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The Hospital Turned Inside Out


Richard Wade

If you’re a “boomer”―one of those Americans born between 1946 and 1964―you have witnessed the most dramatic changes in history in the essential community institution called the hospital. From the technology inside to the kinds of people who deliver the medical care and operate the organization, and from the financial structure that supports it to its image in the eyes of the public, today’s hospital has been radically reformed in the past few decades.

Most Americans don’t like to think about hospitals; they enter our minds only when they must. There’s only one time in the life of a family when they want to be in the hospital. All others are moments of fear at best, human crisis at worst.

As a full-fledged boomer, I remember my early impressions of hospitals: big, mysterious places that sometimes didn’t allow children in. The grownups I knew talked about hospitals with a curious mixture of reverence and fear. If someone died in the hospital, the common notion was that the doctors “did all they could, but Uncle Fred didn’t make it.”

If, heaven forbid, a person faced hospitalization, he or she went wherever the doctor directed. In my small hometown, everybody knew somebody who worked at the hospital, so you at least knew that if you had to go there, you’d see people you knew. And if you knew the people, you trusted the hospital to be a good place where good people did their best for you. And that was about all the information most people had about their local hospital.

Today, the public pressure for information about the inner workings of hospitals is coming from every direction― regulators, politicians at every level, the press, organizations claiming to represent “consumers” and distinct groups such as the elderly and uninsured, unions, the business community, and the list keeps growing. The demand is for an unvarnished took at what occurs in every place, from the boardroom to the billing office to the bedside. How do hospitals govern themselves? Whom do they pay how much? What prevents conflicts of interest? What do they charge for their services, and who actually pays what? What are the policies and practices on charity care, billing, and collections? How many errors do the clinicians make? How many people get infections in the hospital? What are the outcomes of the care? Are patients getting the right care at the right time? Do patients get too much care? Too little? What do you do about inept doctors?

It’s a virtual tsunami for transparency. And hospital people are reacting to this tidal wave in multiple ways. Some are running away from reality. Some are standing their ground. And some are adapting and changing to survive and thrive in an environment vastly different than anything their careers have prepared them for so far.

Because hospitalists are a growing presence and are playing an increasingly important role in all aspects of quality and patient safety, they will be critical to the hospital’s ability to adapt successfully to this new era of transparency and accountability.

The public’s attitudes toward medical error reporting and hospital acquired infections and how hospitals are responding to them today are important clues to the future. In 1999, the Institute of Medicine released its now famous report, To Err Is Human. It estimated that between 45,000 and 98,000 Americans die in hospitals each year from preventable medical errors. The report was nuclear. Not only did it open a national debate on patient safety that continues still, but also it compelled thousands of hospitals to talk with their communities for the first time about what they do to prevent errors.

A recent survey found that 55% of Americans are dissatisfied with the quality of hospital care. In the same poll, 34% said they or a family member had experienced a preventable medical error, and 70% of them said they were not told. Ninety-two percent of the respondents said medical error reporting should be mandatory and public.

Hospitals have agreed that errors should be reported. But unless there’s confidentiality, a culture of blame will discourage reporting and drive errors underground. Caregivers won’t come forward to admit mistakes, making it difficult to get to the root cause and to prevent future incidents. While the national debate goes on, 18 states have passed laws requiring hospitals to report errors to some external body. Some of that data will be made public in some form. Will lawmakers and hospitals be able to resist public pressure over time for public reporting of errors by all hospitals? Can we convince the public that confidentiality will actually lead to safer care and a culture of safety in the nation’s hospitals?

In 2002, the Chicago Tribune reported the results of its investigation into hospital acquired infections, estimating that about 75,000 people died in 2000 from infections that could have been prevented. The Centers for Disease Control and Prevention (CDC) has said that 90,000 patients die annually from hospital acquired infections, adding $5 billion to America’s health care costs. If hospital personnel were more observant of simple infection control procedures, such as regular hand washing, the CDC says thousands of lives and billions of dollars could be saved.

Consumers Union, publisher of the powerful magazine, Consumer Reports, has taken on health care in recent years with the same vigor that it used to get information to the public on autos and appliances. Its current national campaign calls for the reporting and publicizing of hospital acquired infection rates by all hospitals. In 30 states, bills have been introduced to mandate reporting of infection rates. Fifteen states are considering laws to control and oversee hospitals’ infection control practices. The concept that the public should know how well hospitals perform at infection control and prevention resonates strongly. Public reporting of hospital quality measures is in its infancy. Earlier this month, the first public private website opened with information that will allow comparison of hospitals’ performance around pneumonia, heart attack, and heart failure. Soon data on patients’ experience with care―how well they think their doctors and nurses did―will be added. Will infection and infection control statistics be far behind?

And the challenges and tensions are not all in the clinical arena. A recent survey by the American College of Physician Executives found 9 out of 10 physicians concerned about dishonesty, financial conflicts, and unethical behavior among their colleagues.

Eighty percent said they were worried about doctors refusing to treat uninsured patients as part of “on call” responsibilities. And 79% pointed to undue Influence on physicians by medical device companies to perform certain procedures. Physicians’ over treatment of patients to boost income were cited by 78% of the doctors. Another major concern: the influence of drug companies on physicians’ prescribing habits.

In early April, the federal government announced that it would begin investigating the upsurge in tests being ordered for Medicare patients. The issues: medical necessity and rapidly increasing costs.

Hospitals are at a crossroads in their relationships with many publics: their patients, employees and medical staff s, their communities, the government, and the media. The issue is building and retaining trust on so many fronts. Hospitals must be proactive when it comes to accountability and transparency. Doing so will create enormous tensions and challenges inside an institution. This will require leadership and motivation. Hospitalists, given their unique role, are positioned to be powerful catalysts for change―change that will result either in a mountain of cumbersome new laws and regulations or a new culture of openness and trust with the people hospitals exist to serve.

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