Is the Patient Safety Movement in Danger of Flickering Out?

These should be the best of times for the patient safety movement. After all, it was concerns over medical mistakes that launched the transformation of our delivery and payment models, from one focused on volume to one that rewards performance. The new system (currently a work-in-progress) promises to put skin in the patient safety game as never before.

Yet I’ve never been more worried about the safety movement than I am today. My fear is that we will look back on the years between 2000 and 2012 as the Golden Era of Patient Safety, which would be okay if we’d fixed all the problems. But we have not.

A little history will help illuminate my concerns. The modern patient safety movement began with the December 1999 publication of the IOM report on medical errors, which famously documented 44,000-98,000 deaths per year in the U.S. from medical mistakes, the equivalent of a large airplane crash each day. (To illustrate the contrast, we just passed the four-year mark since the last death in a U.S. commercial airline accident.) The IOM report sparked dozens of initiatives designed to improve safety: changes in accreditation standards, new educational requirements, public reporting, promotion of healthcare information technology, and more. It also spawned parallel movements focused on improving quality and patient experience.

As I walk around UCSF Medical Center today, I see an organization transformed by this new focus on improvement. In the patient safety arena, we deeply dissect 2-3 cases per month using a technique called Root Cause Analysis that I first heard about in 1999. The results of these analyses fuel “system changes” – also a foreign concept to clinicians until recently. We document and deliver care via a state-of-the-art computerized system. Our students and residents learn about QI and safety, and most complete a meaningful improvement project during their training. We no longer receive two years’ notice of a Joint Commission accreditation visit; we receive 20 minutes’ notice. While the national evidence of improvement is mixed, our experience at UCSF reassures me: we’ve seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-trained clinicians, and better systems. In short, we have an organization that is much better at getting better than it was a decade ago.

So what’s the problem? I see two major forces slackening the response to patient safety: clinician (particularly physician) burnout and strategic repositioning by delivery systems to deal with the Affordable Care Act. Like a harried parent rushing out to the car to drive the school carpool, only to discover that he’s left his child in the house, we risk leaving behind our precious safety cargo if we fail to ensure that everybody is onboard as we rush headlong into the future.

Let’s begin with burnout. When the patient safety field launched in 2000, one might have expected that physicians would be natural foes. After all, say “medical errors” to a practicing doctor and the Pavlovian response is likely to be “malpractice.” This reflex made physicians unlikely patient safety enthusiasts, and it is axiomatic that nothing important happens in healthcare if physicians are not engaged.

Yet, by emphasizing systems problems – the “it’s not bad people, it’s bad systems” argument – many physicians felt validated, some even intrigued, and a few (like me) even inspired. Physicians turned from active resistors to, in many cases, real allies.

But the blizzard of new initiatives – all well meaning but cumulatively overwhelming – thrust at busy clinicians has created overload. The problem, of course, is that nobody freed up the time to do all this new stuff. When commercial airline pilots recertify every year on a simulator, they do this on company time. When they spend 30 minutes completing a pre-flight checklist, their salary is assured. But for many physicians, these new tasks – learning a new way of thinking, implementing a checklist, or surviving the installation of a new IT system – are usually obligations on top of an already jam-packed day. Even for nurses, who generally are salaried, new mandates to scan bar codes or even to wash hands ate up precious minutes in days that already lacked much white space.

Although many clinicians have been gratified by their work in safety and quality, I’m afraid this additional work has contributed to high levels of burnout. A recent study in JAMA Internal Medicine documented burnout rates significantly higher than those of the rest of the U.S. population – with nearly half of physicians displaying symptoms of burnout. Obviously, patient safety initiatives are not the only cause of this burnout. But the effects on the safety field are very real.

While the statistics are troubling (and, as chair of the ABIM this year, I certainly hear from my share of unhappy doctors), the impact on patient safety really came home during my recent interview of Prof. Bryan Sexton, the Duke sociologist and the world’s leading expert on patient safety culture. I had interviewed Bryan about culture six years ago for the federal website I edit, AHRQ WebM&M, and I thought it might be a good time to check back in. I approached the interview armed with a bunch of questions, covering things like Executive WalkRounds and teamwork training.

