Confessions of a Hospital Administrator: The Good, the Bad and the Ugly

A look at recent data that explains the impact of uninspiring workplace culture. Nurses General Nursing Article

Confessions of a Hospital Administrator: The Good, the Bad and the Ugly

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.

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ServantLeader

About ServantLeader

John W. Mitchell is a retired hospital administrator and author of the hospital novel “Medical Necessity”. In 2009, he and his administrative team were named "Top Leadership Team in Healthcare for Mid-Sized Hospitals" by HealthLeaders Media.

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Would knowingly, purposefully, and chronically under staffing units such that the nurse to patient ratios are at all time highs (and thus increasing the chances of med errors or other problems) be considered to be "bad process"? Because I'm thinking that is one of the major contributing factors to the mistakes that are made in hospitals. And while not "intentional" on the part of the nurses and ancillary staff, it most certainly seems "intentional" on the part of the powers that be. Increasing caregiver to patient ratios is done to boost the bottom line, with no thought whatsoever of the consequences on the caregivers themselves, and ultimately, on patient safety.

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Specializes in GENERAL.

OP: Bienvenido from South Florida, other than New York, the home of Medicare fraud.

In my time I have found that hospital mission statements are assiduously upheld when those statements that laud honesty, integrity and excellence in patient care do not interfere with the hospital's bottom line and therefore the resonable profit expectations of the stakeholders of these gigantic, rich and powerful hospital corporations.

Let's face it. There is and has always been a love/ hate relationship between the doctor, nurses and hospital administrations.This may be because administrators often come an go and the professional staff is usually left behind to pick of the pieces of the former often clueless stuffed suits' disaster.

So while I'd like to jump on the kool-aid band wagon, I.believe the thread ahead of me may have partially hit the nail on the head. We need, at the very least, clearly defined, by law, staffing ratios, especially in high acuity areas. This can best be done by the hospital lobby in each state. But until that idea comes to fruition, I suppose the patients should all have their durable power of attorney and health care surrogate papers locked in the safe withn a copy on the chart.

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OP - nice article.

Are you familiar with Quantum Leadership?

Quantum Leadership: Advancing Innovation, Transforming Health Care: 978

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Specializes in ICU.

I can understand why nurses do not have the Gallop-Index things. Sorry. Forget what they are called. Financially speaking, I made more when I was on disability than I do as a new grad. That, was a tough pill to swallow to be honest.

I thought i was doing the right and moral thing by getting off of disability when I started to get better health wise. That was a joke. I work very hard to make less. I'm taking a huge hit financially. If I didn't have my husband to help, I would be screwed. I was a single mom for a bit.

I work long hours and miss out on my child, to help other families, and I make less. In the beginning, it made me wonder if it was really worth it. The hours are long. 13-14 hour shifts, many days in a row, is hard. It can take me a day to recover if it's several in a row. Only to find an ungrateful family member, educated on webmd, cussing you out. Not the doctor, you, the nurse. It may be your first day caring for that patient. But their entire frustration, ends up on you. I'm missing my child's game or recital for this. I saw a CNA complaining earlier. Really? You go home on time. Your complaining and me just getting tired of asking for help, made me miss his game. It's frustrating.

I know what I'm doing is important. I think my unit is better staffed than most, but we still don't have enough techs. But sometimes, it gets to me. I've shed tears even this evening as I feel I'm failing at life in general. I feel I'm giving so much at work, I have little to give at home. I'm fortunate to have a very understanding spouse and partner in life. He is my rock right now. But I also wonder how long he will be my rock as nurses have high rates of relationship breakdown.

This is why I think medical mistakes happen. We are overwhelmed in every aspect of life. Financially, socially, emotionally, mentally. You can't deplete somebody in every one of those aspects. You just can't.

I dont know what the answer is as I know on the hospital end, so many just don't pay. I won't get into my political beliefs firsthand, but I see the drain firsthand on hospitals directly. I don't know how you pay nurses more. One thing I think is, we need to stop tying reimbursement to surveys. That's the craziest thing.

