You've probably heard of the now controversial Johns Hopkins study that medical mistakes are the third leading cause of death in the U.S. When, as part of an assignment, I asked a Chief Medical Officer at a large healthcare system about medical mistakes, he gave me what I thought a very insightful answer:
"In medicine, we rely on the heroic efforts of doctors and nurses not to make mistakes," he told me. "But people can make mistakes. It's not a matter of fault, but a bad process."
His answer got me to thinking that if most mistakes are a bad process, what kind of mistakes fall into the rare category of intentional? I once worked at a large hospital system as the media spokesperson. We had an inexplicable incident in which hundreds of patients were exposed to contagious diseases because two sterilization techs improperly steamed surgical instrument packs. The techs, for reasons they never explained, did not follow a process with which they were very familiar.
So I started looking around on - as a retired Navy buddy likes to say - "the worldwide Interweb" to see what I could find. Nurses still come off looking pretty good. In case you didn't read my first column last year, nurses have been ranked as the most honest, ethical profession by the public 14 years in a row in a Gallup poll.
But this doesn't make the job any easier. Another recent poll found that of the five factors that make up the Gallup-Healthways Well-Being Index - purpose, social, financial, community and physical well-being -more than half of all healthcare workers are thriving in none or only one element of well-being. Additionally, fewer than one in ten workers is thriving in all five elements. As a former hospital administrator, this makes me ashamed.
I don't know if this falls under a bad process or not. But a recent study just found that if a healthcare worker knows they are being observed, they are twice as likely to comply with handwashing protocols. I'd be very interested in hearing your thoughts for this finding, which has been dubbed the Hawthorne Effect.
Lax handwashing practices pale compared to the $1 billion Medicare fraud bust the feds just made in Florida. Three owners of a home health and assisted living company, as well as a hospital administrator and a physician's assistant were just indicted on money laundering and conspiracy committed over 14 years. Given that close to $2.5 trillion is spent on more than four billion health claims a year, $1 billion may not seem like much (HA - just kidding...). But the laundry list of charges turned up the usual stock in trade for fraud. This included: billing for services never provided; up-coding, including unbundling; performing medically unnecessary procedures; falsifying diagnosis and test results; accepting kickbacks for patient referrals (inurnment); and waiving patient co-pays and deductibles.
Physicians have their challenges as well. A recently published JAMA article found significant evidence that doctors who received as little as one free meal from a drug sales rep prescribed the discussed drug at a rate that was significantly higher than their peers. A ProPublica story and a Harvard Medical Business School study earlier this year both concluded that doctors who accepted payments from pharmaceutical and medical device industries prescribed those specific brands at a higher rate than their peers.
In an article in the New York Times, an M.D. clinical assistant professor of psychiatry at the N.Y.U School of Medicine wrote an article titled "The Illicit Perks of the M.D. Club." He cited a former Cigna executive whistle-blower who stated that "insurance companies profit by introducing hurdles in the coverage and claims process." The author also noted that since 2010 when the ACA was adopted, "the major insurance companies have seen their stock prices soar. Though the act expanded coverage to millions, a report last year by the Robert Wood Johnson Foundation revealed that 41 percent of health plans sold on the government exchanges had physician networks described as "small" or "extra-small," covering less than 25 percent and 10 percent of local doctors, respectively."
So what does all this mean?
To me, it suggests that our healthcare system is only as good as its weakest link. Asking unit secretaries to convey orders, appointing nurses as security guards and expecting physicians to deal with insurance companies are, as the Chief Medical Officer said to me, "a bad process". The people in a hospital whose primary job is to identify bad processes are administrators.
There are administrators in every organization who develop best practices for safety, quality, compliance and ethics. But a hospital administrator's primary job is to make sure everyone - from nurses to physicians to housekeepers - feel inspired to get up and come to work. It takes a servant leader to be really successful. This is easy to say, but hard to do.
One of the biggest misperceptions about servant leaders is they don't hold people accountable to the values and metrics of the organization. My experience is that it is easy to hold people accountable when they have a say in what the values and metrics should be. This, I finally learned, is the easiest way I know to be in charge. Because there is no competition for an engaged workforce.