But within 10 minutes, I had scrapped all of my questions, because Bryan focused almost entirely on clinician burnout. In his work, he is seeing physicians and nurses so overwhelmed that getting them to think about anything else – safety, quality, teamwork – is nearly impossible. “It’s like Maslow’s hierarchy,” he said, in that people aren’t able to focus on higher needs until their basic needs are secured (the full interview will be published in the spring). Because of this, he has shifted his focus to improving “resiliency” – basically, helping docs and nurses restore joy in their work. As Dr. Richard Gunderman points out in a recent article in The Atlantic, while reducing dissatisfiers (hassles, bureaucracy, pay cuts, clunky IT systems) is an important part of addressing burnout,

… the key [to combatting physician burnout] is promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment.

I cling to the hope that improving systems of care will bring fulfillment to clinicians (both from the work itself and the fruits of the labor), as it has for me and many of my colleagues. But it is important to recognize that for many clinicians (and not just the pre-retirement folks), this work is yet one more thing that stands between them and professional satisfaction.

The lack of evidence that all our hard work is paying off is also contributing to burnout. Several influential papers (such as here and here), using the IHI’s Global Trigger Tool methodology, have documented continued high rates of harm; one study of 10 hospitals in North Carolina showed no evidence of improvement between 2002 and 2007. On top of that, a steady drumbeat of studies (beautifully chronicled by Brad Flansbaum) demonstrates that nearly every policy intervention that we thought would work (readmission penalties, “no pay for errors,” pay for performance, promotion of IT, resident duty-hour reductions) has either failed to work, or has led to negative unanticipated consequences. For people who have given their hearts and souls to making the system work better for patients, the result is more demoralization.

My second major concern about patient safety stems from the Affordable Care Act (ACA), one of whose main goals, paradoxically, is to place a premium on value over volume. You’d think that the patient safety field would benefit from such a law (which also includes significant new spending on safety), and perhaps it will… eventually. But in the short term, the ACA is yet another speed bump on the road to a safe system.

Just as physicians are overwhelmed and distracted, so too are hospital CEOs and boards. As the healthcare system lurches from its dysfunctional model to a (God willing) better place, healthcare leaders are scrambling to be sure that their organizations have seats when the music stops. The C-suite and boardroom conversations that, a few years ago, were focused on how to make systems better and safer now center on whether to become Accountable Care Organizations, how to achieve alignment with the medical staff, what the insurance exchange will mean for our reimbursement, and the like. To the degree that people remain interested in improved value, here too the emphasis has shifted from the numerator of the value equation (quality, safety, patient experience) to the denominator: cutting costs.

Dr. Gary Kaplan, CEO of Virginia Mason Health System in Seattle and probably the most admired hospital leader in the country, recently reflected on the state of patient safety in a note to the board of the Lucian Leape Institute at the National Patient Safety Foundation (we’re both on the LLI board). Gary wrote,

[The] reduction in reimbursement and increasing consolidation threatens to make the focus on economics, size, and market competitiveness take precedence over getting better in terms of quality and safety. This will be in part because the ‘line of sight’ from senior leaders to the front lines of care will be even more distant. 

We simply must reorganize our healthcare systems to deliver the highest-value care. Of course, this will require big picture, strategic planning – new relationships, new institutions, new IT systems, and more. It will also depend on the creation of a bottom-up culture that allows those who deliver the care to improve it. Together, this is an awfully full agenda for both leaders and clinicians, and it is a noble one.

But as we proceed, we must remember that healthcare is delivered by real humans, working in organizations that are led by other real humans. Ignoring the pressures that both groups are under may lead us to create lovely systems and dazzling org charts for organizations that continue to harm and kill. In other words, we risk the dystopian world that the great healthcare futurist Ian Morrison has warned of, one in which our hospitals and clinics have the anatomy of high-performing organizations, but not the physiology.

