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Health Care Academics' Unrest and Bad Health Care Leadership?

Last month we <a href="http://hcrenewal.blogspot.com/2012/08/will-another-study-on-physician-burnout.html">discussed</a> a recent, large scale study of physician burnout, and wondered whether it would finally inspire some discourse about why physicians are really so upset.  In particular, we hypothesized,  based on some real, if limited data, that physician angst, dissatisfaction, burnout, etc may mainly be a response to the problems with leadership and governance of health care organization we post about on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal.</a> After that post, one of our scouts found a very interesting and relevant article from earlier this year which got little attention at the time, but deserves more.  [Pololi LH, Krupat E, Civian JT, Ash AS, Brennan RT. Why are a quarter of faculty considering leaving academic medicine? A study of their perceptions of institutional culture and intentions to leave at 26 representative U.S. medical schools. Acad Med. 2012; 87: 859-69. Link <a href="http://www.ncbi.nlm.nih.gov/pubmed/22622213">here</a>.] Study Design This was a cross-sectional survey of faculty at 26 medical schools in the US, selected to be similar to the general population of medical schools in the country.  At each school, 150 faculty were randomly chosen stratified by sex and age, and then the sample was enriched to include additional minority faculty and women surgeons, for a total of 4578. The faculty were sent a multi item survey to assess their perception of the organizational culture of their institutions, and asked about their intentions to continue in or leave their current positions and academic medicine.  Responses to each survey item were allowed to be from 1 = strongly disagree, to 5 = strongly agree.  The items on the survey were combined into various scales.  A number of items on the survey seemed to be related to issues we frequently discuss on Health Care Renewal.  These items ended up in three different scales, entitled Relatedness/Inclusion, Values Alignment, and Ethical/Moral Distress.  The survey items are listed below, grouped by issue, with the scales into which they were combined noted. Issue: <a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management">Mission-Hostile Leadership</a> Administration only interested in me for revenue   (Reverse coded) (Values Alignment) Institution committed to serving the public (VA) Institution's actions well-aligned with stated values and mission (VA) Institution puts own needs ahead of educational/clinical missions (RC) (VA) My values well-aligned with school's (VA) Institution awards excellence in clinical care (VA) Institution does not value teaching (RC) (VA) Have to compromise values to work here (Ethical/Moral Distress) Issue: <a href="http://hcrenewal.blogspot.com/search/label/deception">Deceptive</a>, Unethical Leadership Felt pressure to behave unethically (Ethical/Moral Distress) Need to be deceitful in order to succeed (EMD) Others have taken credit for my work (EMD) Issue: Generation of the <a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect">Anechoic Effect</a> by  Suppression of <a href="http://hcrenewal.blogspot.com/search/label/free%20speech">Free Speech</a>, <a href="http://hcrenewal.blogspot.com/search/label/academic%20freedom">Academic Freedom</a>, Dissent, <a href="http://hcrenewal.blogspot.com/search/label/whistle-blowers">Whistle-Blowing,</a> Feel ignored/ invisible (RC) (Relatedness/Inclusion) Hide what I think and feel (RC) (R/I) Reluctant to express opinion/ fear negative consequences (RC) (R/I) So in summary, the survey contained quite a few questions about mission-hostile management, comprising nearly all of the Values Alignment scale, some questions about deceptive or unethical leadership, all in the Ethical/Moral Distress scale, and some about generation of the anechoic effect by suppression of free speech, academic freedom, dissent, and whistle-blowing, all in the Relatedness/Inclusion scale. Results The response rate was 52% (N=2381.) Unfortunately, the article did not include the distributions of the responses to individual survey items, and only included the mean and standard error of the scale scores.  The values for the scales of most interest were: Relatedness/Inclusion  3.56 SE= 0.022 Values Alignment  3.25 SE=0.028 Ethical/Moral Distress 2.36 SE=0.022 Note that the article did not address the degree individual items, especially those listed above, contributed to variation in the scale scores. A small majority of faculty indicated their intentions to stay at their institutions (57%).  Of the remainder, 14% were considering leaving their school due to dissatisfaction, and another 21% were considering leaving academic medicine due to dissatisfaction.  The remainder were considering leaving due to personal/ family reasons or to retire. The authors did complex multinomial logit modeling to assess the relationships among the various scales, demographic factors, and intention to leave.  Most relevant to us, Relatedness/Inclusion was significantly related to intention to leave the institution due to dissatisfaction (Coefficient -0.69, p lt 0.001, OR =0.50), as was Values Alignment (-0.39, p=0.04, OR=0.68), but not Ethical/ Moral Distress.  Furthermore, Relatedness/Inclusion was related to intention to leave academic medicine due to dissatisfaction (-0.48, p lt 0.001, 0.62), as was Ethical/Moral Distress (0.60, p lt 0.001, OR =1.82). The article did not address whether individual survey items, including those of most interest listed above, were related to intention to leave.  The article also did not address whether responses to the survey or intention to leave varied across faculty characteristics, medical school characteristics, or individual medical schools.  Summary and Comments This very large survey of faculty from multiple US medical schools showed that more than one-third were considering leaving their institutions or academic medicine due to dissatisfaction, indicating a striking prevalence of faculty distress.  Their responses to questions about perceived organizational cultural and leadership problems, including those possibly related to leadership's perceived hostility to the mission, leadership's perceived dishonesty or unethical behavior, and leadership's suppression of dissent, free speech, academic freedom, and whistle-blowing were related to their intentions to leave due to dissatisfaction. These results suggest the hypothesis that much of faculty angst may be due to the sorts of problems with leadership and hence organizational culture that we discuss on Health Care Renewal.  Since this was a cross-sectional survey, it certainly does not offer scientific proof of this hypothesis.  Note that there is other evidence from numerous cases discussed in Health Care Renewal, qualitative studies and our much smaller study published only in abstract form that also supports this hypothesis (look <a href="http://hcrenewal.blogspot.com/2012/08/will-another-study-on-physician-burnout.html">here</a>).  One part of the author's discussion of their findings was particularly relevant: <blockquote class="tr_bq">Our findings are congruent with metaanalyses of 25 years of organizational justice research outside medicine. These studies suggest that employee perceptions of organizational justice and an ethical climate are related to increased job satisfaction, trust in leadership, enhanced performance, commitment to one’s employer, and reduced turnover.  The scale of ethical/moral distress (see Table 1) reflects reactions to the prevailing norms and possible erosion of professionalism and increased organizational self-interest. There is a growing belief that organizations influence and are responsible for the ethical or unethical behaviors of their employees.To our knowledge, faculty perceptions of 'moral atmosphere' and 'just community' embedded in our survey have not been previously investigated in academic medicine, even though the ethical concepts of professionalism and justice can be used to guide the pursuit of excellence in the missions of medical schools. Several scholars have called for academic medicine to attend to its social justice and moral mission. Faculty perceptions of organizational justice are pivotal to the critical issue of professionalism in medicine. The ethical/moral distress scale in the survey reported here included items such as 'the culture of my institution discourages altruism' and 'I find working here to be dehumanizing.' (See Table 1 for other items in this scale.) In that ethical/moral distress was more strongly related to intent to leave academic medicine entirely than intent to leave one’s own institution, these negative feelings among faculty must be particularly disheartening to them and may color major career decisions.</blockquote>I believe that the study by Pololi et al adds to the evidence that physician distress is a symptom of a dysfunctional system in which major health care organizations have been taken over by leaders more devoted to self-interest and short-term revenue than the values prized by health care professionals and academics.  This applies obviously to academic medical institutions, but also to other organizations that might have been expected to defend such professional and academic values, such as professional associations, accrediting organizations, and health care foundations.  As we <a href="http://hcrenewal.blogspot.com/2012/08/will-another-study-on-physician-burnout.html">said before</a>, if physicians really want to address what is making them burned out and dissatisfied, they will have to regain control of their own societies, organizations, and academic institutions, and ensure that these organizations put core values, not revenue generation and providing  cushy compensation to their executives, first.

