Big Brother Arrives: Monitoring Patient Safety Compliance By Remote Video

Today came the announcement that Suzanne Delbanco, founding director of the Leapfrog Group, has assumed the presidency of a company that tracks compliance with safety and quality practices via remote video. Big Brother, meet the Joint Commission.

The report, in today’s Modern Healthcare, describes the process this way:

Video auditing refers to a system in which cameras are mounted in targeted locations to continuously capture specific clinical processes, such as observing handwashing and hand-sanitizing stations. [Using video] fed through a Web-based link, independent, third-party observers audit the recordings and provider reports on safety incidents.

Did you ever doubt this was coming? Virtually every other industry with compliance standards has long used video to monitor compliance and to goose workers into following the rules. If video surveillance is good enough for Vegas croupiers and Kansas meat packers, why wouldn’t it be good enough for neonatal nurses and ER docs?

Consider hand hygiene. Until a few years ago, low hand hygiene rates were just accepted as inevitable and unfixable – “we can’t control what the docs and nurses do,” lamented many infection control practitioners. But now that infection rates are being measured and reported (and soon tied to payments), hospitals are doing backflips to promote hand hygiene. With this focus, many hospitals, including my own, have seen hand cleansing rates skyrocket, from previously mortifying levels of 20-30% to merely embarrassing rates of 60-80%. But even with all the attention we’re lavishing on preventing nosocomial infections, we can’t seem to get to 100% (for a nice discussion why, see Gawande’s insightful essay).

Hospitals everywhere, under tremendous pressure to get these rates up, now conduct spot audits – with infection preventionists hiding in dark corners of ICUs and wards, recording whether providers cleaned their hands. Everybody accepts this kind of monitoring as the cost of doing business in the Patient Safety Era.

Several years ago, at one of our medical center quality meetings, I suggested that we should consider remote video monitoring of key clinical areas like ICUs. It seemed to me that – as long as we were going to go through the trouble of deploying people to snoop on their colleagues – why not just bite the bullet and put up cameras, which would be less intrusive over time, less game-able (folks putting forth their best behavior in response to an auditor’s visit) and ultimately less expensive than human observers. “We can’t do that,” came the shocked reply. I never got an answer to the “why not?” question.

Of course, it is natural to be slightly repelled by this concept. Companies like Delbanco’s (called Arrowsight Medical) are generating the predictable concerns about patient and provider privacy, and these creeping willies are likely to crescendo, particularly once the first nurse or doctor is reprimanded after being caught with dirty hands. (Perhaps this will ultimately be like those automatic traffic video systems that send drivers tickets after running red lights – in this case, the camera will notice that you didn’t wash your hands and submit an incident report on you.)

Just as predictably, Delbanco and others coo that these systems won’t be used punitively:

…the concept is meant to bolster individual control over patient safety practices, not give a hospital any control over providers, according to Delbanco. Video monitoring contributes to a culture of safety; “part of the team culture is measuring performance,” she said. When team members see their collective performance increase, there is “enormous pride. That was a feature that sold me,” she said.

Yeah, sure.

You can see where this is going. Now that safety practices are being publicly reported, required by accreditors and even legislators, subjected to media scrutiny, and even paid for (or payment withheld when they are absent), the pressure to measure these practices is escalating faster than the cost of a Wall Street bailout. Unlike quality measures that can be captured through chart review (did the patient receive aspirin and beta blockers?), many safety measures rely on provider self-reports or the observations of others. Was the head of the bed elevated? Did the surgeon conduct a time out before the first incision? Did the patient receive full barrier precautions before central line insertion? Did the nurse come running when the bed alarm went off? Did providers clean their hands? All these practices can be monitored easily and relatively inexpensively via remote video.

Although the privacy concerns are real and the concept does give me a bit of the heebie jeebies, I predict that video surveillance of safety practices is here to stay.

So get used to it. Who knows, it might even save a few lives.

12 Responses to “Big Brother Arrives: Monitoring Patient Safety Compliance By Remote Video”

  1. DZA September 23, 2008 at 10:58 am #

    bob,

    take it out just another notch. consider this scenario (i have):

    audio/video in every pt room. activated (with consent of both parties, or by default depending on circumstances) for every meaningful clinical encounter to record exactly what was said and done by who and when. this is compressed, saved to memory (cheap), archived, backed up, and submitted for documentation, education, compliance, medico-legal and billing all in one.

    payors can audit randomly. if payment is time based (like lawyers and anesthetists) then payors can use robots to do this. overhead slashed and billing simplified.