28 Responses to “Is the Patient Safety Movement in Danger of Flickering Out?”

  1. Lorenzo Alonso February 18, 2013 at 12:07 pm #

    Excellent and critical comment about the patient safety movement.From a
    quite different part of the world,in a social security health system
    as the one in Spain ,the situation for physicuans is similar:the see thus field as theoretical and distant.I believe that the main effort has to be implementes in meducal Schools,changing radically the physician syllabus.Learning from error and tking account patient safety must be the flame for the change.
    Lorenzo Alonso.Medical Oncologist
    Malaga,Spain

  2. Patient Safety Science & Technology Movement February 18, 2013 at 7:16 pm #

    Dear Dr. Wachter,

    We echo your worries about the patient safety movement and launched a summit in response to the need for actionable focus to reduce preventable patient safety deaths. Learn more at http://www.patientsafetysummit.org.

    We’d love to have you involved! Please email us at info@patientsafetysummit.org

    Yours in health,
    Patient Safety Science & Technology Movement

  3. Jairy Hunter, MD, MBA, SFHM February 18, 2013 at 7:58 pm #

    Bob, thanks for framing these two major ironies in a cogent, insightful way. I think you are absolutely correct in that we are seeing something that sounds good (to patients and voters), and probably aspire to noble intentions at their core, but the implementation and methodologies result in unintended and completely unanticipated outcomes. And not in the good ways. While the Quality movement has been great about putting everyone in the mind of ostensible “quality,” it has yet to be clearly defined as “the way everyone should go.” Airlines have it over medicine in this way–the outcomes are pretty concrete (“Did the airplane crash/make it on time/lose my bags?”). Patients and even clinicians can agree on what a true reflection of Quality looks like (I suppose “not-dying” is one. Sometimes.).

    At this point, it seems that readmissions initiatives may supplant quality efforts. In my own position, we have devoted significant resources and energy toward something that we seem believe (intuitively? makes sense, right?) will have a broad impact, but as yet, it’s insanely hard to measure. Potential for unintended consequences abound.

  4. Stan Jackson, MD February 18, 2013 at 9:28 pm #

    Bob,

    I am having a difficult time discerning whether you think that your EHR and CPOE systems that modulate the care of all of your patients has improved outcomes and reduced costs or not.

    I recently read a special feature on someone who has serious doubts about wiring hospitals with systems of devices that have not been assessed for safety: http://www.kaiserhealthnews.org/Stories/2013/February/18/Scot-Silverstein-health-information-technology.aspx

    Has your safety movement locally reported on the adverse events from your electronic care records and ordering? Have your costs gone down? What were the costs of wiring UCSF? Have outcomes improved because of the digitization of care? Orrr, do you simply have the anatomy but not the physiology to operate user unfriendy devices as has been the case in the UK: http://www.readingchronicle.co.uk/news/roundup/articles/2013/02/16/86796-hospital-ready-to-ditch-30m-computer-system-/??

    Here’s to you

    Stan

  5. Michael Bennett February 18, 2013 at 9:45 pm #

    A well-written article that covers the problems…from an insider’s perspective.

    From a patient’s perspective, however, this piece seems to miss a critical point: safe and competent care is all we ask for. Yes, the practice of medicine is complex and not always an exact science. And hospitals are even very complex institutions. But when it comes down to care at the bedside, such things as infection control, correct medications, communicating with the patient and his or her family, and bringing a specialist aboard rather than letting one’s ego stand in the way of doing what is best for the patient are time-honored and effective components that should be basic.

    The overwhelming changes in healthcare that Dr. Wachter sites and their adverse effects on clinicians need to be discussed and confronted. But I think that one element that should be added to that discussion is the unfortunate fact that healthcare, because of its decades-long history of dysfunction has brought this on itself. Everyone needs to be reminded of the immeasurable suffering and untold number of deaths that that culture has wrought on patients. As in all walks of life, there is no true repentance without recognition and character improvement.

    Most caregivers are wonderful at what they do. Too many are not. And it is us, the patients, who suffer far worse than those who complain of burnout from a burdensome bureaucracy.

    Michael Bennett
    The Coalition For Patients’ Rights

  6. Menoalittle February 19, 2013 at 4:18 am #

    Bob,

    I see there is another unintended consequence of HIT systems: clinician burn out.

    When the US rushed headlong into deploying CPOE and EHR systems without any understanding if they were safe, efficacious, and usable, safety was left behind and has been dealt a serious blow up side the head.

    I am curious how you allude to, even brag about, your “state-of-the-art computerized system” in a piece on patient safety, when the device about which you brag, has not been approved by the FDA or any one else as being safe.

