The first reports of hospitals talking to patients about mistakes brought gasps and headshakes through the healthcare world. Maybe they could do it at another facility, they said, but not here. Risk managers shook in their boots, malpractice lawyers salivated at the thought of physicians admitting guilt. But behind the notion of transparency was the idea that you can’t learn from mistakes — nor can the wider medical world — if you are not open about them. Other areas of transparency that have been touted as helpful — such as openness between hospitals — were likewise met with distrust. The word proprietary was bandied about. And could providers and frontline staff be transparent with each other? Could they be free to speak up when they felt it was in the patient’s interest? In many hospitals, the answer was “no.” And sharing quality data with the public? Well, they couldn’t possibly understand it.
But over the years, the fears about openness have been challenged. Litigation at those open hospitals has actually decreased in many cases. Hospitals are increasingly willing to share data, tools, and success stories that help to improve patient safety and quality. And those who care for patients feel freer to talk about patient care with each other, to speak up when they think something is wrong, and to report errors without fear. Lastly, while there is still a question about whether quality improves through public reporting, there is ample proof that reporting of quality data has spurred hospitals to act to improve specific quality indicators, and that those indicators have improved in the last 15 years.
Still, what has happened so far is not enough, some experts say. The National Patient Safety Foundation released a report in January through the Lucien Leape Institute that goes through some of the things it says healthcare organizations, providers, policy-makers, and other stakeholders can and should be doing to create a more transparent, and thus safer, healthcare system.
The report goes through each of the four domains of transparency — patient/clinician; clinician/clinician; organization/organization; and organization/public — and looks at the benefits and barriers to achieving greater openness. For example, looking at clinicians, the report notes that they can share best practices and reduce redundant testing (and thus risk and cost to patients). Among the barriers to such sharing? They may not know how to do thorough root cause analyses and often want their discussions on mistakes to be held in a protected and safe environment, and they are fighting against a culture where errors are equivalent to shame and the rule has always been to protect colleagues.
Many of the ideas to help organizations move toward transparency that are in the report have been seen before, says Bob Wachter, MD, chief of hospital medicine and chief of the medical service at UC San Francisco Medical Center and one of the chairmen of the group of stakeholders who developed the report. He says that what is new and important is that the foundation is “putting its weight so strongly behind this idea. And linking the different pieces together. That’s novel.”
The Lucien Leape Institute has, in the past, put forth reports that have influenced “agenda setting and put issues in front of the public pretty effectively,” Wachter says, and he hopes this will be the same. “We are 15 years into the patient safety movement, and a lot hasn’t worked as well as we thought it would. Computers, changes in the payment system, medication reconciliation — we have tried them all and they have worked, but not as well as we hoped. But transparency? That has worked better than we would have thought.”
Of the 39 recommendations in the report (some are divided into multiple parts) — items such as ensuring disclosure of all financial conflicts of interest, prioritizing transparency, safety, and continuous learning, and ensuring data such as claims and patient reported outcomes, are accessible to all patients — most are not done, says Wachter. “Given that, I have to guess they do not believe in the veracity of the model. The fear is understandable, and part is the inter-relationships between these things.”
He explains that during the roundtable discussions to create the report, they talked about how public advocacy groups angle for complete openness, but that makes other stakeholders clam up, because they sometimes want to have frank discussions without every ear listening. “There is a tension between those things. But I think we make clear in the report that the real life experience is less scary and works better. There are still tensions that have to be worked through, but the message is that it can be done.”
Wachter also says there is a level of improvement fatigue among stakeholders. “In the current environment, you can’t say you aren’t going to work on sepsis or readmissions. You can’t shift your attention away from those things. But we want to let people know that this is not just another individual initiative.”
Rather, he says, it is an overarching philosophy, an enabler of many other things. “What is clear to us is that when organizations choose to or are forced to be more open, that’s an enabler for other positive activities.”
There are examples in the report of organizations that have experienced this transformation — from the University of Michigan Health System’s apology and disclosure program to inform patients about errors in care to Ohio’s children’s hospitals, which have embraced transparency in all four domains.
The examples should prove that transparency doesn’t have to be the work of Sisyphus, he says. Rather it can free things up and motivate an organization. In his forthcoming book on medicine in the computer age, The Digital Doctor, Wachter writes about a mistake caused in part by a computer system that gave a 40-times overdose of antibiotics to a patient. “We did the committee meetings, the root cause of why and how, and we tried to figure out how to make sure it would never happen again,” he says. “But we also decided to be open about it. The drama of this particular case got people thinking about their work. Every resident knew the story and behavior changed because of it. It changed more than if we had just tweaked a couple of policies.”
A lot of stuff happens in hospitals, Wachter says, and usually if it spreads through the gossip grapevine, it does so in whispers and contains a lot of misinformation, he says. “It is not aired in productive ways. New policies seem trivial, or people aren’t aware of them, or if they are implemented, why. The openness, the story behind the change, well that makes it real.”
He hopes the report will “give organizations courage” while acknowledging there are some practical difficulties in getting from here to there. “But know that this works pretty well among those who have tried.” He suggests starting by looking for ways in your own particular domain to be more open. “Are you disseminating all the information you could and you should? Are you doing it effectively?” Root cause analyses, for example, often do not get to clinicians, who could get real value out of them.
It doesn’t mean you send everything to everyone and it all ends up on the hospital Twitter feed, Wachter says. “But on balance, do more, not less. Publicly report the things that will help people make good decisions.”
The default setting is to hide, he says, and do just what is demanded by the Centers for Medicare & Medicaid Services or The Joint Commission and nothing more. “Ask if there is more you can do. Do you tilt to open or closed? If it is to closed, move the needle the other way.”
As you do this, make sure you include adequate support for your people, he says, such as residents on night shift. You can’t ask them to report errors if you do not provide them with help after they have made a mistake.
“This is not expensive,” Wachter says. “Put the data out there and performance improves. You can see it from the places already doing this. They are the bright rays of light.”
The entire report can be found at https://npsf.site-ym.com/?shiningalight.
For more information on this topic, contact Robert Wachter, MD, Chief of Hospital Medicine, Chief of Medical Service, UC San Francisco Medical Center. Email: Robert.Wachter@ucsf.edu