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Set the Bar High

Maureen Larkin, for HealthLeaders Media, July 9, 2008

Would we have ever heard of Edith Isabel Rodriguez if her death on a Los Angeles hospital's waiting room floor weren't captured on a video surveillance tape? Probably not. That tape, which has been held for more than a year by county administrators as "confidential, official information," was leaked on the Internet last week, reigniting the discussion on cable news stations about the lack of compassion in America's healthcare system.

But in my mind, the discussion should be more about leadership. After Rodriguez's death in 2007, administrators of the county-run hospital repeatedly tried to cover up the event, reporting the woman's death to the coroner's office as that of a "quasi-transient woman with a history of abusing drugs." There was no mention of how long the woman waited in the emergency department for treatment before she fell to the floor, or how six hospital staff members walked by her as she writhed in pain. In fact, a county administrator told the Los Angeles Times in 2007, "If there wasn't a videotape, we wouldn't be discussing it. Period."

Without the videotape, we wouldn't know anything about Rodriguez, or how the lack of action by hospital staff members contributed to her death. Her family would be given a list of excuses, but few answers. Hospital administrators would have covered up the incident and allowed employees to ease their guilt with a list of excuses.

But a good leader knows that to provide quality patient care, there are no excuses. He or she knows that mistakes happen, and when they do, it is best not to cover up the mistake, but share it with the organization so that others might learn from it. This was the case in Boston last week, when Beth Israel Deaconess Hospital's CEO Paul Levy communicated a wrong-site surgery case to his employees.

"This week at BIDMC, a patient was harmed when something happened that never should happen: A procedure was performed on the wrong body part . . . we are sharing this information with the whole organization because there are lessons here for all of us," Levy wrote in an e-mail to BIDMC employees. He later posted the e-mail and follow-up thoughts on his blog, Running a Hospital.

Levy writes that the surgeon in this case immediately informed his supervisor when he realized the error, and the organization's Health Care Quality staff was able to immediately interview everyone who was present in the OR when the error occurred, gathering details that will help them figure out how the error happened—and what can be done to prevent future errors. The patient was told of the error and apologized to upon regaining consciousness, Levy says.

Mistakes happen. We're humans, so they always will. But in order to succeed in providing patients the best possible care, hospitals must have effective leaders—leaders who are ready to admit mistakes when they happen, as Levy did, and examine processes to make sure they don't happen again. Good leaders know the value of true transparency and are prepared to face family members of a wronged patient and offer support to clinicians involved in the event.

What kind of bar have you, as a leader, set for your organization? If an error occurs tomorrow, will you put it out there for the world to see, or will you try to sweep it under the rug? Are you prepared to explain the situation to the affected patient and his or her loved ones? Can you offer support to the medical personnel involved? A good leader will turn an unfortunate error into an opportunity to make their organization safer.


Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at mlarkin@healthleadersmedia.com.


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