How Often Does This Get Repeated? CMS and the Underpants Gnomes
I've recently heard of a scenario in healthcare that I suspect is pretty common, or at least it's not the first time I've heard of this scenario.
There have been stories in the news, but without naming names and without any inside information, here is what is reported to have happened in one of these recent cases:
1) Hospital brings attention on itself by performing a wrong-site surgery on a patient
2) A state-level agency comes in to inspect the situation and finds a number of other problems, including shockingly unsanitary cleaning practices in the O.R., expired medications, and things the state rightfully recognizes to put patients in jeopardy
Right now, this begs the question of whether these SAME problems don't also exist at other hospitals. There might be risks to patients even if there has NOT been a recent wrong-site surgery.
3) The hospital now gets the attention of CMS, from a federal level, and is threatened with losing all Medicare and Medicaid funding if they don't clean up their act
4) There's, apparently, a big scramble to “fix” the problems from step 2
5) The hospital passes a follow-up CMS inspection, things are deemed safe, and the funding will continue
There seem to be at least a few lessons learned, including
a) The government inspectors cannot proactively keep you safe. They can only threaten to punish people who have egregiously bad practices.
b) If the hospital were to lose its CMS funding, thousands of front-line workers might, through no real fault of their own, lose their jobs. The problems described in inspection reports like these are almost always “system problems” that trace back to a lack of good management and a lack of leadership.
c) Front-line staff members and surgeons get suspended or fired, but senior leaders never do, even when there are really embarrassing situations that happened under their watch. It's sure easy for leaders to get away with throwing individuals under the bus.
It also begs the question of “How do we know things will be safe in the future after that follow up inspection?”
I'm sure the state and federal inspectors are well intended and I'll grant that they want to keep patients safe. But, do their methods work? Why do they think they can inspect quality into a process when we know that doesn't work.
It reminds me a bit of the famous “underpants gnomes” from the TV show South Park… who didn't understand the connection between “Phase 1: Collect Underpants” and “Phase 3: Profit.” The poor little gnomes couldn't answer the kids' questions about how exactly they made money collecting underpants. But, they sure were happily busy in their daily work.
I've modified a diagram from the show a bit here… what the gnomes used to try to explain their business model. Phase 2 was “we don't know” with a shrug. But, they were convinced profits were sure to follow (this is a great Lean Startup-related tale, as well).
Phase 2 was likely a one-time “all hands on deck” clean up job.
Let's have a huge sweep to make sure all of the expired medications are gone. Good, patients are safe TODAY.
What has been put in place to make sure there won't be expired medications present in the future??
Do we understand why that problem was there in the first place?
Can we answer that question without blaming our front-line staff?
The same questions could be asked about the other scenarios.
If there were supposedly processes and procedures in place to PREVENT a wrong-site surgery (and they weren't followed or weren't effective, leading to a wrong-site surgery), why does CMS now feel confident that there are policies and procedures in place to protect patients in the future? What is the plan to make sure these errors are truly a “never event” instead of a “rare event”?
Never events are:
the “kind of mistake that should never happen”
But they do. I'm going to call these “so-called never events” until the problem is fixed, I think.
I wonder if CMS will come back to this hospital in 30, 60, or 90 days to see if things are still safe or if they've drifted back to the old ways.
What if they came back even just one week later, for a surprise inspection?
What would they see if they randomly showed up to inspect a random hospital?
This was true back in manufacturing and it's still true today in healthcare — ANYBODY can rally the troops to make things look good when there's a KNOWN inspection visit coming.
I'm reminded of an expression I learned from a British friend:
“The queen thinks the world smells like fresh paint”
And Joint Commission inspectors think nothing is ever stored in hospital hallways, I'm sure.