Maybe hospitals need to take a little hit and pay better. Maybe that will help in the long run. Maybe it's better hours, or staffing. I don't have that answer. I do know, if you want mistakes to stop, look at the big picture and stop making us do stupid web classes every stinking year!!! It's not always education!! Ha!! Sorry. Those annoy me.

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Add to all of the above comments (which I agree with, BTW,) documentation is more complex, you have to "click all the boxes" to be sure you get paid for what you do, you have VERY user-unfriendly computer systems, and (just this week in my case) the computer altered my documentation back to a previous day after I checked it and the computer change made it incorrect for the day in question. Try testifying to "the computer altered my notes" if you ever have to go to court and see if it flies - bet it won't even though it is true. And regarding financial index - I personally took a pay cut from being a waitress to become a nurse (although I DID get health insurance, so that is something.) Jut saying.....

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Specializes in CCU, SICU, CVSICU, Precepting & Teaching.

Your article started with the Johns Hopkins study on medical mistakes and then wandered to the area of the intentional. Mistakes are mistakes; if it's intentional, it isn't a mistake. Two different subjects.

Not all mistakes are process errors, but then, I think, you wander toward the intentional. I've seen some horrific medical mistakes in my time, most of them fortunately not fatal and most of them not even skirting the area of intentional. But there are a few that are so incomprehensible they border on intentional . . . The person who overrides the Pyxis, for example, to take out ten vials of medication. We all know to question the order if we need more than two vials, don't we? I know the nurse in question didn't mean to kill her patient, but what was she thinking?

The intentional "mistake" seems rare, though. Focusing on process mistakes is more likely to yield process changes that can help prevent them.

Understaffing is one very real problem that negatively impacts patient outcomes. Of far more interest to the suits in the boardroom, however, is the fact that it negatively impacts those cherished Press-Gainey scores. It seems to me that patient satisfaction is a ridiculous measure of quality of health care and an even more ridiculous marker for reimbursement -- another process error that needs to be repaired. But be that as it may, requiring healthcare workers to take time from their very busy days to "satisfy customers" at the expense of actual patient care is bound to result in legitimate mistakes.

The nurse whose med pass is constantly interrupted for more blankets, "more ice, but the last ice was too cold so get me some warmer ice" or soft drinks for all eighteen of the patient's visitors is likely to make mistakes. If she doesn't she's a heroine in my opinion. Much of the risk for mistakes with med passes could be eliminated just by hiring more staff. It doesn't even have to be more expensive nurses (you know, the experienced type who don't hesitate to quell such nonsense with a look and can recognize the patient about to go down the tubes from 20 paces), it can be CNAs or even "Customer Service Representatives." CSRs are basically secretaries who can fetch ice, blankets and soft drinks.

Health care is a team event; more team members means less work for each team member and more time for those ridiculous "customer service" requests. A nurse who is interrupted during wound care to "find me a TV set with more channels" or "move the blankets off my brother's toe" is a nurse who may be seething at the ridiculousness of the interruptions and demands while she's trying to maintain sterility or dress a complicated wound. Yet not only is she expected to manage the wound (and document that she did so in at least three places in a computer that, in all likelihood, a visiting resident from the renal service is hogging), she's expected to produce a TV set with more channels AND move the blanket off the patient's toe -- a task which the interrupting visitor could easily have done. Is it at all understandable that she could forget to mark in one of the three places that she changed the dressing? And is it or is it not a "medical mistake" that she failed to note the increase in wound drainage that might have heralded the beginnings of a problem?

If hospital administrators really wish to improve patient outcomes -- something that I truly question -- it seems that staffing appropriately to the workload would go a long way to accomplish that. It seems, however, that patient outcomes take second place to the bottom line. Since reimbursement is tied to patient satisfaction, it seems that hospital administrators are more interested in those Press Gainey scores than in outcome statistics. Make no mistake, there are plenty of problems in health care today. But the understaffing resulting from Administration's focus on the bottom line and the "customer service" model of healthcare are two big places to start if we actually want to fix it. I'm just not sure anyone with the power to change things cares enough to try. Unless of course, like Dr. Peter Pronovost, YOUR father died from a medical mistake.