Health Care Academics' Unrest and Bad Health Care Leadership?

Last month we discussed a recent, large scale study of physician burnout, and wondered whether it would finally inspire some discourse abou...

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Allegheny Health System Computer Crash (Again) and Paper Backups

I reported on a health IT crash in my May 2011 post "<a href="http://hcrenewal.blogspot.com/2011/05/twelve-hour-health-it-glitch-at.html" target="_blank">Twelve Hour Health IT Glitch at Allegheny General Hospital - But Patients Unaffected, Of Course...</a>" Now, there's this at the <a href="http://www.wpahs.org/locations" target="_blank">same healthcare system</a>: <blockquote class="tr_bq"><a href="http://www.post-gazette.com/stories/news/health/computer-system-at-west-penn-allegheny-crashes-655866" target="_blank">Computer system at West Penn Allegheny restored after crash</a>  Liz Navratil Pittsburgh Post-Gazette October 2, 2012 The computer system at West Penn Allegheny Health System crashed about noon today, temporarily leaving doctors and nurses to work off of paper records instead. Kelly Sorice, vice president of public relations for the health system, said all systems have since been restored. She said the servers crashed about noon today when the system experienced a power surge. Doctors in the health system keep paper copies of almost all of their records so they can reference them during power outages or scheduled maintenance times, Ms. Sorice said.</blockquote> Some systems were up eight hours later and others were expected to come online overnight, according to a report at <a href="http://histalk2.com/2012/10/02/news-10312/" target="_blank">HisTalk</a>. Assuming the statement about "doctors keep paper copies of almost all their records" was not spin control regarding skeletal paper records, a question arises. Why, exactly, spend hundreds of millions of dollars on computing if paper records are kept, and are perfectly sufficient to accomplish the following, the usual refrain in health IT crash scenarios? <blockquote class="tr_bq">Ms. Sorice said she did not know of any procedures that had been rescheduled and added that, "Patient care has not been compromised." </blockquote> As a physician/ham radio enthusiast who did an elective in Biomedical Engineering in medical school, I also want to know: 1)  What caused the “power surge?” 2)  Why were the systems not protected against a “power surge?” 3)  Exactly how did the “power surge” affect the IT? Note: I've created a new, searchable indexing term for HIT outage stories with the usual refrain along the lines that "patient care has not been compromised."  See <a href="http://hcrenewal.blogspot.com/search/label/Patient%20care%20has%20not%20been%20compromised" target="_blank">this query link</a> using the new indexing term. -- SS Addendum Oct. 3: Australian EHR reseacher and professor <a href="http://rp-www.cs.usyd.edu.au/~jonpat/" target="_blank">Dr. Jon Patrick</a> opines: <blockquote class="tr_bq">Even if [the paper records are] skeletal they suggest an endemic lack of confidence. I think the hospital spokesperson hasn't seen the implication of their statement.</blockquote> -- SS

Allegheny Health System Computer Crash (Again) and Paper Backups

I reported on a health IT crash in my May 2011 post " Twelve Hour Health IT Glitch at Allegheny General Hospital - But Patients Unaffec...

