Las Vegas Paper Writes Series on Patient Safety Failings, Hospital Culture


I found this lengthy series of articles from the Las Vegas Sun, published under the heading of  “Do No Harm: Hospital Care in  Las Vegas.” The series serves as a good introduction to those who are new to healthcare and the types of systemic challenges that the industry faces. The stories in the series are perhaps frustratingly familiar to those who have been working in this world.

do no harm 500x148 Las Vegas Paper Writes Series on Patient Safety Failings, Hospital Culture lean

I'll post links to the parts of the series with comments below:

I'm not sure if it's intended to be their main summary piece but Local hospitals willingness to change culture would be a step toward better care, transparency. That fits well with the Lean idea that the problem is not with people individually, these quality and safety problems are due to systems and culture and management systems.

The article highlights a fairly common defeatist (some would say realistic) attitude:

You're looking at the problems in Las Vegas and saying there are problems here. No one is denying that, said Dr. Ron Kline, president of the Nevada State Medical Association, of the Sun's investigation. But the argument would be that those similar problems exist in other places.  To some degree you can't eliminate them.

Yes these problems exist in other places because the healthcare culture tends to be the same, of course we get similar results. The Sun paints Las Vegas as being uniquely bad (or at least saying that data shows Las Vegas healthcare is less safe than other places). But to recognize that these problems are universal shouldn't be an excuse to NOT try to improve. Look at what organizations like ThedaCare have done – organizations like theirs have decided that being the middle of the pack or the “best of a bad bunch” isn't good enough. Maybe that leadership is lacking in Las Vegas – they “accept a dangerous culture of mediocrity” as the series claims.

Is  Vegas uniquely bad? The  main page of the series says

There's a running joke about hospitals here: “Where do you go for great health care in  Las Vegas?”

The airport.

The implication is everyone knows hospital care in Southern Nevada is substandard.

But the piece says not everyone knows this. There's certainly a lack of transparency, as a common theme in the Sun articles are the hospital CEOs refusing to talk to the paper, except for isolated cases, as if not talking about the problem makes it go away. The hospitals also hid behind HIPAA as an excuse to not talk about the problem. From  Part 3 of the series, political leaders and those in the know routinely “left the state for elective surgeries.”

�There�s an awful lot of denial,� said Larry Matheis, executive director of the Nevada State Medical Association. �The type of stories you�re doing have to be done in order to change the conversation. That�s working. The next thing is to get the buy-in that something can be done about it. Then you can get the culture change.�

Part One of the series highlights the patient safety problems that many are still very ignorant of, especially in the general public: �Health care can hurt you.� The president of the Nevada Hospital Association questioned the value of medical error reporting as not worth the cost. WHAT??? Is that a patient-first�philosophy?

The Sun reviewed a databased of medical records over the course of two years. They reviewed 425,000 cases and found that �preventable harm, deadly infections, and possible neglect� happen at the rate of one per day in�Las Vegas. This is line with�calculations I�ve done before based on IOM data that suggests the typical 400 bed hospital would have a preventable patient death once per week, on average.

�These are events that no one can be proud of,� [John] Santa said. �They aren�t inevitable. They�re preventable. It just involves attention to detail and a willingness to change the culture.�

Examples are shared in Part One of hospitals that have reduced central line infections and bedsores.

The series highlights how data is supposed to be shared with the feds, but there�s quite a pattern of underreporting and hiding of problems.�Lean thinkers know that making problems visible is the first step toward improvement. The Nevada hospitals seem to be fighting hard to hide problems from the public, as their hospital association seems to be more focused on protecting the hospitals than protecting patients.

Even with data (accurately reported or not), it remains that �no hospital-specific data are available for public review.�

If info were made public, it would woefully understate the problem thanks to systemic underreporting:

  • Hospitals reported�only one sentinel event involving an advanced stage decubitus ulcer � a bedsore that becomes a crater surrounded by dead flesh. The Sun found 72.
  • Hospitals reported�one sentinel event involving central-line bloodstream infections. The Sun identified 336.
  • Hospitals reported�six sentinel events in which a foreign object was accidentally left in a patient�s body. The Sun identified 17.

None of the hospitals disputed the Sun�s findings.

Hospitals lamely argue those cases were just �adverse events� not �sentinel events.� People died � let�s not nitpick over terminology here, folks.

Part Two focuses on infections: �A hidden epidemic.�

The issue of standardized work comes up � people not following procedures and known best practices.

But examples of hospitals�not following their own standards are plentiful � jeopardizing, even, their own employees. A Sunrise Hospital worker�who complained to state officials about being infected with MRSA on the job told health inspectors in June, �This problem has been going on for a while, but has surged recently� and could cause an outbreak.