    How do you know your CPOE device is safe? How many results come back to your EHR and wait for hours or days to be found? How many interface failures are there in which the ancillary service does not get the order? How long are your residents’ progress notes? How many misidentifications are there? How often is the device unavailable to clinicians? Have the falls decreased since you deployed the device? Have the length of stays shortened since you deployed it? Have the outcomes improved? Have the costs gone down? How many unremediated complaints lurk at the help desk?

    You should be able to provide immediate answers with such a state-of-the-art device, eh?

    Let’s hear something other than clinicians are burnt out from filling in the grids in clunky EHRs.

  7. Marc S Frager MD February 19, 2013 at 8:04 am #

    As should be obvious, forced participation in the pseudo-voluntary, ridiculously expensive,unending MOC madness is probably a major reason for physician burnout

  8. bev M.D. February 19, 2013 at 9:42 am #

    A timely post, and one we may eventually point to in retrospect if your fears come true. However, I see 3 causes for maintaining hope. First, the health care law is probably the most significant change in health care in a generation; it is natural for hospital administrators and doctors to be focused on their pocketbooks and what they see as their survival. However, this is hopefully a temporary phenomenon as everyone gets used to the ‘new paradigm.’
    Second and more important, I think one of the problems with the patient safety movement is that we have attempted to layer it on top of our existing dysfunctional ‘system’ of care – which we all know is in desperate need of complete redesign. Of course it results in more work when it’s just bolted on. So perhaps we should be concentrating on the redesign of care processes and incorporate patient safety objectives into that redesign.
    Third, the unfortunate juxtaposition of ‘meaningful use’ with all of the above has served as a powerful force enhancing physician burnout and, paradoxically, hampering process improvement. Although you may have a state of the art IT system at UCSF, as I recall it came only after a major false start with another system, and these systems continue to be problematic. (see below)
    Thus I see a one-time confluence of forces which, yes, probably in the short term will slow progress. Only by recognizing and addressing these forces can we overcome them.

    And by the way, may I address Menoalittle’s constant anti-IT commentary. Bringing health care up to the same level as all other industries in terms of technology is not an option; it is essential. We simply cannot return to the days of the paper chart. Any thoughts otherwise are simply out of the dinosaur age. What you are actually railing against is the entirely inadequate design and installment of systems available today from a health IT industry unwilling to meet the needs of its customers. This too shall pass – competitors will come along who will simply put the old guard out of business. This, too, shall take some time.

  9. Jairy Hunter, MD, MBA, SFHM February 19, 2013 at 12:16 pm #

    Wow. So much hostility toward physicians and the medical profession.

    Bob certainly doesn’t need me or anyone else to defend him. But I hardly see what he is saying as “complaining.” I certainly don’t think he’s “bragging” about the EHRs (and they are clunky). Unless I’m missing it, I thought the point was this: we have seen monumental efforts and so-called advancements in many areas, even having the “state-of-the-art” computer systems, and yet we can’t tell if it has had an impact, or even what would have an impact.

    Sorry if you’re mad about hearing the multiple causes of physician burnout. It’ a fact. Seems to me it should be important to patient advocates and patients and administrators and physician leaders to understand all the forces that contribute to it.

    I guess the point was that despite all the regulatory heat and all the “medicine-is-manufacturing/airline industry/cheesecake factory” discussion, we have a long way to go. Sure physicians should be involved in the development of such systems, EHRs, protocols, and measurement of outcomes, determination of “value.”

    As Bob, mentioned, only recently have we ported the language of business and process improvement to the practice of medicine. Increasingly, physicians are willing to have those conversations and learn extra skills, and accept additional training in disciplines like lean and six sigma and kaizen in an effort to understand and improve our industry–ultimately improve patient care. I will say that I have seen this renewed interest and vision and purpose has rescued some physicians from burnout.