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Honesty and Good Sense on Electronic Medical Records From Down Under

Australians seem to not be as seduced by the Siren Song of cybernetic miracles as health IT leaders in the United States. It took an Australian computer scientist at U. Sydney to dissect and perform a detailed analysis of the internals of an American EHR system, the results of which were <a href="http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146" target="_blank">disturbing to say the least</a>.  This was a task the American members of the American Medical Informatics Association (<a href="http://www.amia.org/" target="_blank">AMIA</a>) should have taken on.  It's not as if they're <a href="http://jamia.bmj.com/site/icons/amiajnl8946.pdf" target="_blank">unaware of clinical IT problems</a>. It also seems to take a group of Australian researchers at the Univ. of New South Wales, the Australian Patient Safety Foundation, and the University of South Australia to perform a forensic analysis on U.S. data in the FDA's Manufacturer and User Facility Device Experience (<a href="http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm" target="_blank">MAUDE</a>) database, instead of Americans themselves.  At least AMIA allowed the Australians the opportunuty to present their findings. In "Patient Safety Problems Associated with Heathcare Information Technology: an Analysis of Adverse Events Reported to the US Food and Drug Administration" (free fulltext <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243129/" target="_blank">at this link</a>), AMIA Annual Symposium Proceedings 2011;2011:853-7 the Australian researchers including Medical Informaticist and critical thinker Dr. Enrico Coiera (see <a href="http://content.yudu.com/Library/A1xcz9/Pulse+ITMagazineJuly/resources/56.htm" target="_blank">here</a>) analyzed healthcare information technology (HIT) events associated with patient harm submitted to the MAUDE database: <blockquote class="tr_bq">We downloaded all 899,768 reports that were submitted to MAUDE from January 2008 to July 2010 and searched for events using a broad definition of HIT as “hardware or software that is used to electronically create, maintain, analyse, store, receive, or otherwise aid in the diagnosis, cure, mitigation, treatment, or prevention of disease, and that is not an integral part of (1) an implantable device or (2) medical equipment.” We retrieved and classified 678 reports describing 436 unique events using a previously published methodology. Of the 436 HIT-related events that we examined, 11% (n=46) were associated with patient harm [this excludes the "near misses" - ed.] ... In this paper we specifically focus on examining the 46 events where HIT problems were associated with patient harm. </blockquote> These submissions are voluntary, and due to systematic, severe impediments to submissions as below, this data likely represents a very small fraction ("tip of the iceberg" per FDA itself, <a href="http://hcrenewal.blogspot.com/2010/02/fda-on-health-it-adverse-consequences.html" target="_blank">link</a>) of the true incidence of these events.  See the addendum to this post "Systematic impediments to voluntary reporting of health IT risks." Summarizing the Australian researchers' findings (read the entire paper at the link above): <blockquote class="tr_bq">Medication problems represented 41% of the events of these types: <ul><li>Wrong patient</li><li>Wrong dose or overdose</li><li>Missed and delayed doses</li></ul> Clinical process problems represented 33% of the events: <ul><li>Use errors in entering information ("use error" is an error due to poor and confusing design, as opposed to "user errors")</li><li>Poor functionality of CPOE and PACS</li></ul> Exposure to radiation occurred in 15% of the events Surgery problems occurred in 11% of the events.</blockquote> The authors recommended that "strategies to improve the safety of HIT should focus on designing safe user interfaces, integrated checks of key identifiers and decision support, and engineering safer clinical processes." Unfortunately, that does not appear to be occurring in the U.S. to any significant degree.  "Certification" of health IT to meet government criteria for financial incentives is unrelated to such measures and is in my view symptomatic of industry regulatory capture (see <a href="http://hcrenewal.blogspot.com/2012/02/hospitals-and-doctors-use-health-it-at.html" target="_blank">here</a> and <a href="http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html" target="_blank">here</a>).  The IOM itself has instituted a "watch and wait" policy, a likely unique special accommodation in current regulation of medical devices (see <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">here</a>). I reiterate this MAUDE data is voluntary and the impediments to its reporting systematic and severe.  See addendum to this post. In the category of good sense on electronic medical records, I note the following articles: <blockquote class="tr_bq"><a href="http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1159:victoria-aims-for-more-open-ict-strategy&catid=16:australian-ehealth&Itemid=327" target="_blank">Victoria aims for more open ICT strategy</a>  Pulse+IT Magazine Kate McDonald 02 October 2012 The newly formed Victorian Information and Communications Technology Advisory Committee (VITAC) has released a <a href="http://www.vic.gov.au/ictstrategy/wp-content/uploads/2012/08/Victorian-ICT-Strategy-2012-Public-Consultation-Draft1.pdf" target="_blank">draft strategy (PDF)</a> describing how the state government should manage and use ICT to better provide government services. The strategy recommends that the government engage more closely with the ICT sector and move away from customised products in favour of existing market offerings. ... It recommends that the government engage with the ICT market early in the procurement lifecycle. “We will avoid being locked into single suppliers by favouring open standards and will be open to any qualified ICT provider regardless of size. Procurement of ICT services will be made more efficient.” The strategy should also provide guidance to agencies to move away from customised major ICT developments and use existing market offerings with little or no customisation instead.