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With all respect to the OP, the article is an over-simplification, as is the statement by the Chief Medical Officer that: "It's not a matter of fault but a bad process." Of course, it would be convenient if the public believed this. The OP chose not to mention poor ethics on the part of some health care providers, and the desire to avoid financial losses to a facility.

I/my family have experienced physicians lie to our faces on a number of occasions in regard to medical care received. On another occasion a family member with numerous serious co-morbidities who presented to the ER with sepsis and ended up being admitted as an inpatient for 3 days (who, significantly, had previously been discharged from hospital within the last 30 days) experienced an ER physician doing their best to discharge them before they were even stabilized in the ER - as I mentioned above, this physician did end up admitting them as an inpatient - but not before I had told my family member to refuse to sign the discharge paperwork (which they agreed with, as they knew they were far too sick to go home). Think of the huge physical/psychological stress that a patient with sepsis presenting to the ER goes through, and the stress of the family member accompanying them, and then add to that stress the ER physician talking to them/their family about discharging them (while they are still unstable), and even drawing up the discharge paperwork. If I hadn't been present with my family member in the ER I dread to think what would have happened to them. So, while I understand the desire to shift personal responsibility for medical errors to the anonymity of a "faulty process", I think most people see through these efforts. The bottom line is money and protecting the facility and health care providers associated with the facility who bring in income to the facility.

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Specializes in Adult MICU/SICU.

Yeah, I was dismayed at how little I earned as a new grad: in 1994 the highest pay in Tucson, AZ was $12.75/hr for a new grad BSN. Many new grads make what I make now, 22 years later. I worked insane over time just to make ends meet, and missed buku milestones my child had while I was at work EVERY SINGLE HOLIDAY. Help on the floor? Not. I knew that before I graduated, because I was a PCT, and there just weren't enough of us. I did everything myself as a new grad. Pt's came - and went - and came - and went, and I got home 2 hr's late every night in order to finish everything. My husband thought I was having an affair with a MD - as if, they were not very nice during my workday, no way I would stay in their company by choice - but it was nice not to be trusted. I feared errors because I was just so damned busy. I slept most of my time off - I've felt like a zombie ever since becoming a nurse. A bit more help please? Staffing is always subpare no matter where I've worked.

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Specializes in PICU, Pediatrics, Trauma.
Your article started with the Johns Hopkins study on medical mistakes and then wandered to the area of the intentional. Mistakes are mistakes; if it's intentional, it isn't a mistake. Two different subjects.

Not all mistakes are process errors, but then, I think, you wander toward the intentional. I've seen some horrific medical mistakes in my time, most of them fortunately not fatal and most of them not even skirting the area of intentional. But there are a few that are so incomprehensible they border on intentional . . . The person who overrides the Pyxis, for example, to take out ten vials of medication. We all know to question the order if we need more than two vials, don't we? I know the nurse in question didn't mean to kill her patient, but what was she thinking?

The intentional "mistake" seems rare, though. Focusing on process mistakes is more likely to yield process changes that can help prevent them.

Understaffing is one very real problem that negatively impacts patient outcomes. Of far more interest to the suits in the boardroom, however, is the fact that it negatively impacts those cherished Press-Gainey scores. It seems to me that patient satisfaction is a ridiculous measure of quality of health care and an even more ridiculous marker for reimbursement -- another process error that needs to be repaired. But be that as it may, requiring healthcare workers to take time from their very busy days to "satisfy customers" at the expense of actual patient care is bound to result in legitimate mistakes.

The nurse whose med pass is constantly interrupted for more blankets, "more ice, but the last ice was too cold so get me some warmer ice" or soft drinks for all eighteen of the patient's visitors is likely to make mistakes. If she doesn't she's a heroine in my opinion. Much of the risk for mistakes with med passes could be eliminated just by hiring more staff. It doesn't even have to be more expensive nurses (you know, the experienced type who don't hesitate to quell such nonsense with a look and can recognize the patient about to go down the tubes from 20 paces), it can be CNAs or even "Customer Service Representatives." CSRs are basically secretaries who can fetch ice, blankets and soft drinks.

