Don't Hide Your Mistakes

HealthLeaders Media Staff, April 24, 2009

Nobody wants to harm patients, especially the CEO, but according to Rick May, M.D., an orthopedic surgeon consults for HealthGrades, it's likely your hospital has a culture of hiding mistakes. And it's lurking, just waiting to bite you.

According to a recent study by the healthcare ratings organization, a Medicare beneficiary experiences a patient safety event every 1.7 minutes. And the innocuous nature of the word "event" doesn't effectively describe that it's a synonym for mistake?sometimes one that ends a life prematurely. Some 913,215 patient safety events occurred during the scope of the study, which was conducted from 2005-2007. That means approximately 2.3% of the nearly 38 million Medicare hospitalizations resulted in an error.

Rick May, M.D., an orthopedic surgeon who led the study and consults for HealthGrades on patient safety, says often a hospital's senior leadership team has no idea that its hospital may be a poor performer because they haven't cultivated a culture of transparency within the organization related to patient safety.

That's not to say doing so is easy.

"It's not easy for the CEO," May says, adding that sometimes, he or she is ignorant about data that can show how a hospital's individual departments compare in terms of quality with other organizations of similar size.

As part of a recent consulting engagement, May and his staff, met with the entire C-suite and the head cardiologist in a program with more than 20 cardiologists of a large Midwest hospital. Turns out the cardiology program had subscribed to an American College of Cardiology database that captures information on heart outcomes.

"They had been paying to collect this data for five to six years, and it's expensive," May says. "We were talking with them and noted the fact that they have the data, but what are they doing with it?"

"I take care of it," says the head of cardiology.

"I pay for this and he won't show it to us?" the CEO says.

"No," the cardiologist says, "it's my data, and I control it."


Over the course of a year, May continued his consulting engagement with this hospital. Near the end of the program, he and the CEO were in a conference room, when someone walked in, handed May an envelope that contained the ACC data summary, admonishing him not to tell where he got it.

He didn't.

May then took several pieces of that information, which, in his words, "wasn't terrible" and put it into his presentation to the cardiologists and senior hospital leaders.

"The point is, they were shocked that they were below average," May says.

The rest of the group hadn't seen the data either, and as a result, hadn't been encouraged to improve their performance in the weak areas. Eventually, they shamed the cardiology head into providing the full data.

"If you're working on improving your processes, you can't not have your nurses or staff in the room, or for that matter, the CEO," May says.

That advice goes for the public too, I might add.

Even nonphysician CEOs should be saying that they will support transparency across the institution and let chips fall where they may. Doing so may hurt your reputation in the short term. Understandably, given the liability that could come from admitting mistakes and the hit to revenue that could come from having that data out in public might be an issue, but it doesn't trump the cost to the hospital from medical mistakes in the long run.

"Recognize that your system is most likely set up to conceal mistakes and internally, you have to be very diligent about pursuing the truth."Your first look at the data may be very misleading," May says.

Understand that you're not only concealing this data from the public, you're concealing it from yourselves as hospital operators.

"For decades, their system has been set up not to report medical mistakes," he says, "so you really have to dig. Do not believe your first pass. You might have to create active monitoring systems to really find out what's going on."

It takes lots of resources to make this happen. But look at it this way, based on the HealthGrades study, about 2% of Medicare patients are experiencing an event. That represents only about 50% of the ones who do have an event, May says, because mistakes are significantly underreported.

These mistakes cost between $7 billion and $9 billion over the three-year period of the study, which translates to $1 million-$2 million per hospital, not to mention the incalculable damage that has been done to patients because of errors.

"Before where patients experienced some of these events, it was a perverse incentive and the hospital made money on them," May says.

But given the ever-expanding list of "never events" that Medicare won't pay for, and the idea of paying for episodes of care, as Medicare and Congress seem interested in doing in future regulation and legislation, "anything that extends length of stay is going right to the hospital's bottom line."

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