One Problem with Healthcare Data


This article caught my eye recently: “Canada leads in surgical mishaps.” By “leads,” the article means they have a high number of mishaps (which is really more of a trailing position, not a leading one). I'm not here to quibble about language, nor am I here to bash Canada's healthcare system because I would suspect our healthcare delivery systems (including the way operating rooms function) are more similar than different between the U.S. and Canada, which would likely lead to similar results, you might think.

From the article:

If you are scheduled for an operation, take note: Canada has the third-highest incidence of “foreign bodies” being left inside patients after surgeons sew them up, one of the poor performances noted in a report comparing health-care systems in developed countries.

Looking at another piece of data:

Canada was in the top spot for the number of accidental punctures or lacerations during surgery out of the 17 countries surveyed by the Organization for Economic Co-operation & Development (OECD).

At 525 per 100,000 hospitalizations, its rate was more than three times as high as Britain (174) and the U.S. (166).

OK, so being three times worse than Britain or the U.S. seems like it might be a statistically meaningful difference? So what the heck is going on up there?

Again, from the article:

Ms. Tipper also said the reason Canada may seem to have more mistakes could be in the accuracy of its reporting.

Hmmm…. we know that the underreporting of medical errors is a major problem. It might be easier to avoid reporting an accidental puncture (where the harm to the patient might be chalked up to “complications”), while an item left inside the patient is more cut and dry, right? Could other countries really have such significantly lower error rates solely due to undereporting? I find it hard to believe that Canada could be 3x more dangerous, even in one area like this.

Canada is working to improve their healthcare quality culture, as we are in other countries:

Dr. Simpson, who has been working as a cardiologist for 20 years, said “the culture of safety is undergoing a renaissance in Canada, right now. When I first started, mistakes were something to be ashamed of, and you didn't talk about it. But now, it's completely flipped around.”

Being ashamed of a process problem or human error leads people to hide and cover up their problems. This gets in the way of the improvement needed to prevent future systemic errors.

On the topic of “gaming the numbers” or skewing data (instead of actually improving the system), it's widely reported that the United States has abysmal infant mortality results (USA Today editorial: “No excuse for U.S. infant mortality ranking“).

Twenty years ago, the  United States  was doing better than countries such as Cuba, Poland and Estonia in keeping newborn babies alive. Not any more. As other nations improved this key indicator of women's and infants' health, the U.S. lagged, dropping to 41st worldwide in newborn death rates, behind these three countries and 37 more.

Some argue that the U.S. ranks low because we are actually honest in how we report infant deaths after birth, while other countries might skew the data. From this opposing USA Today editorial (“Another view: Misleading neonatal data distort rankings“):

First, the U.S. strictly adheres to the  World Health Organization's definition of live birth (any that “breathes or shows any other evidence of life”), counting even the extremely premature and most fragile. In contrast, theWHO Bulletin  noted the “common practice in several (Western European) countries to register as live births only those infants who survived for a specified period.”

Can we have meaningful comparisons and improvement without accurate, trustworthy data?

Bringing this back to more local healthcare decisions, how can you or I choose a surgeon or a hospital based on quality and cost (value) without widely-available and trustworthy data? What are your thoughts on this? Leave a comment…

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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.


  1. Mark

    As you know, the first thing to do when faced with any benchmarked measure is to check the definition. Are people measuring the same thing? I agree that it’s unlikely Canada’s rate of 525 per 100,000 admissions is due entirely to definitional issues (but it’s possible) but it may play a part. And removing the data collection bias might reduce the rate sufficiently for us not to consider it an outlier.

    And this brings me onto my second point. In a league table someone is always going to be at the top and someone at the bottom. We all know this but somehow we get caught up in the headline such as “CANADA WORST AT X!”. I use caps deliberately. Better would be to place these rates in the context of an SPC chart where we can see whether the variation is special cause (they probably are an outlier) or common cause (they probably aren’t)

  2. Here is the full set of OECD Data for surgical “never events” and sepsis rates:


    It includes data from a number of countries and you can see there is a 10:1 spread from the best to the worst countries in those data sets. Feel free to chart away if you like :-)

  3. Hi Mark

    The numbers do not surprise me for several reasons, which I will list.

    1. Culture, in Britain almost all doctors work for the government admitting mistakes can cost them their jobs; in the USA doctors can get sued with ease so admitting any mistake you can avoid, helps prevent law suits; while in Canada doctors are independent entities, that are virtually impossible to sue in our legal system, thus they can admit their mistakes far more freely, and have to because the others in the facility may will do it for them. It doesn’t scare me because until mistakes are admitted you cannot find ways to prevent them.

    2. Quailty of our doctors, yes we have some truly great doctors in Canada that have refused the high paying offers of the USA, however a large percentage of our best doctors have been hired away from us, by the US health care corporations. So on the whole our doctors skill sets are not as high as they once where, and Canadians for the most part appreciate those men and women who have stayed here to help us by doing the best they can. It is also almost impossible for a foreign doctor however qualified to move to Canada, our rules restrict their entering and working here are extremely tight.

    3. Our health care system treats a far higher percentage of the population than does the American system, we have univerisal access for everyone, thus the numbers of people that get treatment is higher on a per capita basis, which will lead to more mistakes.

    4. Our doctors often have to use older methods than in the USA, as our publicly funded healthcare restricts spending on equipment. It would surprise people just how out of date some of our hospitals are compared to others. In places like Toronto, Ottawa, and London, everything is state of the art, but when you get to smaller cities such as Windsor, Chatham, Kitchener, and Woodstock. The doctors have far more limited tools to do their jobs, thus they are forced to treat people in a fashion that is less than optimal. These doctors are doing their best to help people despite the limitations, but those limitations are going to result in more mistakes, but most of those mistakes can be fixed, so is not better to have gotten treated and sufferred an extra nick, than to not have been treated at all.

    When you factor all these reasons together it is not hard to see why we would have a higher rate of mistakes, in fact I would be surprised if it was lower. On the whole Canada’s healthcare system maybe be broken, but the big issue is not the mistakes of doctors, nurses, and others providing healthcare those will be solved, it is the politicians, and bureaucrats that have screwed it up, while lavishing themselves with luxury lifestyles, while trying to blame those that actually deliver healthcare for the problems.

    One last point who pays for the Organization for Economic Co-operation & Development, like most international organizations, a handful of countries pay for it to waste millions doing research that proves nothing, and doesn’t solve a single problem. Studying the number in a vaccum is worthless hot air, the moenby could have been used to help doctors develop procedures to help prevent mistakes, instead of paying math majors to play with numbers.

    • I did find this buried in amongst the small print of the article:
      Other differences in data reporting across countries may influence the calculated rates of patient safety indicators. These include differences in coding practice, coding rules (e.g. definition of principal and secondary diagnoses), coding for billing purposes and the use of diagnosis type markers (e.g. “present at admission” ).

      Which only goes to prove that you have to read the small print. With all these potentially confounding factors, I’m surprised that the OECD had the nerve to publish anything.


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