</blockquote> What this means is abandoning the approach of large, single-source (monolithic), proprietary clinical information systems from large health IT vendors that try to cover everything, in favor of smaller, open standards-based "best-of-breed" applications (from vendors of all sizes) that can be woven together to meet users' needs: <blockquote class="tr_bq">The subsequent fallout from the Ombudsman's report led to the Victorian government cancelling several programs, including the $323 million <a href="http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1002:why-the-axe-fell-on-healthsmart&catid=16:australian-ehealth&Itemid=328" target="_blank">HealthSMART</a> program, an ambitious project to roll out common eHealth infrastructure throughout Victoria's public health services. This included implementing iSOFT's (now CSC) <a href="http://www.isofthealth.com/en-gb/Solutions/UK%20Patient%20Management/iPM.aspx" target="_blank">i.PM</a> patient administration system and <a href="http://www.cerner.com/" target="_blank">Cerner's</a> clinical information system in its hospitals, as well as <a href="http://www.intersystems.com/trakcare/" target="_blank">InterSystems' TrakCare</a> platform for community health agencies.</blockquote> I note that another article in eHealth Insider mentions the same strategy in the UK, "<a href="http://www.ehi.co.uk/news/ehi/8048" target="_blank">Winchester switches off Cerner in ED</a>": <blockquote class="tr_bq">The Royal Hampshire County Hospital in Winchester has switched off Cerner Millennium in A&E and moved to Patient First.  The electronic patient record system will also be switched off for theatres and order communications at the old Winchester and Eastleigh Healthcare NHS Trust ... Basingstoke and North Hampshire was pursuing an alternative IT strategy, built around a 'best of breed' approach to building on its existing systems.</blockquote> The U.S. has yet to learn these lessons, and will likely <a href="http://hcrenewal.blogspot.com/2010/12/professors-at-harvard-and-nottingham.html" target="_blank">repeat the same mistakes</a> at the cost of hundreds of billions of dollars. Unfortunately, I have no answers.  I see no way to avoid it, considering the HITECH momentum that favors the large-vendor monolithic product model. -- SS -------------------------------------- Addendum.  Systematic impediments to voluntary reporting of health IT risks: From the <a href="http://hcrenewal.blogspot.com/2010/08/smoking-gun-internal-fda-memorandum-of.html" target="_blank">2010 FDA internal memo on health IT risks</a>: <blockquote class="tr_bq">Limitations of the MAUDE search and final subset of MDRs include the following: 1.  Not all H-IT safety issue MDRs can be captured due to limitations of reporting practices including: ... (a) Vast number of H-IT systems that interface with multiple medical devices currently assigned to multiple procodes making it difficult to identify specific procodes for H-IT safety issues; ... (b) Procode assignments are also affected by the ability of the reporter/contractor to correctly identify the event as a H-IT safety issue; ... (c) Correct identification by the reporter of the suspect device brand name is challenged by difficulties discerning the actual H-IT system versus the device it supports. 2.  Due to incomplete information in the MDRs, it is difficult to unduplicate similar reports, potentially resulting in a higher number of reports than actual events. 3.  Reported death and injury events may only be associated with the reported device but not necessarily attributed to the device. 4.  Correct identification by the reporter of the manufacturer name is convoluted by the inability to discern the manufacturer of the actual H-IT system versus the device it supports. 5.  The volume of MDR reporting to MAUDE may be impacted by a lack of understanding the reportability of H-IT safety issues and enforcement of such reporting.</blockquote> From the <a href="http://hcrenewal.blogspot.com/2011/11/iom-report-on-health-it-safety-nix-fda.html" target="_blank">2012 IOM report on health IT safety</a>: <blockquote>... While some studies suggest improvements in patient safety can be made, others have found no effect. Instances of health IT–associated harm have been reported. However, little published evidence could be found quantifying the magnitude of the risk. Several reasons health IT–related safety data are lacking include the absence of measures and a central repository (or linkages among decentralized repositories) to collect, analyze, and act on information related to safety of this technology. Another impediment to gathering safety data is contractual barriers (e.g., nondisclosure, confidentiality clauses) that can prevent users from sharing information about health IT–related adverse events. These barriers limit users’ abilities to share knowledge of risk-prone user interfaces, for instance through screenshots and descriptions of potentially unsafe processes. In addition, some vendors include language in their sales contracts and escape responsibility for errors or defects in their software (i.e., “hold harmless clauses”). The committee believes these types of contractual restrictions limit transparency, which significantly contributes to the gaps in knowledge of health IT–related patient safety risks. These barriers to generating evidence pose unacceptable risks to safety. </blockquote><blockquote>… “For example, the number of patients who receive the correct medication in hospitals increases when these hospitals implement well-planned, robust computerized prescribing mechanisms and use barcoding systems. But even in these instances, the ability to generalize the results across the health care system may be limited. For other products— including electronic health records, which are being employed with more and more frequency— some studies find improvements in patient safety, while other studies find no effect. More worrisome, some case reports suggest that poorly designed health IT can create new hazards in the already complex delivery of care. Although the magnitude of the risk associated with health IT is not known, some examples illustrate the concerns. Dosing errors, failure to detect life-threatening illnesses, and delaying treatment due to poor human–computer interactions or loss of data have led to serious injury and death.”</blockquote> Not knowing the magnitude of the risks is an effect of the impediments, and does not represent a good environment for national implementation in my view. I also add "fear of medical malpractice litigation" to the lists above. -- SS

