Last week's column pointed out that harm caused by some organizations gets a lot more attention and outrage than does harm caused by healthcare. For example, 13 people died over the course of a decade because General Motors allegedly failed to redesign and replace a defective part in its cars. Yet, millions died over the same decade from preventable infections and blood clots they got in the hospital, medical errors, drug side effects and other complications of care. Which one got a congressional investigation, fines and massive press coverage?
"Oh, well, that's completely different!" some people might say. "A corporation is driven by money! Doctors and hospitals are just trying to help!"
I spent 20 years inside one of world's largest corporations. I found that some people do an outstanding job and others just scrape by; some routinely make choices based on strong ethics and others simply try to get more money or power. I have seen the same variations in doctors' offices and hospitals.
For example, extensive research shows that sometimes doctors make choices that give them more money but harm patients. They may recommend and perform unneeded treatments to earn more money; order tests they know are unnecessary, when they are owners of testing services; prescribe drugs and medical devices for which they get paid "kickbacks" from manufacturers, according to federal prosecutors. And so forth.
On a related note, hospitals may make choices designed to yield higher profits; ensuring that patients aren't harmed may take a back seat. A study of 722 nonprofit hospitals found that only about half counted "quality of care" among the hospital's top two priorities. People running hospitals often say, "No margin, no mission," meaning, "If we don't make enough money (have a profit margin), we'll have to close our doors and won't be able to help anybody, so we have to focus on being profitable."
A senior fellow at the Georgetown Public Policy Institute gave his opinion on this issue: "Many of the nation's nonprofit hospitals earn huge profits, provide relatively little free care to the poor, charge insurance companies and patients up to 10 times the actual cost of drugs and services, and pay their top executives whopping salaries." Government officials raise similar concerns (using less inflammatory language).
What about the idea that corporate executives may fail to act when they know about potential harm but healthcare professionals behave differently? One might ask, "What did they know and when did they know it?" Doctors and hospital executives cannot claim ignorance about quality of care issues and solutions.
The Institute for Healthcare Improvement, a major player in efforts to improve patient care, was founded more than 25 years ago. Its annual conferences draw about 6,000 people and its Open School courses have had about 200,000 participants. It offers extensive help to any organization interested in improving quality of care. It is a visible and available resource.
Issues with quality of care have been featured in the major medical press for decades. For example, an article in the New England Journal of Medicine in 1991 was titled, "Incidence of adverse events and negligence in hospitalized patients."
In 1993, another was titled, "Incidence of preventability of adverse drug events in hospitalized adults." In 1998, the Journal of the American Medical Association ran an article titled "Promoting patient safety by preventing medical error."
Nearly 15 years after I first read hundreds of articles on such topics, I spoke with the author of the above three, a doctor who graduated from Harvard Medical School who lectures at the Harvard School of Public Health. When I explained my work, he was supportive but not optimistic: he has been attempting for nearly 30 years now to drive changes in physician and hospital behavior in order to reduce the shockingly high level of harm healthcare does to patients, and has seen little improvement.
"What did they know and when did they know it?" Doctors and hospitals, even more than GM, cannot claim that they don't know that their practices hurt or kill people with alarming frequency, nor can they claim that nothing can be done about it. That dog don't hunt.