All Hospitals Need to Know They Learned In Kindergarten

On October 20, 2010 HealthGrades released their Thirteenth Annual Hospital Quality in America study, which analyzed mortality and complication rates at all of the nation’s 5000 non-federal hospitals using 40 million hospitalization records obtained from CMS.  The study found that patients treated at hospitals rated as “5-star” by HealthGrades had a 72% lower risk of dying than if they had gone to a “1-star” rated hospital.  A key finding:  If all hospitals performed at the level of a five-star rated hospital, 232,442 Medicare lives could potentially have been saved from 2007 through 2009.

According to Rick May, MD, an author of the study and a vice president with HealthGrades, “We are encouraged by the steady improvement in mortality rates among America’s hospitals, but there’s an unacceptably wide gap that has persisted between the top-performing hospitals and all others in terms of patient outcomes.” Bottom line:  mortality rates overall have improved at our nation’s hospitals, but they are still unnecessarily killing people (or injuring them) at alarmingly high rates.  Note to self:  stay out of the hospital.

HealthGrades’ approach is interesting because similar star ratings are ubiquitously used by consumers to evaluate restaurant and hotel chains, for instance, but are largely unknown to consumers trying to figure out which hospital they should go to (particularly when they arrive by ambulance).  Everyone knows that if they choose a 5-star hotel like the Ritz Carlton they are going to get a clean bathroom and a nice mint on their pillow.  Consumers also know that if they choose a 1-star no-tell motel they are going to have plenty of 8-legged company while they sleep (hey, that bedbug carried off my mint!).

If hospitals were like many other industries that have the ability to materially impact people’s lives, say auto manufacturing or restaurants, the low quality hospital offenders would be subject to significant financial penalties and pretty significant public humiliation.  Just ask Toyota, which was forced to recall over 10 million cars and pay millions of dollars in fines due to their brake failures (89 deaths); or ask Wright County Egg, of Galt, Iowa, which was forced to recall 380 million eggs when several hundred people contracted salmonella (injuries, but no deaths) at restaurants across the country that served their products.    When a hospital kills a few hundred people accidentally, it is rare to see any newspaper article, much less a serious fine, unless the patient’s family actually learns the truth about the incident and files a lawsuit.  If someone dies in a Toyota on their way to eat an omelet in Iowa, you will probably see Diane Sawyer covering it.

Amazingly, hospitals get away with poor performance even when it is widely known that there are solutions to many of the patient safety problems they face.  According to the HealthGrades report, “on average, a typical patient would have an 80.4% lower risk of developing one or more in-hospital complications by going to a five-star rated hospital compared to a one-star and a 63.64% lower risk of developing one or more in hospital complications by going to a 5-star compared to the U.S. hospital average.”  Forget the mints, I want a four-leaf clover and a lawyer on my pillow if I get sick.

I have been intrigued by the numerous articles written recently about how hospital administrators are looking to other industries to learn how to adopt processes to reduce error and improve quality of care.   For instance, there have been a myriad of articles and an entire book by Atul Gawande–The Checklist Manifesto— about how hospitals can take a page from the airline industry, which has raised the application of sophisticated safety checklists to an art form.  By learning to do things the way pilots do, several hospitals have adopted checklist methodologies that have reduced injuries in the operating room and at the bedside.

I recently saw another article, following the publication of an Oxford University study in the British medical journal Quality and Safety in Health Care, saying that hospitals are looking to learn new tricks from the auto racing industry to reduce errors.  Having conducted “structured interviews with the technical managers of nine F1 racing teams, researchers have identified ways that hospitals are can translate the timing and synchronization of auto racing team pit crews to their efforts to achieve better patient hand-offs”.  According to the article, the racing crews can refuel a car and change all four tires in seven seconds, and no F1 driver has died at the wheel in a Grand Prix race since 1994.  Physicians are using these approaches to reduce communication and coordination breakdowns that occur during patient transfers between intensive care, surgery and recovery.

Yet other hospitals are learning from the manufacturing sector, adopting their lean manufacturing techniques to improve the efficient flow of patients through their system and to cut down on errors.  It is perhaps more than a little ironic that Toyota is among the longest-standing proponents of this approach to defect reduction.

As I have come across these instances of hospitals trying to learn from outside industries, I couldn’t help but be reminded of that old poem by Robert Fulghum called “All I Really Need to Know I Learned in Kindergarten.”  Here are some excerpts:

All I Really Need To Know about how to live and what to do

and how to be I learned in kindergarten…These are the things I learned:

Share everything.

Play fair.

Don’t hit people.

Put things back where you found them.

Clean up your own mess.

Don’t take things that aren’t yours.

Say you’re sorry when you hurt somebody.

Wash your hands before you eat.

Flush.

