How Many Must Die? – Part 2

So how did we get to this point? Is health care delivery really that far behind in quality?

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In April 2000, the Institute of Medicine issued a report titled “To Err Is Human: Building a Safer Health System.” This report detailed the incredible number of mistakes and adverse outcomes that occur in American health care. As one might expect, this sort of exposé had many detractors (JAMA. 2000 Jul 5;284(1):93-5).

Of course, it’s nearly impossible to completely remove errors when humans are a major part of the process. No matter how educated or skilled we are, mistakes are bound to occur. There is something in our nature though that seems to prevent us from admitting to making these mistakes and being transparent about them.

As an example, assume you are the parent of a child and your pediatrician makes a mistake. Don’t you think you should have a right to know? Most parents want this kind of disclosure (Arch Dis Child. 2010 Apr;95(4):286-90). Unfortunately, mistakes are often buried and not disclosed. This is even more likely when the pediatrician thinks the parent is less likely to find out about the error. (Arch Pediatr Adolesc Med. 2008 Oct;162(10):922-7).

Obviously, one of the things that works against disclosure is our litigious society. That seems like a rather pat answer though. Lawsuits may actually be more of a symptom of a deeper problem and not the primary cause of what is happening.

There are probably a couple of factors that are playing roles in the health care quality problem.

First, health care has become incredibly complicated. It isn’t just due to the types of care provided using advanced technology but also the business of health care is a massive tangle. If you don’t think so, just try to contact a few hospitals and see if you can find out the cost of something as simple as an appendectomy. It’s unlikely that you will be able to get a straight answer. Some of this is legitimate because of other medical conditions that may come into play because of the cost of care. The crazier part of it though is that the cost isn’t set – it’s completely influenced by the prices negotiated by your health insurance provider. Even if you need to go into an emergency room to obtain care, it’s unlikely that anyone you come in contact with would have any clue as to how much your visit is going to cost you.

This complicated system drives health care organizations into the second problem, structures that are very resistant to change. This is even more evident as organizations become larger and larger. Not only is there a systemic problem, but the large scale of organizations and the multiple approvals needed for projects turns health care systems into institutions with all of the speed and nimble handling of a glacier.

This problem is even more apparent when you look at how long it takes for a new pharmaceutical agent or medical device to gain wide acceptance in the marketplace. Granted, there is some reluctance for providers to become early adopters of new technology until it has stood the test of time. Guess how long though it takes for widespread adoption of new medicine or technology. Do you think it might be five or ten years? Try again. The average is 19 years.

Personally, I use the “loved ones test” when I look at new technology. Essentially, if there is enough convincing medical literature suggesting benefit, I ask myself “would I want this for one of my loved ones?” If the answer is yes, it’s probably a pretty good technology to at least trial if not outright adopt.

This resistance to change might be one of the biggest barriers to improving quality in health care. It’s both a problem of organization size and inertia along with something that is much more sinister and not discussed –  the problems of power, ego, and self-interest. On the surface nobody will admit to this, but I have seen these themes crop up over and over again. For example, I worked at a large metropolitan hospital and wanted to empower patients to ask their caregivers if they had washed their hands. Seems like a simple thing, doesn’t it? Obviously it wasn’t. I had to bring the idea before the nursing union which adamantly blocked the process. I had never dealt with the union before and I wasn’t sure why the senior administration wouldn’t tackle this issue with them since they were responsible for union negotiation issues.

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This whole problem reminds me of a book I read that was recommended to me by a friend years ago (thanks Jennifer). The book is People of the Lie: The Hope of Healing Human Evil by M. Scott Peck. In it, Peck gives a number of case studies of individuals who appeared normal on the outside but clearly had problems of evil within their cores. Maybe that’s something that our superficial culture has spawned. Later in the book though, he discusses corporate evil, which is one of the most fascinating topics and arguments I’ve ever read. He conducts an organizational case study of the Mỹ Lai Massacre by a unit of the US Army during the Vietnam War. He poses the question “How is it that approximately five hundred men, the majority of whom were not evil as individuals, could all have participated in an act as monstrously evil as that at MyLai?” The answer to that question has fascinated me since I read the book years ago. The entire discussion on the topic of organizational evil is really a must-read for anyone interested in organizational culture.

So are health care organizations evil? Usually not. Do they have evil characteristics? Sometimes. You don’t have to look far to find ones who blatantly put profit over safety. For example, in 2008 it was discovered that an endoscopy clinic in Nevada was reusing syringes and medication vials in attempt to cut costs. The incident led to the largest public health investigation (40,000 people) in US history. I’m board-certified in infection prevention and was dumbfounded to hear that something like this occurred with so many patients at risk and so many providers at fault. This is exactly the kind of group think that Peck was referring to in his book.

There are other problems that occur in the health care system as well. For example, I’ve seen instances where physicians are allowed to make decisions around preventative measures in a hospital that would potentially impact the volume of work they would see in their private practice. In other industries, that would be considered a major conflict of interest but that problem didn’t even seem to make anyone’s radar because it was the normal way of doing things. That thinking and process must change if we are to see improvements in health care quality.

So here is the real question. Why is it that health care is following the lead around manufacturing processes (the Toyota Production System in order to learn to be lean, Six Sigma from Motorola to reduce variability and improve quality) or simple things like preflight checklists in the airline industry to ensure safety? Health care is making progress in these areas but shouldn’t health care be the leader instead of the manufacturing and transportation industries? Where did we go wrong?