Hospitals Prioritize Spending on Pretty Buildings over Safety?


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Here's an excellent commentary by  Ashish K. Jha, M.D., M.P.H, a professor at the Harvard School of Public Health: “In The Race For ‘Fanciest Hospital In Town,' Patient Safety Loses Out.”

Dr. Jha argues that hospitals glad spend millions of dollars on superficial pretty features that might boost patient satisfaction scores… partly because there are financial incentives from the government for doing well on “HCAHPS” scores.

He asks why hospitals aren't spending more on patient safety… because it's not profitable to do so?

He writes:

Currently, improving patient safety requires real investments of time, effort, and money with little payoff. Yes, some patient safety interventions are cheap (like washing hands) but others are expensive (such as redesigning intensive care unit management). Investing in these efforts save lives, but they can also reduce revenue. Asking hospitals to engage in efforts that increase cost, reduce revenue, and ultimately hurt their bottom line? Sorry, but that's a pretty hard sell.

I'm not sure that improving patient safety requires spending tens or hundreds of millions of dollars. Yes, proper hand hygiene practices should be inexpensive… but I think the lack of hand hygiene  is more a matter of poor management than a lack of spending.

Hospitals still rely too much on cute posters encouraging hand washing… yet foam and gel dispensers are empty far too often (from my own first hand checks).

Does it cost a lot of money to make sure everybody is following the “universal protocols” before surgical procedures to prevent wrong-site surgeries? Does it cost millions of dollars to create a culture where people speak up when they see a problem (and a culture in which they are listened to?).

Yes, there are some things we can do to improve patient safety that would cost money — perhaps increasing nursing staffing or other staffing changes… Dr. Jha has a story that's a bit discouraging on the surface:

The challenge of poorly aligned incentives was brought home for me in a recent conversation with a CEO of a large hospital system. His board, made up of caring, committed people, usually approved small investments in safety. But when he wanted to do something big with a potentially large financial downside, the resistance was stiffer. During a particularly tough financial year, he proposed a pricey but highly effective program to reduce medication errors: having pharmacists round with every medical team. When the finance department calculated the impact on the bottom line, his board said no.

Maybe there were other factors involved in the decision, but hospitals have a moral obligation to do all they can to provide safe care — it shouldn't just be an issue of “ROI.”

His recommendations?

The solution is reasonably straightforward: first, Medicare should require that every hospital systematically collect data on medical harms and report it publicly. Second, payers should not pay for any hospitalization where a patient is hurt from a preventable medical error.

To the first point, other healthcare leaders like John Toussaint and Paul O'Neill have called for better reporting of patient harm data. To the second point, I thought CMS and many private payers were no longer paying for the care associated with “never events.

Dr. Jha's point is a good one and it's a point I've made here on the blog and in presentations before — how can hospitals, in good conscience, focus on pretty marble lobbies and large pretty atriums with fountains and piano players when patients are being harmed every day?

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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. I was in an A3 workshop some time ago with PI staff from a large respected hospital in a competitive market that was losing breast imaging market share to a competitor down the street in spite of lower cost, faster time to diagnostic imaging, and a lower false-positive rate. What they didn’t have was a garden atrium, valet parking, and the aroma of a premium coffee cart in the lobby. What to do? It’s almost like an arms race chasing after those valued customers who quite often aren’t even able to express what is really important.

    • I can understand the need to compete on those fancy-schmancy superficial dimensions.

      It seems like the hospital with lower cost, faster time, and better quality has a piss poor marketing department if they can’t communicate those benefits to the community or to referring physicians (or the payers).

  2. This is simply another problem to be solved. Lean is always to do more with less, do if you want the big shiny new toy, how can you afford it AND have ask the patient safety built in? How do you change your process to gain more roi and value somewhere else to offset your coffee cart? Better yet, rent the space to a coffee vendor and make your cash that way without having to incur coffee supply costs.

    As a side note, it hospital just started the rounding with the pharmacists! Working great from what I hear! Better patient safety…like dictating right after visit rather than batching thenm for later!

  3. Glad you shared this article on your blog. Glad there’s more discussion about the satisfaction-safety tension with which hospital management teams need to deal.

    More of a point of information than anything else: to your concluding statement about payers not paying for Never Events, not all preventable medical errors are Never Events. Jha might be alluding to non-Never Events.

    • Right, non all adverse events are “preventable errors” and not all of those are “never events.”

      I wasn’t real precise about all of that language… but my point is that healthcare leaders need to focus more on safety.


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