Warm cookies and cold milk are good for you.

The poem ends with this:

And it is still true, no matter how old you

are – when you go out into the world, it is best

to hold hands and stick together.

In thinking about this classic of 1990’s pop psychology, it struck me that while high technology fields such as auto racing, manufacturing and aviation can offer some important ideas about process management to America’s hospitals, many of the foundational ideas for how to run a high quality hospital were first learned in kindergarten but just didn’t stick.

For instance:  Share everything.  If hospitals did a better job of sharing data between caregivers, departments and families, the process of care delivery would be vastly improved. Yes, this can be done with the electronic medical record (EMR) systems that everyone is talking about, but if kindergarteners know the importance of sharing, why is it so controversial for hospitals, many of which are still noodling about whether they need to adopt technology to manage patient information.  According to the 21st Annual 2010 HIMSS Leadership Survey,  only 22% of hospitals have EMR systems fully implemented across their entire organization and another 26% have EMRs implemented in one facility of their hospital system.  That means that more than 50% aren’t in a position to effectively share data about patients to maximize quality of care and eliminate redundancies and error.

Put things back where you found them?  This is a good one for the surgical suite where there is a terrible problem of surgical sponges and other tools accidentally being left inside of patients.  Estimates have varied as to whether this happens in 1 out of every 1000 surgeries or 1 out of every 18,000 surgeries, but with about 50 million surgeries occurring each year in the U.S., it is a big number either way.  Physicians and nurses are required to count the number of sponges that go in and then count them again on the way out.  While new technologies such as radio-frequency tags and bar codes exist to perform this function more effectively, most hospitals still do this the old fashioned way–manually. The problems come in when doctor and nurse disagree over the accuracy of the count on the way out, and this is where the mistakes are often made.  This process must be improved through the application of technology to take the chance out of it.

Wash your hands before you eat?  I’ll add a slight change: wash your hands before you touch a patient.  This is another basic kindergarten skill that everyone in hospitals should know.  Hospital-induced infections are among the highest cost medical errors out there, accounting for an estimated 98,000 deaths per year.  Did any of you catch that September 16 article in The Health Care Blog entitled, NYC Train Station Bathroom Yields Cleaner Hands than Hospitals? In the article Michael Millenson, a visiting scholar at the Kellogg School of Management, compared data from a recent survey of public bathroom hygiene in the U.S. to hand hygiene compliance rates in U.S. hospitals, and found that “the guy who just used the toilet at Grand Central Station is … way more likely to have clean hands than the guy walking up to your bed at the local hospital.” If you weren’t nauseous when you got the hospital, this ought to make you throw up for sure.

Say you’re sorry when you hurt someone?  That’s an oldie but goodie—you probably started hearing it even before kindergarten. So why do physicians and hospitals decline to apply this basic rule?  35 states have laws offering at least partial legal protection to physicians who apologize to the patient or their family after causing an adverse event. Unfortunately, medical malpractice liability carriers are not quite so empathetic and typically advise physicians against an implied admission of guilt that may be construed from such an apology.  This is a shame, because a fair amount of research has been done to prove that when hospitals and physicians apologize for their medical errors, claims can decline by as much as 40% and liability settlements are considerably lower than in cases where no apology was offered.

In an article in the AMA publication American Medical News, Douglas B. Wojcieszak (the founder of the Sorry Works! Coalition, which promotes the apology, disclosure and compensation concept among physicians, insurers and hospitals) estimates that only 5% to 10% of hospitals nationally are taking the “I’m sorry” approach. Wojcieszak adds that many hospitals decline to publicize their adherence to this policy out of fear of drawing attention from trial lawyers (who are apparently lingering outside the ER having chased an ambulance to the hospital); nothing like institutionalized lack of transparency to warm the heart.   Everyone suffers from fear and embarrassment when they commit an act that warrants an apology; just ask any kindergartener.  However, when it is well documented that this small act of civility could dramatically improve our healthcare system, you would think that this life lesson would spread more quickly to our nation’s hospitals. For this one, no technology is even required.

While many successful industries can offer lessons in quality improvement that can significantly improve hospital operations, I contend that some of these lessons are quite simple and flow from the well-accepted tenets of decent human behavior.  You don’t need a high-priced hospital consultant to tell people to wash their hands or apologize when you hurt someone (although it turns out you do need one to make sure they actually do it—maybe kindergarten teachers could improve their pay grade by moonlighting on the inpatient floor to counsel physicians and nurses?).

There’s another lesson in the Fulghum poem and it’s best directed to patients and their families as they walk up to the hospital admissions desk:  hold hands and stick together.  If you don’t watch out for yourself and your loved ones when being treated in the hospital, there is a good chance that no one else will.

An excerpt from this post appeared October 26, 2010 in Xconomy.