Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care
by Marty Makary, MD
4OurElders' key Takeaways (with some personal commentary thereon in bold) from the recent book Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care by Marty Makary, MD (Highly Recommended) (Dr. Makarty also is the author of a chilling feature article in the September 24, 2012 issue of Newsweek entitled Hospitals Can Kill You (also has appeared in The Wall Street Journal); and he has a website at www.TransparentHeathcare.org).
Healthcare is shrouded in secrecy and "unaccountability" to the detriment of patients and their families.
We are in a time where we have the technical capacity but we do not yet have the collective will to make our healthcare system transparent and more accountable.
Transparency means that 1) certain key data must be kept by providers of the care, 2) metrics are created and coordinated in ways that make sense to the professionals (NOT administrators) involved, 3) data are collected independently (or independently audited if self-reported), 4) the results revealed from the metrics and data will be made public in meaningful, easy-to-understand and use forums and formats so that consumers can make informed choices among competing providers and 5) the data and measurement results are used to hold professionals and institutions accountable for deviations from at least average care scores if not the best are scores of competitors in the health care marketplace.
Consumers should demand transparency and accountability, but they cannot bring change alone. We need to encourage and grow the small groups of professionals already out there working for transparency and accountability--Doctors, nurses, PAs, Nurse Practitioners and the associations and companies that license, represent and insure them. These are people who want safer care and better patient outcomes even and especially if it means speaking up and breaking the code of silence and resulting retaliation in the workplace against those who dare to speak, which has been too long the norm in health care.
"[W]here health care workers go for their own care tells you everything. The only people really able to rate the safety and quality of other doctors are those who work with them." (Italics in original)
Some startling statistics: "The number of U.S. patients killed annually by medical errors is equivalent to 4 jumbo jets crashing [and killing all on board] each week." "At nearly one third of hospitals [in the U.S.], fewer than 50% of employees said they'd feel safe there as patients;" unbelievably, in some hospitals the affirmative answer to the question was as low as 19%. Trust me, my own family and my friends are only going where 90-plus percent said yes. AND you have no way of knowing which ones they are. Even worse than this statistic, in my experience, IF the same question were put to ELDERCARE professionals in LTC homes (which question, by the way, is almost never even asked in LTC facilities) I estimate that more than 1/2 of elder care facilities would NOT have even this 50% of respondents who would "vouch" for the health and safety of their residents/patients. So, sadly, whether in acute or long term care environments, picking a provider is little more than blindly throwing darts at a dart board! That's exactly why 4OurElders exists-through WHAT we do and HOW we do it, we eliminate the guess work (and darts) for our clients! We ask all the right questions of current staff (including all the questions Dr. Makary raises in his book as critical for good care and safety) to better predict future care, safety and service by evaluating the current parameters most important-teamwork, safety, care and service, quality of care staff, quality and focus of management, the culture-is it profit-centric or care focused? and satisfaction levels of staff, patients and their families. "Forced to make outcomes public in [one New York] Medical Center cut its heart-bypass mortality rate from 18 to 1.7%." "Introducing transparency…brought something very novel and powerful to health care: public accountability."
"The shocking truth is that some prestigious, large hospitals have four to five times the complication rates of other hospitals in the same city. And [even] within good hospitals, pockets of poorly performing services abound." "Much of the wide variation in the quality of…medical care can be explained by culture-an institution's level of teamwork and its local sense of common mission." "Medicine is its own culture. It has its own language, ethos and code of justice. How a doctor approaches a patient's problem and whether he or she takes care of it or refers it to another more specialized doctor depends to a large extent on their institution's workplace culture. At some medical centers, profits are king, while at other places teamwork is a core value." 4OurElders knows that the same is true in the LTC arena; far too many facilities have profits as king and this culture driver directly, fundamentally and adversely affects patient care and service. Dr. Makary cites one example of a profit-driven culture: perverse compensation incentives-for example, basing a Doctor's bonus on the number of surgeries done. We see this throughout LTC-many facilities base bonuses for in-house marketers AND the Administrator based in part or whole on "census-filling the beds," which leads to very different results than when bonuses are based on quality care and service metrics. "When choosing a hospital, beware of clever marketing…and a culture [that prioritizes] keeping a patient's business over the best care." AMEN to that. In 4OurElders' experience LTC facilities take in hundreds if not thousands of residents/patients every week who they cannot and will not properly care for. Bad outcomes are virtually assured.
"[What makes [the] Mayo [Clinic] great has been answered. Mayo's administrative-system details seem…almost irrelevant. No business formula [makes] Mayo great, nor advertising nor new technology. It [is] Mayo's great hospital culture, one that permeates to even the janitorial staff….Some health-services researchers say Mayo's standardization of procedures hospitalwide (sic) is what makes it unique. Certainly that helps. Administrators there act more like investigators, walking the halls in search of problems to fix. In …[DR. Markay's opinion] Mayo's strong hospital culture of quality, safety, and patient-centeredness is rooted in a strong tradition of LISTENING TO EMPLOYEES. 4OurElders completely agrees and that is exactly what we do for every client-we interview staff at every level-including the janitorial, maintenance and housekeepers-to be in a position to real-time evaluate the facility's culture and competence in terms of care and service.