There are many cases of families sharing their stories of how �they killed her� and �they�re not as dutiful a they should be.�

Lean thinkers known we need to look beyond blaming individuals for not washing their hands and for not properly following procedures � what are the systemic forms of waste that get in the way? Where is the leadership that would create an environment for quality?

There�s the story of a woman who was BILLED $3600 for antibiotics required to treat the infection that she got at the hospital. Where is the justice in that? Value to the patient? I think not�

The piece talks about how the VA and other hospitals test every patient for MRSA on admission so they can properly isolate patients to prevent the spread of MRSA. But no other�Vegas hospital, outside of the VA, does this � they claim its not cost effective. Again, is this patient focused? The story cites a study from Illinois that showed testing everyone WAS cost effective as it reduced infections by 80%.

From the piece:

The rise of lethal bacteria � combined with infection-control failures � has made being a patient, visitor or worker in�Las Vegas hospitals increasingly dangerous.

Some doctors and hospital employees fail to take even the most simple infection-control precautions. Asked if all hospital staff consistently wash their hands, Dr. Eugene Speck, a respected�Las Vegas infectious-disease specialist, said, �Of course not.� He wasn�t being glib. Every health care practitioner interviewed for this story agreed with his assessment, and national studies say the same. Hospital employees are too�busy, distracted, apathetic, stressed or short-staffed to keep up with hand washing.

So we need to look for the root causes of distraction, stress, and short staffing (the flipside explanation being too much waste in the system�.)

What are some other process-based cause of infection?

Also at UMC, she said, patients known to have contagious infections were placed in rooms with uninfected patients. At St. Rose Hospitals � Siena Campus, she said, technicians who ran the department where intravenous catheters were inserted and angiograms were performed�rarely cleaned the room between patients, resulting in contamination by bloody refuse.

�It�s a multisystem failure,� Schofield said.

How is this not fixable?

More failures to follow standardized work include:

  • MD doing colonoscopies in street clothes, instead of surgical scrubs
  • A C. diff patient roaming the hallways
  • A dialysis company that didn't have nurse oversight (and had infection control problems)
  • The hospitals weren't communicating infection control methods to visitors, leading to confusing and uncertainty
  • Draping a patient before flammable alcohol solution had dried, leading to a fireball in the O.R. (and the hospital further violated procedures by not calling the fire department)
  • A mother was oversedated during childbirth and the hospital failed to follow policies requiring them to report the problem

Then we have what seems like a bit of political corruption in the mix:

In the 2009 legislative session, Sen. Barbara Cegavske, R-Las Vegas,  introduced a bill to require every hospital in Nevada to create a MRSA program identifying colonized patients, isolating them, enforcing hand washing and reporting infections to the state.

The effort took an abrupt turn when Ann Lynch, lobbyist for Sunrise Health System, spoke during a hearing. Lynch informed the senator that the hospitals keep MRSA information internally and have no convenient way of reporting it to state health officials, Cegavske said.

Cegavske,  who received $6,500 in campaign contributions from hospitals in 2006,  reduced the bill to a simple promise to discuss the subject.

Wow, talk about a systemic problem!

Part Three talks about surgical errors: “Patients at risk under the knife.”

What are some of the systemic things that contribue to the culture of mediocrity? No morbidity and mortality conferences. There are implications of a culture of doctors covering for other doctors so they don't jeopardize getting more referrals from other docs.

Some argue in piece that standards in Vegas just aren't high enough – seems to highlight a possible problem with benchmarking:

A physician who has sat on multiple hospital committees overseeing colleagues has compared his peers to a group of  supposedly world-class sprinters who are satisfied running the 100-yard dash in 25 seconds when they should be doing it in under 10 seconds.

The standards are so low they don't even recognize a problem that's staring them in the face, said the doctor, who asked not to be identified because he feared retribution from colleagues.

Part Four of the series is called: “Why we suffer: Substandard hospital care has roots in a culture of seeking profits, shunning best practices, turning away from problems.”

The piece highlights staffing problems, including cases such as:

Hospitals suffer from staffing problems, both in numbers and quality.  At one hospital, each nursing assistant was required to care for up to 26 patients at a time, an unmanageable number, and administrators were unresponsive to complaints by employees for months.

The article implies that the for-profit hospitals in Vegas are putting profits ahead of patient care. There are similar problems in plenty of non-profit hospitals that are badly managed.

There are stories of inadequate staffing and poor response to patients:

Ron Serino suffers with a bedsore he acquired in April at a Las Vegas hospital. Serino, 60, a retired Army captain, said there were not enough nurses and aides to shift his body to prevent the bedsore.