Honesty and Good Sense on Electronic Medical Records From Down Under

Australians seem to not be as seduced by the Siren Song of cybernetic miracles as health IT leaders in the United States. It took an Austral...

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Traits that "Define a Great Hospital CFO" - Honesty, Integrity, Accountability not Included

A recent <a href="http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/6-traits-that-define-a-great-hospital-cfo.html">article</a> in Becker's Hospital Review entitled, "6 Traits That Define a Great Hospital CFO" [Chief Financial Officer] was most remarkable for what traits were not included. The Six Traits Based on interviews with a managing director of health care recruiting for a large executive search firm, and an experienced CFO of large hospital system, the included traits were: - "Conviction," including "some type of conviction and confidence that their decision-making abilities will lead the hospital to great healthcare outcomes, a healthy population and — as a result — a more financially stable organization." - "Nimbleness and flexibility" - "Calm demeanor" - "Willingness to understand the clinical aspects," in particular, the ability to "at least understand the [clinical] processes from a layperson's point of view, and the most effective CFOs have great working relationships with physicians, nurses, technicians and others." - "Ability to think long term" - "Sense of humor" To be fair, I am glad to see expectations that hospital leaders, even chief financial officers, know something about clinical care, and that they have some sort of commitment to it. This seems to be in contrast to our frequent <a href="http://hcrenewal.blogspot.com/search/label/ill-informed%20management">posts</a> about how the leadership of health care organizations often seems ignorant and uncaring about the health care context and health care values. (However, the phrase above about conviction was not clearly worded. In particular, it did not explicitly suggest quality clinical care ought to be a higher priority than revenue, and could have been read to mean that good care is just a means to increase revenue.) I am also glad that the article promoted long-term thinking. It also seems to contrast with concerns (e.g., <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">here</a>) about how health care leadership may put short-term revenue ahead of all other goals, also called "<a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>." However, again, the article did not explicitly give long-term goals a higher priority than short-term ones. What was Missing However, what was more striking were the dogs that did not bark. In particular, transparency, honesty and integrity or even being law-abiding were not on the list of key traits for a CFO. This is particularly noteworthy given how often we have discussed bad behavior by large health care organizations, including various kinds of <a href="http://hcrenewal.blogspot.com/search/label/deception">deception</a> and dishonest behavior, as well as outright <a href="http://hcrenewal.blogspot.com/search/label/crime">crime</a>, such as <a href="http://hcrenewal.blogspot.com/search/label/fraud">fraud</a>, <a href="http://hcrenewal.blogspot.com/search/label/bribery">bribery</a> or <a href="http://hcrenewal.blogspot.com/search/label/kickbacks">kickbacks</a>, etc. Also, the list of important traits did not include responsibility or accountability.   This is also noteworthy given that rarely if ever have the leaders of these organizations taken any responsibility or paid any penalty for bad behavior occurring on their watches. Although may large health care organizations have made numerous <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">legal settlements </a>of accusations that include fraud, kickbacks, etc, the leadership almost never admitted wrongdoing in any of them, and almost never had to accept any financial penalty form the organization. This parallels how the US legal system has rarely sought to punish any leader of a large health care organization in such cases, suggesting that health care leaders now have developed <a href="http://hcrenewal.blogspot.com/search/label/impunity">impunity</a>. Given that the article appeared in <a href="http://www.beckershospitalreview.com/">Becker's Hospital Review</a>, a leading publication for hospital leaders, its apparent cynicism about what once were considered indispensable characteristics of good leadership was disturbing.  It is also disturbing that at the time this was written, the only comment on the on-line version of the article, also the only comment to note this lack, was written by your this humble scribbler. Summary This may test some CFOs' sense of humor, but instead let me propose my hopes for better health care leadership. To truly reform health care we should seek reasonable leadership that draws on the collective knowledge and values of health care professionals, and that shows accountability, integrity, transparency, honesty, and ethics.  Not asking our leaders to be honest, ethical and accountable just enables the current dysfunction.

Traits that "Define a Great Hospital CFO" - Honesty, Integrity, Accountability not Included