Health care is a team event; more team members means less work for each team member and more time for those ridiculous "customer service" requests. A nurse who is interrupted during wound care to "find me a TV set with more channels" or "move the blankets off my brother's toe" is a nurse who may be seething at the ridiculousness of the interruptions and demands while she's trying to maintain sterility or dress a complicated wound. Yet not only is she expected to manage the wound (and document that she did so in at least three places in a computer that, in all likelihood, a visiting resident from the renal service is hogging), she's expected to produce a TV set with more channels AND move the blanket off the patient's toe -- a task which the interrupting visitor could easily have done. Is it at all understandable that she could forget to mark in one of the three places that she changed the dressing? And is it or is it not a "medical mistake" that she failed to note the increase in wound drainage that might have heralded the beginnings of a problem?

If hospital administrators really wish to improve patient outcomes -- something that I truly question -- it seems that staffing appropriately to the workload would go a long way to accomplish that. It seems, however, that patient outcomes take second place to the bottom line. Since reimbursement is tied to patient satisfaction, it seems that hospital administrators are more interested in those Press Gainey scores than in outcome statistics. Make no mistake, there are plenty of problems in health care today. But the understaffing resulting from Administration's focus on the bottom line and the "customer service" model of healthcare are two big places to start if we actually want to fix it. I'm just not sure anyone with the power to change things cares enough to try. Unless of course, like Dr. Peter Pronovost, YOUR father died from a medical mistake.

RubyVee...EXCELLENT! You said just about everything I would say to this. I do want to add something to the time wasting processes list. Where I practice, we have patient acuity systems the nurse completes on each patient, each shift. It is supposed to help determine staffing based upon the compexity of the patient. So far, I have never used one that actually was accurate.

The majority of times you end up with the same assignment no matter what you score. It is one more thing on the list of charting/tasks that nurses are required to do that is a complete waste of time. What's more, I have had charge nurses at one institution I worked for tell us to change our acuity ratings in order to make staffing the next shift easier. If we changed one thing here and one thing there, they could get away with using 1 or 2 less nurses the next shift. We nurses were frequently told we were completing them incorrectly, and wouldn't you know it, somehow our mistakes never resulted in causing less staff than what was required. The systems, seemed to be geared towards the ratios that were already in place or usual for the numbers. In other words, if 10 nurses cared for 40 patients, there always were 10 nurses for 40 patients regardless of actual need or particular issues with certain patients. The systems never seemed to allow for changes in patient's status or unexpected amounts of admissions and so on. In the past 10 years or so, I have rarely had a comfortable assignment. Meaning, nearly everyday I went to work, I felt nervous/worried about getting everything done. I was prone to rush. My mind constantly filled with "don't forget to's " rattling around my brain making it so difficult to stay focussed at times. Interruptions abound making it so difficult to stay on a flow regarding the initial plan for the shift. Mind you, I have been feeling like a new grad all over again as the amount of work (to be done properly, with all safety steps included), was simply too much. I relate to what so many nurses say in that their personal lives suffer. Apart from the long hours, we come home drained and exhausted from the pace and worry maintained for 8-12 hours straight. There is nothing left in us at the end of a day. It is more the mental/emotional drain I am referring to. The brain and adrenal load makes it difficult to focus on anything else. We come home, but we are absent.

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If they REALLY want to know why mistakes happen, I worked 23 years on an oncology unit. I 95% of the time was doing primary care on 6 - 7 patients, and 99% of the time (I can count on the fingers of one hand I when wasn't) I was giving 2 units of blood to at least 2 patients in addition to giving chemotherapy to at least 2 patients, plus the others were usually immunocompromised, and we had one STNA for the 14 to 17 patients. THAT is how mistakes happen!

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Specializes in Administrator inspired by nurses.

I have been in the room when superiors cut staffing to reduce costs. They never went up on the floors, as did I, to see how such reductions impacted nurses.

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