  10. Jim Conway February 19, 2013 at 6:34 pm #

    Bob, thanks so much for this very thoughtful posting. As I read, I found myself saying, yes, YES, YES! A few years ago I was part of a team on a consultation. We were interviewing lots of front line staff with two questions: what do they love about their practice and what gets in the way of that happening 100% of the time? Responding to the later, a staff nurse said “Every day she comes to work and sits at the bottom of the waterfall. The stuff comes and comes and comes. She is drowning.” Since then, I’ve shared her waterfall with many groups and EVERYONE wants to talk about their waterfall—front line staff to trustee. They are drowning to.

    I’m worried that we are working on everyone’s list but no one has THE list, that we are working independently on clinical, financial, service, and patient / staff experience outcomes. Missed is that these outcomes collectively are part of an elegant dance, playing off each other, impacting each other. We need the centrality of the patient and family, integrated strategy, cascading goals, alignment, focus, and prioritization to manage the waterfall flow. In my current work I am seeing that high performance teams can accomplish everything and that crappy cultures produce crappy results.

    I close most presentations these days with some words of Donabedian “Quality improvement begins with love and vision. Love of your patients. Love of your work. If you begin with technique, improvement won’t be achieved.”

    Thanks again for your counsel in for showing the way.

  11. Jon February 19, 2013 at 11:10 pm #

    The irony of this latest entry to Wachter’s World is the fact that the unproven unvalidated extremely onerous MOC process that Bob unflinchingly promotes is a major contributor to physician burnout.

  12. Bryce Cassin February 20, 2013 at 11:10 am #

    An insightful and honest analysis of the patient safety movement by Dr Watcher.

    My doctoral dissertation explores the experience of facilitating over 100 RCAs between 2003 and 2006 in one Australian hospital. While there is slight evidence of significant change at the organizational level, there is tangible evidence of an unexpected local impact: the RCA team meeting process opened up a new conversation space among front-line clinicians. Organizing is inherently local. In practice, there is no such entity as ‘the organization’ it would seem.

    The ‘reorganizing’ Dr Watcher speaks of will be driven by local clinicians, working together, collectively making sense of the hospital as a workplace.

    Distancing is needed from top down quality improvement because the contradictions in complex care delivery cannot be captured by a managerial concept like a ‘patient safety movement’. Funding and strategic impetus must shift to provide clinicians with the time, resources and knowledge to drive bottom up understanding of the everyday interactions and transformations that constitute clinical care. The new ‘physiology’ will be human, it will involve taking ideas such as ‘distributed work’ and developing new models of the clinical workforce.

    But this is only a beginning. At the heart of real change will be a new language, a complete transformation of clinical conversation and the social ordering of clinical work. Getting closer to the experience of patients and the human enterprise of care delivery will require a new vision of what healthcare is, a new framework to interpret care delivery, and systems that resonate with clinicians and facilitate ongoing transformation of the clinical workplace at the local level.

  13. Shirie Leng February 20, 2013 at 3:39 pm #

    Dr. Wachter – great summary. I am an anesthesiologist, and when I walk into the pre-op area of my hospital every single clinician is staring at a computer screen. The paperwork takes longer than some surgical procedures. Nurses have become typists. Anesthesia has hired master’s prepared nurses to help with our paperwork. New rules are added almost daily. This can continue because doctors and nurses continue to accept the new responsibilities on top of the old because that is what we’ve been trained to do. I wish I had something useful to say about a fix for this paperwork “waterfall”. More typists? Billing by the 15 minute block like lawyers do? Voice recognition software? Somebody sort of like a court-reporter except in the exam room?