A recent article in Becker's Hospital Review entitled, "6 Traits That Define a Great Hospital CFO" [Chief Financial Officer] ...

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Ontario must rethink health care ... including costs of health IT

Hat tip to a commenter for the link below to a Toronto newspaper opinion piece on Canadian healthcare rationing and the costs of health IT. The line: <div></div><blockquote class="tr_bq"><div>"While billion-dollar scandals like eHealth make these stories all the more frustrating for Ontarians, because of the appalling waste of scarce health-care dollars, the truth is governments across Canada, not just the Dalton McGuinty government in Ontario, are struggling with the same issues" </div></blockquote><div></div><div> could have been written by me.  </div><div></div><div> (In fact, I've written exactly such lines about the "National Programme for IT in the HHS" a/k/a the HITECH Act, regarding the waste of precious healthcare resources such as at my Jan. 2010 post "<a href="http://hcrenewal.blogspot.com/2010/01/electronic-medical-records-and-going.html" target="_blank">Electronic Medical Records and Going For Broke: Jackson Health System's Financial Future Appears Grim</a>".) This from the Toronto Sun:  <blockquote class="tr_bq"><a href="http://m.torontosun.com/2012/09/28/ontario-must-rethink-health-care" target="_blank">Ontario must rethink health care</a> Toronto Sun Saturday, September 29, 2012, 6:20 PM The simple truth is Ontario’s health care system is running out of our money to pay for our health care. That’s why we keep hearing about cases of patients being denied necessary surgery — particularly when it has to be done in the U.S. — and life-prolonging medications. In the Sun’s news section today, Queen’s Park columnist Christina Blizzard tells the story of Erika Crawford, 17, whose family plans to go ahead with life-saving surgery in the U.S. to prevent her death from Ehlers-Danlos Syndrome, even though OHIP has callously refused to fund the expensive procedure. Recently, Blizzard wrote about the plight of three-year-old Liam Reid, whose parents went ahead with eye-saving treatment available only in Detroit, with no guarantee OHIP will pay for that. Over the summer, Blizzard wrote about 67-year-old Percy Bedard, denied OHIP funding for a life-prolonging drug for his prostate cancer because the health ministry doesn’t believe it’s cost effective. The truth is that as time goes on, there are going to be more and more stories like this. While billion-dollar scandals like eHealth make these stories all the more frustrating for Ontarians, because of the appalling waste of scarce health-care dollars, the truth is governments across Canada, not just the Dalton McGuinty government in Ontario, are struggling with the same issues. </blockquote></div><div dir="ltr"> I presume they're referring to the scandal such as I wrote of in May 2009 at my post "<a href="http://hcrenewal.blogspot.com/2009/05/canadian-health-it-ripoff-is-anyone-in.html" target="_blank">Canadian Health IT Ripoff ... Is Anyone in the U.S. Paying Attention?</a>" (Addendum Oct. 1, 2012:  per the commenter, also see this July 2012 Toronto Sun story:  <a href="http://m.torontosun.com/2012/07/14/ehealth-needs-surgery" target="_blank">eHealth Needs Surgery</a> and this quote:  "Auditor General Jim McCarter, in his clinical dissection of Ontario electronic health records woe in 2009, said $1 billion had been spent by over 10 years by two different governments, without getting full value for those dollars. He’s since been more specific about the numbers, saying “hundreds of millions of dollars” were likely wasted.") From my aforementioned Jan. 2010 post: <blockquote class="tr_bq">... I have written on numerous occasions that health IT in its present form, often poorly designed and implemented under current IT leadership structures, is often a waste of precious healthcare resources. The resources might be better spent on essentials such as patient care for the poor or improved human staffing, until this experimental technology is perfected.</blockquote>   Add "and for the not so poor" to that list.  <blockquote class="tr_bq">Since there isn’t enough money to give everyone the care they need, politicians and health bureaucrats routinely deny medically necessary services and treatments to save money. This often means choosing between who will live and who will die, and who will suffer and who will lead a normal life. To be sure, this review process has always been in place, particularly for out-of-province treatments and for funding new medications, since no publicly funded health care system can possibly provide every service to everyone. But as the health care budget creeps towards eating up half of all spending in Ontario, these decisions are only going to become more frequent, and harder.</blockquote>   But in the U.S. let's go merrily ahead and spend <a href="http://hcrenewal.blogspot.com/2012/09/wsj-koppel-and-soumerai-major-glitch.html" target="_blank">a trillion dollars for health IT</a>, even if it's bad health it (BHIT), which there currently is no reason for manufacturers to stop producing (e.g., complete lack of regulation).  No problem, right? -- SS   </div>

