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Voices for Safer Care

Insights from the Armstrong Institute

See one, do one, harm one?

Pronovost with groupI recently cared for Ms. K, an elderly black woman who had been sitting in the intensive care unit for more than a month. She was, frail, weak and intermittently delirious, with a hopeful smile. She had a big problem: She had undergone an esophagectomy at an outside hospital and suffered a horrible complication, leading her to be transferred to The Johns Hopkins Hospital. Ms. K had a large hole in her posterior trachea, far too large to directly fix, extending from her vocal cords to where her trachea splits into right and left bronchus. She had a trachea tube so she can breathe, and her esophagus was tied off high in her throat so oral secretions containing bacteria did not fall through the hole and infect her heart and lungs. It is unclear if she will survive, and the costs of her medical care will be in the millions.

Ms K’s complication is tragic—and largely preventable. For the type of surgery she had, there is a strong volume-outcome relationship: Those hospitals that perform more than 12 cases a year have significantly lower mortality. This finding, based on significant research, is made transparent by the Leapfrog Group and several insurers, who use a performance measure that combines the number of cases performed with the mortality rate. Hopkins Hospital performs more than 100 of these procedures a year, and across town, the University of Maryland tallies about 60. The hospital where Ms. K had her surgery did one last year. One. While the exact relationship between volume and outcome is imprecise, it is no wonder she had a complication.

Ms. K is not alone. Of the 45 Maryland hospitals that perform this surgery, 56 percent had fewer than 12 cases last year and 38 percent had fewer than six.

One day, after the ICU team—nurses, medical students, residents, critical care fellows and the attending—made rounds on Ms. K, we stepped outside of her room. We talked about what we could do to help get her well and to a lower level of care. But we also discussed the evidence for the volume-outcome relationship, highlighting that the hospital that performed Ms. K’s operation performed one in the previous year. Upon hearing this, the medical students cringed, quizzically looking at each other as if observing a violent act. The residents and fellows, the more experienced clinicians, stood expressionless; they commonly see this type of tragedy.

The team asked why the hospital would perform an operation in which it has little experience. The medical students were especially concerned. As the conversation ensued, the team discussed issues of professionalism, health care disparities and accountability—issues that don’t typically come up in rounds but should more often. Don’t the hospital’s trustees and leaders have a responsibility to ensure that their physicians are competent to perform certain procedures? Doesn’t the surgeon have a moral obligation to tell the patient that the hospital did this procedure infrequently? Is it possible that Ms. K’s gender, race and socioeconomic status influenced the discussion about risks?

We don’t know all of the factors that led Ms. K to undergo the procedure where she did. However, the care team rounding on Ms. K agreed that surgeons should inform the patient about the volume-outcome relationship and that she would likely have a lower chance of dying if she had the operation at a higher volume hospital.

(Privately, later in the day, I asked Ms. K whether the hospital mentioned that her risks at this hospital may be higher. Unable to speak due to her tracheostomy, she shook her head no. I did not tell her that the surgeon and hospital put her at increased risk. I thought about it, reflected on what moral obligations I had to give her this information, and weighed what it would do to her, to the surgeon and hospital that performed the operation, to me and my hospital. Perhaps I protect the “tribe”—fellow physicians. In the end, I remained silent.)

At one point our team had been discussing Ms. K for 20 minutes. We had 10 more patients to round on, and two were due out of the operating room in an hour. We felt production pressure to continue rounds, discharge patients and make room for new admissions, yet no one wanted to stop the discussion. The ICU fellow said, “We spend too little time discussing safety, ethical and policy issues. We should continue and shorten rounds on less sick patients.”

As our conversation continued, we talked about what could be done to prevent these situations in the future. The ensuing discussion revealed deep political convictions regarding the role of regulation and free markets in addressing societal ills. Trying to unite the care team, I observed that our markets are the best wealth-generation machine humanity has ever known, as they have lifted more people out of poverty than any other intervention. Yet the markets work best when participants compete fairly, when all traders transparently know the risks and costs. Left to their own devices, markets often fail, competing on half-truths or sometimes outright lies.

The Leapfrog Group helps to level the playing field for consumers, by making public which hospitals meet its standards. However, only 20 percent of hospitals will voluntarily submit information to Leapfrog in its annual survey. Outside of the social pressure engendered by the group’s public reporting, there is no mechanism to make this information available and no regulatory requirement that doctors and hospitals with low volumes in a given procedure tell patients that they are at increased risk.

The ICU team discussed how policymakers have a spectrum of regulatory tools to use, ranging in restrictiveness. On the less restrictive end, legislation could require transparency by hospitals, ensuring that all patients in the market understand risks and benefits related to volumes. Policymakers could also create economic incentives for patients to use hospitals with better outcomes or higher volumes. On the more restrictive end, legislators could prohibit hospitals from performing certain procedures in which they have low volumes or poor outcomes.

One model that we can look to for solutions comes from the Centers for Medicare and Medicaid Services in how it ensures high quality care in transplant surgery. It is not perfect, yet it works reasonably well. Only CMS-approved centers of excellence perform transplants. These centers’ outcomes are closely monitored, and if a hospital’s outcomes fall below a threshold, CMS may eventually revoke its ability to do transplants. Our ICU team concluded that CMS should take the lead, replicate what it did in transplant surgery, and ensure safe care for other high-risk surgical procedures.

Ms. K may die needlessly, and the error will remain invisible. We need policies to protect her and to reduce the chance that what happened to Ms. K and thousands of others like her, never happens again.


