Patient safety requires hospital leaders to take personal responsibility

A quality-driven MD colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  “I suggested that instead of being embarrassed, maybe we should own the data.” This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the “the lawyers will not let us do this.”  S/he wonders, “Who, exactly, is our primary concern?”

At another meeting, the chief nursing officer asked why there had not been more progress made with regard to central line infections in the ICUs.  It turned out that there had been meetings with  the bedside staff which identified a number of problematic workarounds they had created. However, the team was limited in what they could do because decisions about equipment and kits are made based on cost, away from the bedside. The CNO was upset because the local folks had not shared with her what they had already done and wanted to know why they hadn’t told her about these problems – while acknowledging she couldn’t do anything about them.

My friend summarized:

I explained that if she wanted to find out what was going on – she need only walk onto the unit and ask.

This all reminds me of the scene in The Untouchables. Elliot Ness talks about busting Al Capone if only he knew where he was making his booze. Sean Connery’s character (Jimmy Malone) takes him to a post office across from the police station.  Ness can’t believe the booze is there. Malone says, “Mr. Ness, everybody knows where the booze is. The problem isn’t finding it, the problem is who wants to cross Capone.”

The problem isn’t knowing how to fix this problem. It’s doing what it takes to accomplish that — over-ruling the lawyers and accountants and doing the hard-work to change the culture. This can’t happen if the C-suite leads from meeting rooms.

These stories exemplify the huge cultural schism in the country between the minority, those institutions that have taken on the quality and safety agenda and internalized it into their decision-making and process improvement efforts, and the majority, the ones that have not.  Each year at the IHI Annual Forum, I hear from nurse managers and young doctors asking, “What can I do to get my CEO/CFO/CNO/Board of Trustees to support us in what we know must be done?”

I want to state this as clearly as possible.  The leaders of academic medical centers and medical schools are failing to be the leaders the country needs at this time. In their failure, they sow the seeds of burdensome governmental and regulatory requirements, for those in policy positions will see the vacuum and will fill it. In their failure, they persist in accepting the view that “these things happen,” and are personally — yes, personally — responsible for thousands of preventable deaths and injuries each year.  This is the most significant ethical issue facing the profession, and they simply fail to accept responsibility.

Paul Levy is the former President and CEO of Beth Israel Deaconess Medical Center in Boston and blogs at Not Running a Hospital. He is the author of Goal Play!: Leadership Lessons from the Soccer Field and How a Blog Held Off the Most Powerful Union in America.

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    medicine is shackled by cowardly leadership in the federal government and the corporate suites. we can vote the government out, but the nabobs on the top floor are harder to eradicate. i spend 20 years as division head at henry ford hospital battling quality issues. the leadership was so concerned with process they forgot how to pronounce results. committee upon committee stultified any initiative.  very frustrating situation

    • ES4P

      We ar trying to teach process improvement to all physicians.  Physicians understand the problems and work around them crating dangerous situations.  They expect the administration to fix these problems.  The administration is only a marginal stakeholder in many of these problem processes and have no motivation to devote resources to the solution, until a sentinel event and then it is too late to do anything but assign blame. Physicians, wake up, learn to fix your own problems. ES4P

  • Anonymous

    The problem goes back far in the intrusion of government and law into medicine, and the failure of medicine to take responsibility for itself.  This culture problem needs to change from the top down.  Money is the root cause of the problem – where it comes from and what strings are attached.  Patients don’t pay for their care – government (and private insurers) do, and medicine answers to them, not the patient.  Tort systems and government grant programs rather than Safety Boards rule the “quality” department, and thus decisions are made based on non-medical quality issues rather than real patient safety.

    heartsurgeryguide, the problem is that government is involved, period.  The problem is that health care has become BIG BOX STORE BUSINESS, and the WalMart versions like Henry Ford and Wayne State strangle out innovation both within and outside their doors with their heavy handed politics.

