreciate that an adverse patient event impacts the system’s reputation at that patient’s level, for the family and community they live in, but it also has important financial impacts. When an adverse event happens, there is often a direct loss of revenue for that patient. But in areas where health systems are taking on risk, the cost of an adverse event can be theirs to bear. Absorbing thousands of dollars in cost related to a single incident can erase the profitability of an entire service line for a period, limiting a health system’s ability to invest in things meaningful to everyone involved in care.
Can’t you picture the Venn diagram? The place where patients’ needs, revenue, and expenses all overlap is right there. Unfortunately, the pace of change and the complexity of delivery in healthcare works against the goal. Constant internal communication about the value of safety is a critical part of the effort. Also, the goal of transparency and disclosure needs to be constantly reinforced to achieve “frequent sharing of bad news” as a normal part of culture. Evaluation of that paradigm shift needs to be frequent as well. Using a vehicle like the SAQ avoids the famous Shaw quote “The single biggest problem in communication is the illusion that it has taken place.”
Frank and timely disclosure is not only a requirement of patients but is supported by caregivers and patients alike. Studies indicate that patients with good communication around an adverse event have less trauma, and better outcomes, and are less likely to litigate. This should not be controversial but is often one of the most difficult things to get right. Where there are questions about liability risk, resources are available and outcomes are documented? (see the excellent discussion in Health Affairs of the Massachusetts implementation of CARe program in resources, below.) For patients, an apology is expected and helps maintain trust in the physician and health system relationship. So why do we continue to fail at this critical part of the healing process? Many of the lessons boil down to Ben’s point about disclosing bad news: do it frequently and get people over their resistance through hard work and executive commitment.
Lastly, one of my favorite lessons from a client is that organizations need to spend time and energy keeping things that get fixed, fixed. The worst case is having an incident and finding out that there is a system policy designed to prevent that incident. Often this is because you had that kind of incident before and are not following your own policy.
System failures are well known to be the great majority of errors, and once a system has been “fixed” through redesign, forcing functions, etc., the urge to regress to old processes is strong. Here is where health systems that have a strong compliance organization have a real advantage. The same infrastructure for maintaining financial, security and regulatory compliance, if tasked with internal safety compliance, can be a significant asset in keeping patients from harm.
A great story from one of our clients surrounded a near miss where, during an extremely stressful event, a physician opened a cabinet to pull a kit and found new and unfamiliar supplies and not the expected tools. Although the patient did well, under analysis part of the cause of the issue was a purchasing process that did not involve all departments that might be using that kit. A well-intentioned change driven by a particular area had changed the supply requirements. Several years later, the organization continues to survey the providers to ensure stakeholders are represented in purchasing, and that survey process is on a compliance checklist. Now that is an organization with a memory.
Getting to zero harm is an endless task, but not a thankless one. Patient satisfaction and improved outcomes that come with financial and risk benefits align all stakeholders, which is often missing from healthcare. As one CMO shared specifically about disclosure, “if it wasn’t so hard, everyone would be doing it.” The last 12 months have certainly been a time of re-alignment and re-examination of priorities. With all of that going on it seems the message “go find bad news to share” should fit right in.
“Association Between Medicare Expenditures and Adverse Events for Patients with Acute Myocardial Infarction, Heart Failure, or Pneumonia in the United States” JAMA Netw Open. 2020 Apr 1;3(4): e202142. doi: 10.1001
“Disclosure of patient safety incidents: a comprehensive review.” Elaine O’Connor, Hilary M. Coates, Iain E. Yardley, Albert W. Wu. International Journal for Quality in Health Care, Volume 22, Issue 5, October 2010, Pages 371–379.“
“Effects of A Communication-And-Resolution Program On Hospitals’ Malpractice Claims And Costs” Health Affairs, Vol. 37, NO. 11
“An Organization With a Memory” https://webarchive.nationalarchives.gov.uk/20130105144251/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4065086.pdf
About the Author
Mark Crockett is an experienced Chief Executive Officer with a demonstrated history of working in the hospital & health care industry. Mark’s experience ranges from Healthcare Consulting, Disease Management, Executive Development, Medicaid, and Emergency Medicine. Mark is a strong business development professional with a EDP Program focused in Business from The Wharton School, University of Pennsylvania.