Peter Pronovost

One of the world’s leading authorities on patient safety, Peter Pronovost served a the director of the Armstrong Institute, as well as senior vice president for patient safety and quality, at Johns Hopkins Medicine from 2011 until January 2018.

5 thoughts on “See one, do one, harm one?”

  1. Sometimes the choice to have a procedure done where it is done is mere logistics and knowing that the doctors that have been treating you are the ones that will continue to treat you. If its at a hospital where you have been treated successfully before, albeit maybe not for something as serious, but still, in some patients minds a hospital is a hospital and should be able to treat all things.

    Then there are the ones that have had a bad outcome at one of the larger more progressive hospitals, and wish to avoid that experience. Speaking as someone who has a loved on in a local hospital at the present, and one that has had that same loved in one in a larger hospital earlier in the year, my loved one is more comfortable where he is at now. The larger hospital, while probably one of the best in the state, gave little concern for his mental status during his stay. The nursing staff was rude (at best), the doctors were condescending and belittling, case management was ignorant, and patient relations was useless. The entire stay left him shaken to the core, questioning whether living was worth what he went through. The hospital where he is at now, has been wonderful in caring for the whole patient, and he feels as though he doesn't have to "die or be as close as possible to dying" to get some treatment as he did before. He is treated as a patient, not as a number in a long line of numbers where the sickest gets treatment and the less sick get pushed to the side.

    We've been told he may not survive this hospital stay, but he feels as though he still has a chance to live, whereas if he went back to the other hospital he would simply give up right then.
    He has been to Johns Hopkins, and this explanation is not a "dig" at the hospital, in fact if he would be able to go there to get treatment, he would. It was just to explain, that there are many reasons people go to smaller hospitals to receive treatment, even if the experience record isn't as large as the bigger hospitals.

    1. Patty, thank you for stating this obvious point. Too many times medical professionals ignore the maxim generally attributed to William Osler: "the secret of the care of the patient is in caring for the patient." My husband, too, has experienced rude nurses, condescending doctors, and suffered from grossly ignorant case management. What troubles me most about what you describe is the fact that in the first, larger, hospital in which he was treated, your husband felt that he had to be "as close as possible to dying" in order to get treatment and attention.

      Not coincidentally, perhaps, the statement that jumped out at me in this otherwise thoughtful blogpost was that of the ICU fellow who said, "We spend too little time discussing safety, ethical and policy issues. We should continue and shorten rounds on less sick patients." Really? Each one of those "less sick" patients is a person either immediately post surgery or otherwise "sick enough" to be in ICU. Each one of those "less sick" patients has a frightened family that deserves the comfort that may be derived from the already-rushed visit of the attending physician; a family to whom the relative term "less sick" is irrelevant, because it is their loved one laying in this particular hospital bed.

      I am not minimizing the need for medical students, residents, and doctors to have these important conversations about patient safety and ethics and policy. Indeed, they should be a much larger part of all medical training, especially with the numerous changes and choices the Affordable Heallth Care Act will bring about. I find it terribly ironic, however, that in this example, at least, the discussion about patient safety and medical ethics took place at the expense of the patient, by shortening the time for- and thus denigrating the importance of- direct interaction of patients and doctors.

      I hope that your loved one has a good outcome.

  2. Great case study, terrible problem.

    Unfortunately, there are no hospitals who actively employ volume thresholds. It remains controversial, especially since Dimick et al published a series of articles regarding 'failure to rescue'- that the actual complication rate for surgeries is similar in low and high volume hospitals, but the higher acuity hospitals (teaching, >50% occupancy, higher tech like cardiac surgery, >200 beds....not volume by MV analysis) saved them better after the complication developed.

    As a surgical leader in NY, I never saw a cardiac program closed because numbers dipped below volume criteria, even tho there are clear critera. Data is even published on individual volumes for CT Surgeons, but it was very difficult to break into a clear volume metric even for credentialing of individual doctors. Fortunately, the new Focus Professional Practice Evaluation criteria from Joint Commission, made easier to at least start.

    Here is the problem: (1) We surgeons are brought up the wrong way. Thoracic surgeons are trained to do esophageal resections, so they can, and want to do them. They feel a right to do so after spending so much time training. They tell their patients they can do them. Not doing operations we like to, are trained to do, and think we can comfortably do eats into our core values....So, I am sure the surgeon really believed he could do the operation, tho this particular complication is quite rare and makes one wonder how many s/he has recently done. (2) Hospitals want these cases. Hospitals make monies with interventional procedures, and more monies with more complicated procedures. They still make monies off the complications, but this will change soon.
    One cannot blame hospitals for chasing a positive bottom line, especially in this era of decreasing revenue. The lesson is that standard business models just do not work in medicine.

    All that being said, I am trying to change exactly this in the my new role as a surgical regional director for a great health care system. One example is that we are recruiting a thoracic surgeon for one hospital which is building a cancer program, and my plan is that s/he will do appropriate cases safely there, more complex cases here at a nearby higher acuity hospital where we have 3 CT surgeons and great 24/7 ICU teams and hospitalists, and send the esophageal cases to our tertiary care partner.

    I am currently arranging such appropriate transfers with pancreatic and liver resections. Interestingly, a patient asked me yesterday if I could do her hepatic resection for a terrible gallbladder cancer at the tertiary center, otherwise she wanted to stay to have me do it here at our community hospital. It is remarkable how attached our patients get after 10 minutes!

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