Ontario must rethink health care ... including costs of health IT

Hat tip to a commenter for the link below to a Toronto newspaper opinion piece on Canadian healthcare rationing and the costs of health IT. ...

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UK: Another Example of IT Malpractice With Bad Health IT (BHIT) Affecting Thousands of Patients, But, As Always, Patient Care Was "Not Compromised"

<div class="post-title entry-title" itemprop="name">At my Dec. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/12/yet-another-glitch-affecting-thousands.html" target="_blank">IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient Care Was "Not Compromised</a>" and others, I noted:</div><div class="post-title entry-title" itemprop="name"> </div><blockquote class="tr_bq">... claims [in stories regarding health IT failure] that "no patients were harmed" ... are both misleading and irrelevant: Such claims of 'massive EHR outage benevolence' are misleading, in that medical errors due to electronic outages might not appear for days or weeks after the outage ... Claims of 'massive EHR outage benevolence' are also irrelevant in that, even if there was no catastrophe directly coincident with the outage, their was greatly elevated risk. Sooner or later, such outages will maim and kill.</blockquote> Here is a prime example of why I've opined at my Sept. 2012 post "<a href="http://hcrenewal.blogspot.com/2012/09/good-health-it-v-bad-health-it-paper-is.html" target="_blank">Good Health IT (GHIT) v. Bad Health IT (BHIT): Paper is Better Than The Latter</a>" that a good or even average paper-based medical record keeping system can facilitate safer and better provision of care than a system based on bad health IT (BHIT). Try this with paper: <blockquote class="tr_bq"><a href="http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-coverup-over-lost-cancer-patient-records-8191066.html" target="_blank">NHS 'cover-up' over lost cancer patient records</a> Thousands awaiting treatment were kept in the dark for five months when data disappeared Sanchez Manning The Independent Sunday 30 September 2012 Britain's largest NHS trust took five months to tell patients it had mislaid medical records for thousands of people waiting for cancer tests and other urgent treatments. Imperial College Healthcare NHS Trust discovered in January that a serious computer problem and staff mistakes had played havoc with patient waiting lists.</blockquote> It's quite likely the "serious computer problem" far outweighed the impact of "staff mistakes", as disappearing computer data does so in a "silent" manner.  One does not realize it's missing as there's not generally a trail of evidence that it's gone. <blockquote class="tr_bq"> About 2,500 patients were forced to wait longer on the waiting lists than the NHS's targets, and the trust had no idea whether another 3,000 suspected cancer patients on the waiting list had been given potentially life-saving tests. Despite the fact that the trust discovered discrepancies in January and was forced to launch an internal review into the mess, including 74 cases where patients died, it did not tell GPs about the lost records until May.</blockquote> That is, quite frankly, outrageous if true and (at least in the U.S.) might be considered <a href="http://legal-dictionary.thefreedictionary.com/Criminal+Negligence" target="_blank">criminally negligent</a> (failure to use reasonable care to avoid consequences that threaten or harm the safety of the public and that are the foreseeable outcome of acting in a particular manner). <blockquote class="tr_bq">Revelations about the delay prompted a furious response yesterday from GPs, local authorities and patients' groups. Dr Tony Grewal, one of the GPs who had made referrals to Imperial, said doctors should have been told sooner to allow them to trace patients whose records were missing. "The trust should have contacted us as soon as it was recognised that patients with potentially serious illnesses had been failed by a system," he said. "GPs hold the ultimate responsibility for their patient care."</blockquote> That is axiomatic. <blockquote class="tr_bq">The chief executive of the Patients Association, Katherine Murphy, added: "This is unacceptable for any patient who has had any investigation, but especially patients awaiting cancer results, where every day counts. The trust has a duty to contact GPs who referred the patients. It's unfair on the patients to have this stress and worry, and the trust should not have tried to hide the fact that they had lost these records. They should have let the GPs know at the outset."</blockquote> Unfair to the patients is an understatement,  However, if one's attitude is that computers have more rights than patients, as many on the health IT sector seem to with their ignoring of patient rights such as informed consent, lack of safety regulation, and lack of accountability, then it's quite acceptable. <blockquote class="tr_bq">The trust defended the delay in alerting GPs, arguing that it needed to check accurately how much data it had lost before making the matter public. It said a clinical review had now concluded that no one died as a result of patients waiting longer for tests or care.</blockquote> That would be perhaps OK if the subjects whose "data had been lost" through IT malpractice were lab rats. <blockquote class="tr_bq">Despite this, three London councils – Westminster, Kensington and Chelsea, and Hammersmith and Fulham – are deeply critical of the way the trust handled the data loss. Sarah Richardson, a Westminster councillor who heads the council's health scrutiny committee, said that trust bosses had attempted to "cover up" the extent of the debacle. "Yes, they've done what they can but, in doing so, [they] put the reputation of the trust first," she said. "Rather than share it with the GPs, patients and us, they thought how can we manage this information internally. They chose to consider their reputation over patient care."</blockquote> As at my Oct. 2011 post "<a href="http://hcrenewal.blogspot.com/2011/10/cybernetik-uber-alles-computers-have.html" target="_blank">Cybernetik Über Alles: Computers Have More Rights Than Patients?</a>", to be more specific, they may have put the reputation of the Trust's computers first.  <blockquote class="tr_bq">Last week, it was revealed that Imperial has been fined £1m by NHS North West London for the failures that led to patient data going missing. On Wednesday, an external review into the lost records said a "serious management failure" was to blame for the blunder.</blockquote> Management of what, one might ask? <blockquote class="tr_bq">Imperial's chief financial officer, Bill Shields, admitted at a meeting with the councils that the letter could have been produced more quickly. He said that, at the time, the trust had operated with "antiquated computer systems" and had a "light-touch regime" on elective waiting times.</blockquote> Version 2.0A will, as again is a typical refrain, fix all the problems. <blockquote class="tr_bq">Terry Hanafin, the leading management consultant who wrote the report, said the data problems went back to 2008 and had built up over almost four years until mid-2011. Mr Hanafin said the priorities of senior managers at that time were the casualty department and finance.</blockquote> Clinical computing is not business computing, I state for the thousandth time.  When medical data is discovered "lost", the only response should be ... find it, or inform patients and clinicians - immediately. <blockquote class="tr_bq">He further concluded that while the delays in care turned out to be non-life threatening, they had the potential to cause pain, distress and, in the case of cancer patients, "more serious consequences" ... The trust said it had found no evidence of clinical harm and stressed that new systems have now been implemented to record patient data. It denied trying to cover up its mistakes or put its reputation before concerns for patients. "Patient safety is always our top priority," said a spokesman.</blockquote> "More serious consequences" is a euphemism for horrible metastatic cancer and death, I might add.  The leaders simply cannot claim they "found no evidence of clinical harm" regarding delays in cancer diagnosis and treatment until time has passed, and followup studies performed on this group of patients. This refrain is evidence these folks are either lying, CYA-style, or have no understanding of clinical medicine whatsoever - in which case their responsibilities over the clinic need to be ended in my opinion. I, for one, would like to know the exact nature of the "computer problem", who was responsible, and if it was a software bug, how such software was validated and how it got into production. -- SS Oct. 1, 2012 Addendum: What was behind the problems, according to another source?    Bad Health IT (BHIT): <blockquote class="tr_bq"><a href="http://www.ehi.co.uk/news/EHI/8094/poor-it-behind-imperial-cancer-problems" target="_blank">Poor IT behind Imperial cancer problems</a> e-Health Insider 28 September 2012 Rebecca Todd An independent review of data quality issues affecting cancer patient referrals to Imperial College Healthcare NHS Trust has identified “poor computer systems” as a key cause of the problem. The review’s report highlights the trust’s use of up to 17 different IT systems as causing problems for patient tracking. However, it says the trust should be aware of the risks of [replacing the BHIT and] moving to a single system, Cerner Millennium, because of reported problems in providing performance data after similar moves at other London trusts. In January 2012, the report says the NHS Intensive Support Team was reviewing the way reports on cancer waiting times were created from Imperial’s cancer IT system, Excelicare. The team discovered that almost 3,000 patients were still on open pathways who should have been seen within two weeks. In May, letters were sent to GPs to try and ascertain the clinical status of around 1,000 patients.</blockquote> BHIT must be forbidden from real-world deployments, and fixed rapidly or dismantled (as Imperial College Healthcare NHS Trust appears to be doing), although the "solution" might be just as bad, or worse, than the disease. -- SS

