Leadership & Business Model Failing to Support Patient Safety & Quality

In this post by Paul Levy, former CEO of BIDMC, and staunch patient safety advocate, points out the failings of healthcare leadership in creating a culture of safety.

Juxtapose his call-to-arms with this Letter to the Editor written by the Illinois Hospital Association stating that "hospitals .. firmly believe in providing the highest level of safe, quality care to every patient" (which comes on the heels of a fairly damning report recently in the Chicago Tribune about lack of investigation about patient safety concerns at Illinois hospitals).

I can't think of any healthcare entity or practitioner who would not stand behind a statement similar to that issued by the IHA - after all its what we all believe healthcare should be about (and it is the politically correct statement to make). Healthcare institutions and leaders are not deceiving us when they say they believe in quality and safety, and that they are working towards improving these outcomes. Yet the industry is still collectively failing to meet the needs of patient safety and quality. How then do we explain the gap between "what we all believe" and "why we are failing"? I would point first to a few logical disconnects:

• belief does not equate to action
• belief does not equate to the right action
• belief does not equate to primacy of belief
• belief may not equate to sufficient action

We can justify our belief in patient safety by committing some resources to the activity, and undertaking a few choice initiatives. However, this does not necessarily lead to the outcomes that ultimately everyone is concerned about - demonstrable improvements in quality and safety, and organizations driven by the same. The rate of improvement that these activities can sustain may not even keep pace with the increasing complexity of the healthcare delivery system, which continues to yield unfortunately visible, dramatic signs of failing the patient.

As Paul Levy states, quality and safety have to be " internalized it into .. decision-making and process improvement efforts". However, this approach is also vulnerable to the following challenges:

• quality and patient safety are as yet not adequately measured
• institutional leadership is generally constrained by the rules of the industry
• societal leadership has to change the rules of the game 

If the primary objective for hospitals is revenues and volumes, healthcare executives will inevitably subjugate patient safety to these business drivers. Our healthcare institutions need to be rebuilt with the ideas of maximizing patient safety and quality first, and restructuring the business model around quality and safety. Pay-for-performance (P4P) programs, quality measurement, public reporting, value based purchasing are all initiatives that support the "quality and safety movement", however, are not sufficient to transform the industry and its leaders to "think quality first". They are seen by many within the industry at worst as "bureaucracy", "regulatory burden", "added costs", and at best as "nibbling around the edges". Attempts to measure additional dimensions of quality and to increase transparency are generally met with similar immediate reactions. The industry is not generally rushing forward to embrace and evolve into a quality-driven model. This is largely to be expected, as the current business model does not allow for the typical healthcare institution to be "built around quality".

The Accountable Care Organization (ACO) concept is generally a push in the right direction - at least it is an attempt to create more of a platform for quality while reducing the model's demand on volume for profitability. However, the dimensions of quality measurement as yet are significantly limited - is the patient's experience of safety truly measured by patient satisfaction surveys? are physicians' views about quality incorporated into the "core measures"? are nurses' concerns about safety incorporated into "hospital acquired complications"? And even though the ACO model changes the focus from "doing more for every patient" it subtly subverts the business incentive to "do as little as possible (within the limitations of measurable quality) for every patient" and "sign up more patients (through hiring more physicians) to join the ACO".

In order to drive real transformation of the industry - rather than just "payment reform" - a true "quality-driven" business model needs to be developed. As opposed to the "volume" or "frequency" turnstile, we have to develop a "quality and safety" turnstile. Quality and safety should be measured at the level of the individual patient, and drive the payment mechanism only if deemed adequate. Institutional leadership can only rise to the challenge if the rules of the game are changed at the societal level.