I would ring the buzzer, and they wouldn't answer it,  up to hours at a time, he said.

When there's too much waste in the process, nurses are understandably frustrated – and too many are leaving the profession, exacerbating nursing shortages.

Thirty percent quit their jobs in the first year and 57 percent quit within two years, many complaining that administrators did not staff enough nurses to care for patients. Patient safety issues were cited in the UNLV study as the most negative aspect of the job and the most common reason for leaving.

A nurse who cared for up to eight patients at a time said on the survey: The outcome for patient care was poor. I witnessed so many frightening events that I decided to quit after one year and transfer to another hospital.

Another nurse noted, The patients were wonderful, but I had so many I felt I wasn't giving them the care they deserved.

The article lays blame at the feet of management, “soft” boards, and industry groups that are more cheerleader than “watchdog.”

Joint Commission is also held up for ridicule, as the article highlights a hospital given their “Medal of Honor” that was performing so poorly (death rates 2x the norm) that Medicare threatened to stop paying them for kidney transplants. I've seen a similar pattern, where high profile medical errors (like the Quaid twins overdose) happen right after a successful Joint Commission inspection.

After all of the gloom and despair,  Part Five focuses on improving healthcare, “How to put patients first: Rising above a fear of malpractice suits, pioneers in health care safety enact seven pillars that work.”

They focus on reporting problems and learning from mistakes, again common themes with Lean. It's cited how reporting and admitting mistakes leads to FEWER lawsuits, not more.

The article calls for  seven guidelines or pillars:

  • Incident reporting: The vast majority of reports are cases of unsafe conditions or close calls where patients could have been harmed.
  • Investigation: Every report is investigated within 72 hours, and no findings are withheld from the patient and family.
  • Disclosure and communication: The hospital maintains open communication with the patient and family until the issue is resolved.
  • Apology and remediation: When the hospital does not meet the standard of care, resulting in harm to a patient, it apologizes and offers some sort of solution to the problem. In the most extreme cases, compensation is extended.
  • System improvements: The staff takes steps to prevent the recurrence of the problem.
  • Data tracking and analysis: The hospital collects and analyzes patient safety incidents to improve quality and prevent harm.
  • Education and training: Doctors, nurses, administrators and support staff take annual competency exams and attend monthly patient safety meetings and other training.

System improvements are the key. Let's focus less on fining, blaming, and punishing and focus more on fixing problems afte they are identified or, better yet, proactively identifying things that COULD go wrong, fixing the system before there's patient harm. Instead of reducing payments for lawsuits, let's reduce the number of lawsuits by improving patient safety (and not just by apologizing after a problem). From the piece:

Tort reform is a blunt instrument, Gilchrist said. Has it made the system safer? Has it made doctors more accountable? Has it restored people who are hurt? I don't think so.

The article tells a story that�s reminiscent of the aviation-safety principles of everyone on a surgical team being willing to speak up. Or, as we�d say in�Lean, EVERYONE should be able to �pull the andon cord� to identify problems as they occur.

Patient safety also means encouraging staff to challenge superiors.

Surgeons were about to sew up a patient after a late-night emergency liver transplant this year when nurses Tessie Trocio and Noemi Tueres noticed during their routine count that a thin, flat sponge � about the size of a sheet of paper � was missing. Protocol called for an abdominal X-ray to rule out any retained objects, but the image was inconclusive. The nurses demanded another X-ray, which showed nothing in the abdomen.

Nurses are often hesitant to challenge doctors, particularly in the operating room. And in this case, the nurses were trained in the Philippines, where the cultural tendency is to not challenge authority.

The operation had taken more than seven hours. The surgeons were waiting. But the nurses � on their hands and knees digging through the trash to find the missing sponge � demanded a third X-ray, and that it be read by a radiologist.

The sponge was identified, balled up behind the liver. It was safely removed.

�That was a medical save,� said Kathy Pinschke Winn, the hospital�s professional development coordinator. �That patient would not have survived.�

The case was celebrated throughout the hospital, in a newsletter and at a luncheon to honor the nurses, Winn said.

Anyway, there�s a lot to take in from the series. I read it a couple times over the course of the last week. I know this�blog post is a lot to take in. I hope it inspires more leaders to create the right culture for quality and patient safety. I hope it inspires others to get involved in helping to FIX the system that is, sadly, broken in so many ways.

It�s not a problem of �bad people.� It�s about �bad systems.� And we need more leaders like�Gary Kaplan,�John Toussaint, and others who are willing to speak up and admit that hospitals are dangerous places and that we can actually fix things�

Please read�the whole series. There�s a lot to take in. Share your comments or reactions here in the comments section.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


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