UK: Another Example of IT Malpractice With Bad Health IT (BHIT) Affecting Thousands of Patients, But, As Always, Patient Care Was "Not Compromised"

At my Dec. 2011 post " IT Malpractice? Yet Another "Glitch" Affecting Thousands of Patients. Of Course, As Always, Patient C...

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Hype, Spin and Health Care: the Case of an Apparently Failed Hospital Purchase by Steward Health Care

Health care is drowning in a sea of hype and spin.  We have frequently posted about <a href="http://hcrenewal.blogspot.com/search/label/deception">deceptive</a> <a href="http://hcrenewal.blogspot.com/search/label/marketing">marketing</a> used to sell drugs, devices, and health care services.  We have also posted about deceptive <a href="http://hcrenewal.blogspot.com/search/label/public%20relations">public relations</a> and<a href="http://hcrenewal.blogspot.com/search/label/stealth%20lobbying"> lobbying</a> used to sell policy positions and strategies favorable to health care organizations, and usually most favorable to their leaders. Nevertheless, there rarely is much public skepticism about or criticism of such marketing and public relations messages when they appear.  Rather, often the media and other public voices, including those of politicians with power over the relevant public policy issues, seem to accept the messages at face value. The Case of Steward Health Care and Landmark Medical Center The Buy-Out Falls Apart Therefore, it is instructive to look at examples of how such messages in retrospect appear to be fallacious, to use a polite term.  A local example that just popped into view was documented in two short news items by Felice Freyer in our own Providence Journal.  (Web access to a longer version story that appeared in the print version of the journal is <a href="http://digital.olivesoftware.com/Olive/ODE/ProJo/LandingPage/LandingPage.aspx?href=VFBKLzIwMTIvMDkvMjc.&pageno=MQ..&entity=QXIwMDEwMA..&view=ZW50aXR5">here</a>.)  The <a href="http://news.providencejournal.com/business/2012/09/deal-to-sell-woonsocket-hospital-to-steward-may-be-falling-apart.html">first item</a> included, <blockquote>The deal to sell Landmark Medical Center to Steward Health Care System may be falling apart. In a court filing this week, Jonathan N. Savage, the special master in charge of the hospital, made reference to the possibility that Steward would withdraw. The Boston hospital group faces a Sept. 30 deadline to complete the sale. </blockquote>The Message Promoted by Steward Health Care  We have <a href="http://hcrenewal.blogspot.com/search/label/Steward%20Health%20Care">blogged</a> about the rapid expansion of Steward Health Care, despite the name, a for-profit company owned by private equity/ leveraged buyout firm <a href="http://hcrenewal.blogspot.com/search/label/Cerberus">Cerberus Capital Management</a>. Steward has hyped its supposedly world class "new health care" model in its advertising (look <a href="http://hcrenewal.blogspot.com/2012/08/private-equity-obfuscatory-advertising.html">here</a>). In promoting its bid for Landmark, Steward's well-paid CEO (look <a href="http://hcrenewal.blogspot.com/2012/07/steward-health-care-vs-rhode-island.html">here</a>), displayed his vision for promoting the medical center through "economies of scale," "right-siting," and emphasizing ties with the community: "it's not a community hospital system. It's really a health care system," as reported by Felice Freyer in April, 2012 (Freyer F. Landmark Medical Center. A Leap into the unknown. Providence Journal, April 22, 2012.)  In a dispute over payment rates with Rhode Island Blue Cross Blue Shield, Steward ran full-page newspaper advertisements claiming that insurance companies leaders issued an order to "terminate Landmark Medical Center," because they did not care if "residents would lose their only hospital, ... employees ... would lose their jobs, or the elderly ... would have to travel for care." (Look <a href="http://hcrenewal.blogspot.com/2012/07/steward-health-care-vs-rhode-island.html">here</a>.) That implied, of course, that Steward, which did not mention that it is a for-profit corporation owned by a private equity firm in the ads, cared deeply about the health care of residents of Woonsocket. Some Skepticism, but More Acceptance The article by Felice Freyer above did feature journalistic skepticism and include interviews with some local physicians who questioned whether Steward could possibly fulfill all its promises to simultaneously increase the quality of care and reduce costs. However, the article showed that there was lots of positivity about Steward's track record in neighboring Massachusetts. Predictably, the President of Steward owned Quincy Medical Center boasted, "Not one person has been laid off. We have not reduced any service lines. Our focus is on enhancing." However, some people who were apparently independent of Steward also had favorable views.  A Massachusetts consumer advocate said "as far as we know, it's going fine." A Brandeis University Professor said, "it's impressive how successful they've been." The Politicians' Buy In Elsewhere, there were plenty of statements of support for Steward by local politicians.  The Mayor of Woonsocket supported Landmark (and implicitly Steward) it its dispute with RI BCBS, as <a href="http://news.providencejournal.com/breaking-news/2012/07/woonsocket-mayo-5.html">reported</a> by the Providence Journal, saying that the proposed buyout by Steward "is far too critical for our city, and I must take every step possible to ensure that the interests of the city and those who rely upon Landmark (Medical Center) for healthcare are being protected [by taking Steward's side in the dispute.]" Also, as <a href="http://www.woonsocketcall.com/node/5343">reported</a> by the Woonsocket Call, RI Congressman David Cicilline said, "I look forward to working with Landmark's new administration [that is, Steward] to ensure that it continues to deliver affordable, quality health care and well-paying jobs for hardworking Rhode Islanders." To fulfill Steward's wishes, The Rhode Island state legislature rushed to make its laws about for-profit conversion of non-profit hospitals more lenient (see the <a href="http://www.pbn.com/Legislation-to-speed-Stewards-Landmark-bid-introduced,64973">Providence Business News</a>). The Attorney General Later Says it was All About the "Bottom Line" However, now Steward has apparently pulled out of the deal with nary a public mention of the reason why, much less demonstration of its concern for the poor people of Woonsocket. As reported in a second small <a href="http://news.providencejournal.com/breaking-news/2012/09/ag-steward-leaves-landmark-in-a-worse-positionready.html">item</a> in the Providence Journal, <blockquote>Steward Health Care System, which is apparently backing out of its deal to buy Landmark Medical Center, 'has left the hospital, its patients and its employees in a worse position,' </blockquote><blockquote>Attorney General Peter F. Kilmartin said in a statement today. 'It has become very clear that Steward's only interest was the bottom line, not, as the Company claimed, the patients, the employees or the Woonsocket community,' Kilmartin said. </blockquote>Summary This is just one local kerfuffle about a small hospital system. However, looking at it in granular detail says a lot about how big health care organizations, like the one that here attempted to buy the local hospital system, push misleading messages to secure their private interests. These misleading messages often promote these organizations' commitments to the traditional health care mission, often in the modern argot of quality, access, and affordability), when their leaders may really care more about short term revenue. This case also shows how at least some local policy makers may be drawn in by such messages, and how the few skeptics get lost in the shuffle. An important feature of the modern, commercialized, laissez faire health care system in the US is the role of opinion manipulation through modern, sophisticated marketing and public relations in promoting the short-term financial interests of health care organizations and their leaders at the expense of patient's and the public's health. This role seems rarely to be discussed, particularly in health care research and policy circles. It may be that some members of the public, health care professionals, and health policy makers are naturally skeptical of marketing and public relations hype, spin, and deception. However, we have seen too many <a href="http://hcrenewal.blogspot.com/2012/05/ceo-as-false-messiah.html">examples</a> of health care leaders promoted as "visionaries" who are anything but. Health care professionals, patients, policy makers, and the public at large ought to be extremely skeptical of the self-serving messages packaged by marketing and public relations. Academics ought to be dissecting these messages more often. Skeptics need to make their voices heard. Meanwhile, look out for the next "visionary," or the next "new health care" promotion. They may not turn out to be what is advertised.

Hype, Spin and Health Care: the Case of an Apparently Failed Hospital Purchase by Steward Health Care

Health care is drowning in a sea of hype and spin. We have frequently posted about deceptive marketing used to sell drugs, devices, and h...

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