    QA implications are obvious.

    education implications are wide reaching, and again, obvious.

    data portability, or more significantly, single sign on access is now possible. pts can be given a flash drive with their hospital visit recorded upon d/c.

    documentation is indisputable. all medical legal issues will submit to arbitration as evidence is transparent and reliable. expensive and ineffectual malpractice essentially solved. (my real mistakes have never been detected by conventional means, though i always cop to them with the patients involved and avoided suit every time…my one suit was frivolous and dismissed with prejudice and without reward).

    everyone will suddenly be very well behaved. and pt and their families might see how they behave(or misbehave) as well. and the bogeyman TA who abuses granny every night will be exposed.

    the archive can be edited to suit the application (eg pared down for pt portable record, expanded for medico-legal analysis).

    pt and clinician can “opt out” and use their conventional insurance. my idea ( i call it “middle brother” in a TOTH to orwell and doctorow) is essentially an insurance product. opting out means the usual paper or electronic documentation, billing, oversight, and adversarial adjudication of malpractice. pick your poison.

    i have long thought of patenting this, or pitching this, to my buddies at google and aetna. but i have a day job. a hard one. adoption and, if appropriate, attribution, are my only wants.

    respectfully and without trepidation,

    DZA

    /30 year combat veteran…20+ in EM, now 8+ in hospital medicine
    //yeah i think about this a lot…

  2. menoalittle September 24, 2008 at 1:03 am #

    Bob,

    Great report. The website of Leapfrog, the business consortium mentioned in your post, lists 8 staffers, 17 Board Members, and 6 Liasons to the Board. Only one of the 31 is a physician. This group represents the financial interests of big business under the guise of improving patient care.

    This group has promoted the virtues of CPOE devices and intensivist staffing of ICUs as two of the four major “leaps” for hospitals, yet expensively disruptive CPOE devices do not have safety and efficacy studies to back them and you already reported (June 4, 2008) on the study showing lack of benefits of intensivists in the ICU.

    Now, its former CEO, Delbanco, is spearheading a big business moneymaking opportunity consisting of an invasion of privacy of patients and physicians in the trumpeted (but not proven) interest of improving patient care. Sounds like a HIPAA violation to me.

    There is a rule not permitting cameras in patient care areas yet the interests of big business will likely trump this and the C suite folks will undoubtedly use the unfettered spying for purposes other than improving care, such as “peer review” and disciplining employees.

    Best regards,

    Menoalittle

  3. andrewmc September 24, 2008 at 4:00 pm #

    Police cars have constantly rolling digitised recorders in place to document exactly what happens during any particular shift so that in the event that “bob” (I’m going to have to stop using Bob as an example if I post here) gets a little carried away and drives off, assaults someone and so on and so forth.

    Custody cells have cameras to protect the police from the accusation of mistreatment, though you’d be surprised how many police men and women forget it is there when they choose to take a baton to a prisoner.

    I’m becoming concerned about how much I know about police cameras.

    The police record interviews with witnesses and suspects to ensure there is clarity surrounding the record.

    Whilst businesses will prosper from the introduction of cameras to patient areas. It is pretty difficult to argue that a camera pointing at, for example, a door on to a ICU that covers both the door and the Hand Gel device is somehow invading Bob’s (the patient this time) privacy.

    Menoalittle

    As to proving the effectiveness of video in documenting whether compliance can be improved, if a tape captures a physician entering a patients room and touching the patient having not washed their hands I’d suggest there are few circumstances under which that would be considered acceptable. Do you disagree?

    What do you think the repercussions should be? none? disciplinary action?

    Its interesting that the response within health care to the idea that people would verify that whats meant to be done is actually done is “its an invasion of X’s (fill in patient or member of staff) privacy”. Where as everyone feels quite reassured when you see on the news that the lowly gate agent detected the odor of a 1/5th of Jim Beam on the pilots breath as he walked past him and called the police.

    The fact is that in any other sector where you jeopardize your own or others safety you are subject to internal disciplinary action and in some instances legal action.

    Why should health care professionals be exempt? and why should organizations not protect their own interests by ensuring that their staff are following procedures that they have agreed to by accepting their jobs?

    If Bob (the real one here that works at UCSF) accepted the role he currently has, he also accepted to abide by the health and safety rules and regulations in place. If he chooses to ignore these then the organization is well within its rights to explain to him that following health and safety regulations or procedures is not optional.

    I’m not sure that there is a legitimate reason for objecting to this beyond the fact that people don’t want cameras in the work place.

    I’d be interested to know your thoughts about how you think we can continue to improve the standards given the limited and “embarrassing” level of success that we’ve had to date.