"Culture defines the quality and safety of any community or workplace, and medicine is not exempt. As small hospitals are increasingly becoming large corporate storefronts via the many mergers and acquisitions in health care, it is critical that medicine's culture of putting patients first be preserved, rather than succumbing to distant managers." As true as this is in acute care settings, it is equally if not more true in elder care housing, particularly given the appearance of REIT owner/operators and the prevalence of large chains owning and operating hundreds of facilities in dozens of states. It is why 4OurElders includes in each facility evaluation an examination of the role of distant owners/operators/managers in the provision of care and service at the local level.
In one study Dr. Markary cites only 5 of 66 (less than 10% of) hospitals surveyed had at least 80% of its staff agreed that the hospital gives priority to "what is best for the patient." (Remember Dr. Makary's 90% minimum rule above in line 5 of numbered paragraph 6.) Looked at differently, and unbelievably, almost 50% of those hospitals surveyed had 50% or MORE of its staff identify "what is best for the patient" is NOTa priority. 4OurElders, in its experience, believes the numbers would only be worse in LTC facilities.
"INSIST on the STATS…Hospitals are treasure troves of data…Consumers are starving for good data that are user-friendly to understand. One large study found that quality of care is people's biggest concern in choosing a health plan….But for the vast majority who seek medical care, it continues to be either very difficult or impossible to find this data. The statistics are either not collected because hospitals have no incentive to collect it, or the data are collected and highly guarded." (Italics in original.) Ditto and even worse in elder care housing!
"Data point to the fact that good teamwork and a good safety culture prevent errors and lead to better-quality (sic) care. Surveys cited by Dr, Markary confirm that answers to 2 key care and service-related questions-'would you have your own care at your hospital? ' and 'is management responsive to [your] safety concerns?'-have graphs "very similar in slope and range" as those displaying complication rates. By the way, the study cited on safety revealed that over 60% of the hospitals surveyed had NEGATIVE answers from staff to the question "does your hospital have a good safety climate?"ranging from 40% to about 86% "NO." Unbelievable and, again, our experience suggest strongly that the numbers would be worse in elder care housing.
"[M]illions of Americans might have avoided the nightmare [they] experienced if [they] had known exactly the right questions to ask…" (See page 64 of the book for one example list). Asking the right questions and getting truthful answers that will inform our clients is exactly what 4OurElders does-prior to selection of and admission to a LTC facility.
While some professionals, Patient Advocacy groups and Hospitals are stepping up to efforts for health care providers to be more transparent, "Nonetheless, so far much of the most effective pressure for change has come from patients-OR, SADLY, FROM THEIR BEREAVED FAMILY MEMBERS." (emphasis added)
Easy to use and readily available metrics for easy patient access that Dr. Makary recommends include: "Bouncebacks"-- (percentage of hospitalized patients who are readmitted to any hospital within 90 days, categorized by discharging [and presumably readmission] diagnoses; Complication Rates, defined as any adverse event or outcome after treatment; so-called "Never Events" (things that should never happen in a hospital); Safety-Culture Scores--all hospitals (around 1500 hospitals in the U.S. DO currently ask these questions, but you cannot see the results) should be required to ask, collect and publish the results of answers to the following 3 questions posed to doctors, nurses and other health care workers: 1) "Would you have [a medical procedure] done at the hospital in which you work?" 2) "Do you feel comfortable speaking up when you have a safety concern?" 3) "[Is there good teamwork here] and [D]oes the teamwork here promote doing what's right for the patient?"; Hospital Volumes--(reporting how many patients with a particular type of medical condition they treat and, hopefully, outcomes associated with each by category); Transparent Records, Open Notes and Video Recording--"Consumers should be able to find out…[who has] programs to streamline access to written and video records. [Institutions] that have family- and patient-centered programs or policies mandating full disclosures of all drug- and device-related financial conflicts of interest should be easy to find for prospective patients…" I would add another, even though I know the author intends this list to be a starting not an ending point-I want to know by health care worker and professional, by category (e.g., supervisor, charge nurse, chief, etc), by shift, turnover rates by quarter and year to-date. WHY? Because where there is high turnover in a LTC facility, the risks for bad outcomes skyrockets.
"If you can't [or don't or won't] measure it, you can't improve it." And if you do measure it but don't use AND share it, what good is it for the consumer?
"Congress should make transparency a condition of Medicare reimbursement." I would say the same for State legislators with Medicaid reimbursement. "With universal transparency…leadership would also develop a fast-moving protocol by which to conduct crackdowns whenever new problems come to light….But, under our current, largely unaccountable system…problems [remain] out of sight and out of mind [and] just pile up until they get so out of hand, only a major, punishing scandal can hope to remedy them." This is, sadly if not unforgivably, PARTICULARLY true (as evidenced by countless examples) in elder care housing in this country.
Communications are critical in most settings, but none more important than in health care institutions. "The Joint Commission on hospital accreditation reports that the vast majority of medical mishaps result from breakdowns in communication….[It] reports that [these] breakdowns…cause more hospital mishaps than equipment failures and inadequate training combined." Equally true or truer in LTC facilities, despite the fact that they should be easier than most hospitals to ensure clarity of communications simply because they are smaller-in number of beds, employees and specialties-- than most hospitals surveyed.