Some healthcare organizations have started using "fake patients" who "mystery shop" the hospital or physician office experience, a tool that many retail stores use to measure how they're serving customers. The use of this tool in healthcare, however, has sparked a debate about whether these "fake patients" take away from doctors' time with real patients, and could prevent a truly sick patient from receiving timely care.
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.
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New York hospitals had a higher rate of infection in surgical intensive care units in 2007 than the rest of the nation, according to a report. Compared to the national average of 2.7 infections per 1,000 days of central-line treatment, New York surgical intensive care units had 3.7 per 1,000. The report on hospital acquired infections was conducted by the state in compliance with a 2005 law that required New York to track statewide infection trends. The data for 2007 are not broken down by hospital, but in 2009 that information will be provided for hospitals in 2008.
The daughter of a woman who died unnoticed on the floor of a Brooklyn hospital's psychiatric unit has called for criminal prosecution of the workers who did nothing to help her. The family notified the hospital, New York City, and the city's Health and Hospitals Corporation that they intend to file a $25 million lawsuit. Surveillance footage showed the death of Esmin Elizabeth Green, 49, who collapsed face-down on the floor of the Kings County Hospital Center's psychiatric emergency waiting room, where she had been for nearly 24 hours.
Gov. Ed Rendell has signed an executive order reopening the highly regarded Pennsylvania Health Care Cost Containment Council after an unexpected weeklong hiatus. The agency fell victim to the budget season's political battle, and the order allows it to resume operations through November and send its 44 employees back to work. The council is an independent agency considered a national leader in studying the quality of healthcare and its cost at the state level.
Officials at Gallatin, TN-based Sumner Regional Medical Center say they're addressing procedures that led to a federal investigation into allegations of poor care provided to a man who died in the hospital's emergency room. Investigators with the Centers for Medicaid and Medicare said if the hospital had not taken corrective action, it could have cost the hospital its Medicare funding. One of the deficiencies cited in the investigation was in the nursing staff levels during one shift over a 14-day period.