    Cheers

    Andrew

  4. Suzanne Delbanco September 24, 2008 at 4:07 pm #

    As a doctor’s daughter and sister-in-law to a nurse, I know up close and personal that health care professionals work extremely hard to help and heal their patients. I know also that it is rare for them to receive specific and actionable feedback on whether they are following key safety practices, such as those Dr. Wachter cites. And as a very close relative to someone who recently spent six months beating back a hospital-acquired infection, I also know there are patients who wish that more caregivers would adopt safety practices that work. Who knows, patient safety might even become a hospital’s competitive edge. Wouldn’t that be good for patients, and UCSF, as it works hard to fill its beds?

    Arrowsight takes privacy seriously, and we work closely with staff and managers to develop and deploy video auditing programs. Our goal is to promote best practices, and most require high standards of adherence. Minimizing camera views of the patient to what is absolutely necessary is a key goal. Similarly, it goes without saying that both professionals and patients need to be fully informed of the program. Indeed, by definition all staff are aware of Arrowsight’s monitoring – they get regular feedback from it, their supervisors use data as coaching tools, and they trust and rely on the data because they come from a third party. Compare this to the on-site observation Dr. Wachter references, where health care workers are asked to monitor their peers without their knowing, and to the “mystery shopper” and similar espionage programs that some institutions house.

    Here’s a thought. Can you imagine a National Football League where coaches and players excelled without game film? Sure, health care is different from football, but I have never once heard of a professional athlete complain about the use of video analytics to optimize their performance. And what about the cameras in elevators, at bank machines, and in almost all schools? In fact, for several decades now, video technology has been become an accepted way to promote safety in everyday life.

    Patients’ lives are at stake, and in today’s hospital systems they are in harm’s way when dirty hands enter the room. I really appreciate this conversation at Wachter’s World and invite readers to learn more about hospital video auditing by visiting http://www.patientsafetyfocus.com, an Arrowsight-sponsored blog with resources about patient safety and the use of video to improve care.

    Best regards,
    Suzanne

  5. btruax September 24, 2008 at 8:04 pm #

    Bob,

    For a minute, put aside the “big brother” aspect of the videotaping program and consider how use of such a program with appropriate deidentifiers and QA confidentiality protection can be utilized to produce true quality and patient safety improvements.

    We can learn again from our colleagues in the aviation industry. They often utilize a program called the Line Operations Safety Audit (LOSA), which began as a human factors research project at the University of Texas. This is a tool in which trained observers ride in the cockpit jump seat and record a whole host of data about threats encountered, types of errors committed, and responses to the threats. They also include information on how the crews interact with each other and do structured interviews with the pilots on how to improve safety. Airlines then use the LOSA data to improve their processes.

    The same principles can certainly be applied to healhcare settings. Obviously, the operating room would lend itself nicely to the concept. We’ve often talked about the need to audit the surgical timeout because, although all hospitals have a timeout policy, not all practice it religiously. The LOSA concept, if done unintrusively and with appropriate confidentiality and QA legal protection, could provide valuable feedback to healthcare organizations about their patient safety vulnerabilities. Whether it is done by reviewing video of an OR procedure or by having a trained observer physically be in the OR to do a LOSA audit is probably a moot point. We’d probably be at the mercy of the court system to ensure protection of video data but audit data done for QA purposes can be deidentified and used to produce meaningful improvement.

    The point is that the audit can be an extremely valuable patient safety tool that is also cost-effective.

  6. menoalittle September 24, 2008 at 10:28 pm #

    Bob,

    I am duly impressed by the self-promoting and entrepeneurial efforts by commenters 1,3,4, and 5 to devise experiments to alter, and possibly improve, the administration of medical care. All should be made aware of the work of an infection preventionist, Marcia Patrick, RN, MSN, CIC (Director, Infection Prevention and Control, MultiCare Health System, Tacoma) who has achieved the goal in remarkable fashion; without spying on health professionals and invading the privacy of patients (go to APIC’s website). As she states…”compliance can be achieved…without armed guards”. By the way, her program is a lot cheaper. I shall sell my company that supplies armed guards trained in hospital surveillance.

    I wonder if Dr. Debanco’s company can develop a camera to remotely video and record the deliberations of C suite folks when they are discussing the budget for infection control; which would include housekeeping, patient care aids and technicians, cleaning dirty keyboards of the CPOE devices, cleaning bodily fluids from floors (before the next wheel chair or gurney wheels through it), user friendly sinks in sufficient numbers, and cleaning fluid dispensers and towel dispensers in appropriate locations; to mention a few.

