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Hospital learns the pros and cons of openness
Mistake makes front-page news
After a baby was nursed by the wrong mother at Immanuel St. Joseph's — Mayo Health System in Mankato, MN, the family members involved were understandably very upset — and very vocal. They alerted the news media, which reported on the incident, and staff were educated about processes to ensure this would not occur again.
Six weeks later, the same exact thing happened. Another baby was nursed by the wrong mother.
Since this time, the family members involved already knew of the first mistake; they were doubly outraged that the hospital had not effectively fixed the problem. This time, the incident made front-page news in the region.
"We had a number of choices when presented with this situation. We could have run and hidden behind corporate barriers; we could have issued a statement saying how we take this very seriously and then drop the ball — or we could be transparent," says Kevin Burns, the hospital's chief communications officer.
The hospital's president and CEO publicly apologized for what happened and agreed the incidents were inexcusable. Clearly, he told reporters, the hospital had systems and processes that were broken.
A few days after the flurry of news coverage, he received a phone call from a Canadian man who explained that he had read about the incident and that technology was available that could solve the hospital's problem. The hospital followed up and adopted technology that eliminated this error from happening again. The system uses arm bands for parents and ankle bands for newborns to ensure the right baby is paired with the right parent.
"Because we were so public, someone in another country offered assistance, which helped us solve this particular quality issue," says Burns. The morale of the story: By being open, you risk negative reactions, bad publicity, and even lawsuits; but it's also a powerful tool that could lead you to solutions for problems you otherwise couldn't fix.
Posters are hung all over the hospital citing quality data for all to see, such as handwashing and infection data by unit, all periodically updated. "We post any of the quality measures that we have on our scorecard, which is pretty robust," says Gregory Kutcher, MD, president and CEO. The hospital also posts financial, employee retention, and patient satisfaction data by unit, including the emergency department, diagnostic imaging, and dialysis. Patients on the third floor medical/surgical area can compare that unit with the rest of the organization.
"This has engaged patients, families and visitors in our quality journey," says Burns. "Posting data prompts their interest and gives them an opportunity to get them involved in the process."
It also has spurred some healthy competition among the hospital's employees. "If I'm a clinician on the fourth floor and folks on the third floor are doing a bit better, it prompts some appropriate competitiveness," says Burns.
When patients who have viewed posters about a unit's hand hygiene compliance get hospital-acquired infections such as MRSA, they now tend to try to remember whether staff washed their hands every single time. "So there is heightened awareness, and you could say it causes some problems, but we don't think so," says Kutcher. "We think it just puts pressure on us to do the right thing."
The hospital's approach is to post quality data without regard to whether it's impressive. "We have put up quality data that is not so good — we were not doing well on community-acquired pneumonia and we put that up," says Kutcher. On the other hand, the hospital has some quality data it was particularly proud to post — its mortality data, which decreased dramatically after participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign. "Over the last several years, mortality rates dropped from about 27 deaths per patient admission to 17 deaths per patient admission," says Burns.
"We have taken the tactic that transparency is the best way to go — to be honest about where we're at," says Kutcher. "We all know health care needs to be better, and we think we will get better faster if we include data publically."