  • beverly rogers

    Argh! Mr. Levy writes about taking personal responsibility for not killing patients in hospitals, and the comments blame the government. The government is not going away from health care, people; sorry. That’s another issue.
    What Mr. Levy is talking about is that everyone in the C suite as well as the medical staff needs to feel the same way about a patient dying from hospital error as a surgeon would feel having nicked the aorta during an abdominal laparoscopy. And those hospital error deaths exceed nicking the aorta by an order of magnitude, don’t they.
    Not so hard to comprehend, eh?

  • Sonja McAdams

    In a hospital, work flow is like water. You can channel it, direct it, fix leaks, etc.; however, if you simply don’t have enough people to create a proper flow all efforts are for naught. Workflow follows the path of least resistance like water. Staff do not find work-arounds and short-cuts due to laziness or lack of regard for safety measures put in place to protect staff and patients. Rather, it is the result of direct-care staff being put in an impossible situation. Staff need their jobs, patients need care, there are limits to human ability and time, and when an institution does not staff adequately something has to give. Most corners are cut where it is less likely to cause an immediately identifiable problem – such as infection control measures, skin integrity measures, fall precautions, or charting detail.  Cries of inadequate staffing falls on deaf ears. Instead of listening to the staff that provide direct care charges of inefficiency and laziness are lodged and new cumbersome improvement efforts and more paperwork is piled on.  Why most of these efforts to improve performance of these particular measures most often fail is because they are being added to an already impossible workload.  The money-men, the various levels of administration, and the direct care staff must be in the same room to effectively address the problem.  All are responsible for the issue because nothing happens without money, nothing works effectively without direction, and no effective solution can be identified without the input of the staff who know the intimate details of their jobs.   

  • Linda Galloway

    This is the reason the insurance industry controls healthcare. Physicians were not savvy enough to keep them at bay. We need to start a National Data Bank of hospitas that are guilty of impeding progress with respect to maintaining patient safety. Each sentinel occurrence needs to be including in this Data Bank and the contents published once per month. Sometimes you have to think outside of the box. Frederick Douglas once said “Ask what the people are willing to endure and you have the limits of tyranny.” Physicians have been silent too long. Perhaps it’s time to make some noise . . . publicly. 

  • Lou Aliota

    So true Paul….

    All truths are easy to understand once they are discovered; the point is to discover them

    Personal Responsibility – Personal Accountability – Personal Transparency…Learn it – Teach it – Live it…..Lou Aliota 1946 –
    Erie, PA

  • Anonymous

    There are certainly improvements that can be made in patient care areas in hospitals.  My back-round is nursing-I have had the opportunity to observe care-giving in hospitals both nationally and internationally, and much  of what I saw was apalling, therefore I am not surprised at the number of medication errors, hospital-acquired infections, mis-information etc.  However, there are product that are having an impact on reducing Catheter Related Blood Stream Infections.  One that i am so impressed with is SwabCap.  This is a sterile cap that contains a sponge-like material that is saturated with 70% isopropyl alcohol.  the cap is placed on any needleless connector on an IV line that does not have an infusion connected to it.  It is also placed on y-sites on IV administration sets.  It stays in place between accesses.  It prevents touch, airborne and droplet contamination.  When luered onto the site, it maintains
    seal, thus providing continuous dis-infection, due to the contact with the wet alcohol.  When removed, the site is ready to access.  It has significantly decreased and/or eliminated Catheter Related Blood Stream Infections in those hospitals that have implemented it.  No hospital should be without this product. 

  • Andrei Lemiasheuski


  • Anonymous

    Maybe some of these health care workers/providers need to have a loved one acquire a hospital-based infection.  See the stress and heartache it causes to the patient and families.  My mother’s Total knee replacement has been a nightmare.  She was an independent 85 y/o who has had just those complications.  Everyday at the hospital I observed nurses, pcas, mds, and therapists, not washing hands or using hand sanitizer as the patient education channel showed the video about making sure everyone who entered the patient room, washed their hands.  Even the signs reading “cleanin/cleanout”, did not make a difference.  This was at a major academic medical center.  I observed the same in her visits to the ER.  Of course some providers did very well, but others, never even made the motion.  Rehab, is not much better.  

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