  14. Michael R. Privitera MD February 20, 2013 at 8:57 pm #

    Dr Wachter did a wonderful job of describing the impact of physicians and no major improvements, maybe declining in some cases.. I think the critical piece is how to integrate Dr Wachter’s and Mr Michael Bennett’s from the Coalition for Patient’s Rights points, as I see them as aligned concepts.Provider/staff wellbeing and patient wellbeing are inextrincably linked. There is significant literature that I am happy to share on how many well meaning, but misguided, broad net instead of select targetted interventions wear out the cognitive capacity of the provider, increasing risk of error. From good stress it becomes distress, causing less empathy, less ability for self-effacement, even is a factor in workplace violence of patients on staff.Cognitive capacity gets taken up by extraneous load instead of the needed intrinsic and germane load. The EHR that is designed to capture as many CMS Meaningful Use criteria, to get Federal reimbursement for EHR rollout, is off the mark in making ease, efficiency and accuracy of patient care the goal (the original reason for EHR that made it a goal for US healthcare). Every day of dealing with poorly designed EHR, does not get better with time. Patient satisfaction scores plummet when nurses are so tied up with recalcitrant programs on discharge and have little or no eye contact with patients at discharge.
    There is no evidence that MU criteria improves quality of patient care, nor is there evidence that Maintenance of Certification/Licensure efforts improve quality of care. Board Certification every 10 year recerts takes up time from patient care, is expensive, is a cost put on the physician and has no evidence that questions are relevant to best care at the time the patient is in front of you. We need to combine EBP, with CME, Certification proceedures etc. There is no discretionary time in the docs life to take on any more that is not part of their regular day. There is anticipated MD shortage from ACA that is greater than without it,Congress has been asked to increase medical school slots to help decrease this shortage. MD’s are wanting to leave medicine or retire early, burnout rates are extremely high, and recent information job stress was an identiable factor in physician suicide. We have “stop the blood loss” of existing providers and help our healthcare system be smarter on how we try to accomplish issuesIt is not a benign thing to add more to an overworked, burned out provider system.

  15. Mary Thomas, CMIO February 21, 2013 at 12:52 am #

    http://www.nytimes.com/2013/02/20/business/a-digital-shift-on-health-data-swells-profits.html?ref=todayspaper#comments

    This was the front page lead story.

    Bob,

    Your ED Director stated in the report that he did not like your new EMR but your CIO thopught everyone else liked it. I beleive your ED Director.

    Safety programs are flickering because the devices that the Congress and HIT vendors think improve safety are not safe.

  16. Roz RN February 21, 2013 at 2:50 pm #

    What clinicians need to do is get back to taking care of patients. Caring about what happens to patients. Looking them in the eye when talking to them, not at a chart or computer screen, or any other kind of electronic device. When clinicians care about the patients, they will hopefully pay more attention to basics of good practice such as infection prevention. This means washing your hands so that your next patient will not be getting the germs of your last patient. If administrators care about patients they will give clinicians enough time to do their job so they can listen to patients, really listen, not just with half an ear, while they are imputting data into a computer or talking into their recording device to be typed out later by someone else. Where did the caring go? Is it buried under all the reports that nursing and medical staff need to complete? Has it been squashed by the accounting department who refuses to hire enough nurses to do the job they were trained for, in a way that makes them feel they have taken good care of their patients? Until we go back to caring for patients as individuals, not 15 minute time slots, no new movement, patient safety, or otherwise, will improve patient care, and lessen deaths of patients at the hand of well meaning doctors and nurses.

  17. Richard Rohr February 21, 2013 at 11:50 pm #

    I am very concerned about burnout among physicians. I left hospital medicine a couple of years ago, after spending many years running myself ragged trying to promote quality improvement without being given any resources to do it. I work in a firm providing medical necessity reviews to hospitals and I am one of several hundred physicians in the organization. I am at an age where most physicians have generally wound down their clinical practices, but I have been struck by the number of physicians coming to our organization after only a few years of clinical practice, having been ground down by the forces that you have cited in your post. Primary care has been in crisis for years, and now specialists are selling out their practices to hospitals in droves. I am not at all sure that we will have the resources to provide even cursory and impersonal care to those who need it.

  18. Bart Windrum February 22, 2013 at 5:10 pm #

    First I want to authenticate myself, for I have a different viewpoint to add here, and to express it I’ll combine several areas of thought. I’m a lay person become end-of-life reform advocate after experiencing the 3-week hospitalized demises of each of my parents fifteen months apart in 04/05: Mom/ICU-intubated; Dad/nosocomial MRSA in a Jayco 100 facility. I wrote and published a book, a(n unadopted reform initiative), and last year a work offering a new set of end-of-life (EOL) language primarily to my fellow citizens but also to thanatology.

    All my work emanates from the experience of myriad discontinuities of treatment. I’ve learned a lot, and still harp on patient-family exclusion, especially from EOL education where informed citizen input would greatly benefit everybody, including providers by lightening their load. I mention this because it’s an ongoing example of the problem I see: providers taking more responsibility upon themselves than is their share, to detrimental effect.