    Best regards,

    Menoalittle

  7. andrewmc September 25, 2008 at 9:18 am #

    Menoalittle,

    Apparently you do not let a lack of reading comprehension stop you from lying. That may seem a little strong but I’ve not promoted a business or said who I work for (which is a nationalized health service). This however has not stopped you from leveling accusations that are simply untrue and unfounded.

    No where, and I mean no where, was I self promoting, I do not work for, never have worked for, will (should perhaps not be so dogmatic) / am unlikely to ever work for a hospital surveillance organization.

    In spite of the straw man you still failed to answer the question as to what you believe should be the consequences for a member of staff who fails to follow organizational procedures and how you suggest organizations achieve compliance in a relatively timely fashion given that this should be done in a matter of days / weeks rather than months / years and that the time for discussion about hand washing is / should be largely over.

    I’ve worked in just under 30 hospitals in the past 4 years ranging in size from 2500 staff and a shade under 400 beds to 10,000+ staff and 900 beds and in every single one the discussion is the same. Everyone agrees that hand washing should be done, thats its unfortunate that its not, that we can not discipline people that do not but nothing has really changed.

    The fact is that it should not be a single approach but we should also not be so closed minded as to rule out a tool that may well prove to be instrumental in saving lives.

    Its interesting that since Ignaz Semmelweis people have been and are skeptical of almost any development. Semmelweis’s colleagues believed he was mad and had no foundation on which to base his assertions, we now have technological options that might improve the care of patients and people are equally skeptical. How much evidence would be sufficient for you to be satisfied that other types of surveillance other than audit are required?

    Regards

    Andrew

  8. DZA September 25, 2008 at 11:47 am #

    Menoalittle,

    kind of laughable to be accused of self-aggrandizement. when the day comes, and it will, that all medical clinical encounters are archived with technology available right now (low resolution video/audio, JPEG, AVI) on media affordable right now (flash drives or conventional hard drives), it will be the end of clinicians such as myself. while i compulsively gel going into and out of every pt room, regardless of contact (force of habit and not that difficult to inculcate amongst professionals known for their compulsiveness), i also practice a highly unconventional style. i swear. i tell stories. i wander completely off topic. i cajole, manipulate and outright fib to accomplish my clinical goals. then, i eventually get to the medicine part of the encounter. i just want point of care global access to transparent and complete clinical data for every patient i encounter. and i want it now.

    and if big brother scares you, don’t be alarmed, there is always little brother. (http://www.amazon.com/Little-Brother-Cory-Doctorow/dp/0765319853/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1222342355&sr=8-1). hackers and jammers are always ahead of the mahogany hallway suits and the specter of oppressive surveillance is basically paranoid. do you really think anybody cares so much about what you, or any other individual clinician, does during every moment of the day? who is going to do all the monitoring? the sheer volume of data points will be staggering. the surveillance will be pointed squarely at professional improvement. abuse of authority already exists. the remedy for that abuse already exists. let us use technology and advance the process of what is now an embarrassingly antiquated and co-opted profession.

  9. WRS September 27, 2008 at 6:03 pm #

    A person who is a virtuoso with a scalpel is a master surgeon.
    A person who is sloppy with a scalpel is a surgical hack.
    A person who uses a knife to create a delicious meal is a chef.
    A person with a knife used to hurt others is a thug.

    Whether knives, cameras, computers or other devices, it’s not the tool–it’s the people and how they use it.

    In medicine we see the best of humanity and the worst of humanity–not only in our patients, but our leaders as well.

  10. Hilary November 23, 2008 at 8:35 am #

    As a parent and having studied Oliver Wendell Holmes, as well as Semmelweis, the lack of handwashing even today, is something that has concerned me. Why does the meidcal profession have such a blase attitude about handwashing? Perhaps they don’t learn enough history?

    So I, and my friends, have devised a solution. But it’s not easy to do when parents are ‘scared’ of the medical profession.

    I don’t let anyone in a hospital or a doctor’s practice, touch or examine my child until I’ve seen them wash their hands properly. I stop them and ask them to please wash their hands at the sink where I can see them do it. If they say they washed their hands in the previous room, I ask how many doors they have opened after they washed their hands … did they put their hands in their pockets, blow their nose, shift their ties (ties should be banned in practices or hospitals) pick up files, or even swing around a door frame…

    Usually they do it, but their body language is very grumpy. I know…l, who likes being taken to task for the obvious? Their subsequent tone in conversation can make me feel that I am branded as a trouble maker. It shouldn’t be necessary for a mother to say something because she wants to protect her child.