    I see the burnout problem as real but not under provider control. That pains me, and not just because I as a patient-family member I have, and probably will again, suffer as a result.

    This may be counter-hopeful, but if you’re burned out it’s a greedy system that’s burning you. Just as we were harmed at EOL by severe understaffing, a baseline cause of error, discontinuity, out-of-pocket expense, and death, so are you.

    As I write this it’s one day after Time Magazine’s special issue, “Bitter Pill: Why Medical Bills are Killing Us.” In an accompanying CNN video it’s revealed that last year medicine spent on federal lobbying more than the #2 spender (defense) and the #3 spender *combined*. Executive pay rivals and even trumps that of the highest paid bankers. Profiteering, beyond profit taking, seems to me to be the root cause of all burnout, providers and patient-famillies’. And we are all subject to and pawns in the for-profit health insurance business.

    If I were a doc or nurse I’d want my professional associations fighting all that.

  19. Anna Gardiner February 22, 2013 at 11:41 pm #

    Expecting the ire of physicians and clinicians who dedicated their lives to providing medical care, I submit my thought on the matter of QI and patient safety having become disabled a decade ago as an “hot potato” outpatient. In the last 10 years, I’ve spoken to more patients than I can count who, like me, were either misdiagnosed or not diagnosed as outpatients. Several years of searching led some of us to physicians who listen, perform correct tests, and can help the patient. Typically this occurs after the patient has incurred great financial and physical hardship to put it mildly.
    In my humble opinion, this occurs because the internist, who is charged by most insurance companies with quarterbacking and coordinating patient care through referred specialists, is actually understandably delegating that care to any of the handful of specialists he referred. Specialists inherently assess one problem area without due consideration as to whether the problem area is a secondary health issue or the “root cause” of the patient health woes.

    There is no one in the health care system who puts all the puzzle pieces together (a comprehensive differential) to ascertain the main cause of multiple health issues that present in patients bounced around outpatient specialists. Not determining the root cause directly impacts patient outcome in the hospital setting. How many surgical interventions and hospitalizations take place for a secondary issue before the root cause is found? Isn’t that like changing the starter on a car when the battery is dead? The battery didn’t get tested because that was another specialist’s field and that specialist wasn’t consulted.

    If patient outcome is a metric for QI, the “system” needs to design a way to get a comprehensive reading of the patient as a whole being. Patients are more than the sum of their parts. Patients are the sum of their parts functioning together correctly.

    To reach consensus on cause prior to surgery, a few hospitals now require patients to be evaluated as an outpatient by a team of their own department doctors. While a good start, this doesn’t go far enough. Just like water from a roof leak can travel and cause damage a quarter of a mile away, a problem outside of that department’s grasp may play a major role in the patient’s recovery.

    Under our present medical system, no one has the knowledge nor the time to listen to the patient long enough to piece things together. Physicians differ widely in their beliefs about many health concerns. Conventional doctors rarely if ever administer tests used by integrative doctors to look for heavy metals, nutritional deficiencies, etc. Many doctors don’t recognize fungal infections as anything more than normal flora. Controversies abound over what normal levels for the thyroid are. Most doctors don’t test for and aren’t familiar with anaerobic bacterial infections. Specialists sub-specialize. Patients and other doctors have no way of knowing who knows what so doctors often refer acquaintances and hope for the best. The list is endless of what needs to be addressed to improve patient outcomes. Once you improve patient outcomes, medical costs will go down.

    In a perfect world, there would be a speciality for diagnosticians who patients would see before being put on the conveyer belt of unending specialists without a clue like I was and so many others I met were.

    The culture change needs to start with medical school curricula and funding. Both doctors and patients need to become more educated, accountable and learn to work together.

    I gladly and whole heartedly volunteer my time to work on putting together a prototype to improve outpatient care. Please let me know if anyone knows of such a venture.

  20. Urmimala Sarkar February 22, 2013 at 11:58 pm #

    Both burnout and the competing demands associated with health reform are major barriers to the continuation and growth of the patient safety movement, but I’d like to add another to the list: the lack of resources for patient safety research. We still need an evidence base to inform patient safety initiatives, particularly in outpatient settings, and this research has been predominantly funded by AHRQ, which remains a political target at a time when MORE funding is urgently needed.