    I didn’t think much of Gawande’s essay. It would have been far more hard-hitting had he quoted from some of Wendel Holmes papers about handwashing and puerperal fever. He was speaking out before Semmelweis. All he too wanted, was for doctors to be clean and wash their hands:

    1843: The contagiousness of Puerperal Fever: “… which is no longer to be considered as a subject for trivial discussion, but to be acted upon with silent promtitude. It signifies nothing that wise and experienced practitioners have sometimes doubted the reality of the danger in question; no man has the right to doubt it any longer. No negative facts, no opposing opinions, be they what they may or whose they may, can form any answer to the series of cases now within the reach of all who choose to explore the records of medical science.”

    Gawande takes Semmelweis to task for refusing to put together his views in a “scientific” manner. The man didn’t have to, because as Holmes said, the evidence was there to see in the records of medical science, for those who had the eyes to look. Why should he reinvent the wheel?

    In Holmes’s 1855 paper called “Puerperal Fever, A Private Pestilence”, he was forced to make a very heated 24 page defence against all the experts arrayed against him. He named them all.

    Holmes lost his temper saying on page 22, “I do not expect ever to return to this subject. There is a point of mental saturation beyond which argument cannot be forced without breeding impatient, if not harsh feelings, towards those who refuse to be convinced. If I have so far manifested neither, it is well to stop here, and leave the rest to those younger friends who may have more stomach for the dregs of a stale argument.”

    Semmelweis though, couldn’t let go his anger. Why should that be held against him by Gawande?

    On page 23 Holmes says. “If I have been hasty, presumptuous, ill-informed, illogical; if my array of facts means nothing; if there is no reason to any caution in view of these facts, let me be told so, on such authority that I must believe it, and I will be silent henceforth, recognizing that my mind is in a state of disorganization…. There is no quarrel here between men, but there is deadly incompatibility and exterminating warfare between doctrines…”

    On the last page, he says, “If I am wrong, let me be put down by such a rebuke as no rash declaimer has received since there has been a public opinion in the medical profession of America; if I am right, let doctrines which lead to professional homicide be no longer taught from the chairs of these two great Institutions. Indifference will not do here.”

    The final paragraph is very powerful. He had such a heart for the mothers, babies and especially the fathers left without wives who he mentions many times. He points out that they should look to it, and sort it out, because if the facts, “shall reach the public ear; the pestilence-carrier of the lying-in-chamber must look to God for pardon, for man will never forgive him.”

    True to his word, he never wrote on the subject again, for it infuriated him, as much as it infuriated Semmelweis.

    Perhaps the refusal of his colleagues to listen to the obvious, might be one reason why Holmes went on to write poetry and novels, like “Elsie Venner” (1858) and “The Guardian Angel” (1867)”A Mortal Antipathy”(1885). It was something to keep him sane, while his colleagues swanned on with the arrogance of ignorance, and puerperal fever continued in most of the USA.

    I can only wonder, if the world is around in 2044, whether there will still be discussions about the abysmal rates of handwashing.

    I am not a fan of the non-soap alternatives, which apparently are useless against Clostridium Difficile, another hospital nightmare.

    There are forms of soap which get off the bacteria and don’t trash the skin. Perhaps the problem is, they are expensiv, because of the high percentages of oils in them, to stop that happening.

    Hand washing, as well as the general standard of cleanliness in hospitals, is just as much an issue today, as it was in 1844, or even 1944. It’s an area that can never be let up upon. But watching staff in hospitals, it’s easy to see why familiarity results in contempt and laziness, only to be reigned in, when another patient dies, to the embarrassment of the hospital.

    Video surveillance shouldn’t be necessary.

    Medical training should ensure that for nurses and doctors, handwashing should come as automatically as breathing.

    I would so love to not have to be vigilant about this very simple, but very important issue.

  11. Bob Wachter November 25, 2011 at 4:43 pm #

    Finally, some data regarding this technique — from North Shore University Hospital in NY, reported here in Clinical Infectious Diseases.

    and covered in the New York Times Opinionator Blog.

    The study’s bottom line: the use of the cameras and feedback system increased hand hygiene rates from 10% to nearly 90%, and the improvement was sustained. There’s no information about infection rates in the paper, but it seems a good bet that they improved.

    We’re finally approaching hand hygiene with the seriousness it deserves. Congratulations to the North Shore investigators and to Arrowsight, the company that developed the video system. We’ve implemented this system in some of the units at UCSF – I’ll be interested in seeing our results.

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  1. Lights, Camera, Action… In Healthcare - October 21, 2013

    […] reviews several ways video can be used for peer review, quality improvement, and coaching. I’ve previously described the use of video monitoring for hand hygiene: a study performed at Long Island’s North Shore […]

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