  21. Dallas Spine Surgeon for Pain Management February 24, 2013 at 4:15 am #

    People are all in a hurry today and dont take safety serious!

  22. Mick Koffend February 24, 2013 at 8:26 pm #

    Is anyone having a conversation about alternatives? With the burnout of physician and nurses, and the distraction in the C-suites and boardrooms, perhaps it is time to shift the focus, temporarily at least. Care managers, particularly geriatric care managers, can play an important supporting role during the time described in the article.

    Communication across the various healthcare providers, care transitions and medication management do not depend so heavily on medical or nursing skills, yet provide safety in many dimensions.

    I wish more folks were including this important resource in the conversations about patient safety.

  23. Frustrated Analyst February 25, 2013 at 12:31 am #

    In addition to clinician burnout, there is burnout among some of us who are the foot soldiers in the safety movement, i.e., the hospital abstractors, coders, database analysts, and number crunchers. Part of the problem is the effort by certain organizations (for example, commercial health insurance companies, The U.S. News & World Report, and HealthGrades.com) to exploit the safety movement for their own dubious purposes. The tremendous amount of staff time that it takes to compile information in response to inquiries by such organizations and/or de-construct and critique the often misleading information that they disseminate chews up hospital staff resources that could put to better uses.

    There is also the issue of hospital IT systems and processes that have not kept pace with ever changing requirements for safety related data collection. Installing an EHR helps improve data collection but without significant improvements in IT governance and major investments in disease registries and data warehouse/business intelligence capabilities the hospital industry will continue to drown in a sea of data yet be starved for clinical information that is essential for advancing the quality of care.

  24. Keiki Hinami February 27, 2013 at 5:51 pm #

    I, too, care a lot about this issue and appreciate the discussion here on Wachter’s World. My own experience has me thinking that the notion of burnout is misused by some as simply powerlessness for achieving our desires. We often invoke burnout when we feel unsuccessful at obtaining high income, free time, respect, authority and effectiveness in our work. But burnout, traditionally, is a psychological consequence of caring for people against obstacles to caring. Much of these obstacles are self-imposed by our preoccupation with external motivators that dominate over our instrinsic want to simply care for people, and the resilience we seek may be found in realizing that we are caring not too much, but too little.

  25. Charles T. Low, MD, CCFP July 28, 2014 at 3:34 pm #

    Late reply to this very germane post – my mantra is “Patient Safety literacy and profound commitment from the highest levels”. I didn’t make this up – I learned it from Patient Safety education. We often view the “highest levels” as hospital CEOs or Board Chairs. These people can be i) very hard to reach, and ii) they aren’t actually the “highest levels”. It can hard to pin down exactly where policy decisions and funding mechanisms are controlled, but here in Canada it’s generally at the federal Ministry of Health. (In the U.S. it may be more dispersed. In the UK it’s the NHS.) And although in Canada the feds have a safety division, it doesn’t seem as if they understand it in the way we do, the basics in my mind being a culture of pervasive and transparent communication in which staff feel free to speak up with concerns about Patient Safety. (I didn’t make that up either.)

    All of the procedures and mechanisms we develop seem to me to have a clear history of poor penetrance and non-sustainability in the absence of that kind of top-level fervent leadership. And yet I hear very little about how to gain access to and upgrade the knowledge and skills of those who ultimately decide what is rewarded and what is punished.

    Note that by using the word “punished” I am making an implicit correlation with one of this blog’s themes: physician burnout. I remind managers once in a while of the generally-accepted tenet that without physician-engagement, healthcare initiatives are unlikely to succeed, and that they don’t have that engagement (let alone with other critically-relevant healthcare professions), so the only logical response is to develop an engagement plan. You may guess how well that is received. Burnout may in part be a result of disenfranchisement.

    Anyway, does that make sense, that we need to target those who pull the strings, at much higher levels than generally contemplated? Have we in “the movement” sought the necessary expertise to do that? (I don’t think that that we have the political savvy internally.) Do we ourselves have the extraordinary persistence and fortitude to adopt such a generational project?

    Thanks again, great blog, insightful analysis.

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