If this post is a bit of a rant, I apologize. The problems here are avoidable and fixable. That's one reason I get so fired up about patient safety. Patient harm is not an unavoidable natural disaster, like a hurricane. It's a man-made problem… and people can solve it. See this recent post and these examples. That's my passion… more so than pushing Lean as a solution… I want us to solve the problem of harm and death caused by preventable medical errors, which are caused mainly by bad processes and bad systems…
I was on the road yesterday and picked up the business traveler's hometown paper, USA Today.
Here was the headline that greeted me and I wasn't surprised… my thought was “which hospital is being highlighted this time?” Again, I'm reminded of the line from the movie “Fight Club” — it's a major one. I also thought, “There was room for an ‘s' at the end of the headline… why are they singling out one hospital when this is a widespread problem?
What's noteworthy here is that it's MedStar Washington Hospital Center. I guess systemic patient safety problems are supposed to matter more when it's a hospital that treats D.C.'s political elites.
Patient safety caused by preventable error is a national problem, if not a global one, when you look at the stats.
Here is the online version of the article, with the headline:
Here is a video with a retired trauma surgeon talking about how good their reputation was (was that ever really the best indicator of quality and safety?), construction that may have led to the sewage problems, and how cost cutting and layoffs can lead to quality problems (the latter being an issue I have blogged about a lot).
Being overworked (and/or understaffed – same thing) is going to hurt quality and fatigue and overwork are going to lead to safety issues for staff or patients. The same is true in an auto factory (look at complaints about Tesla) or a hospital.
Lean is about reducing waste and making work easier. It's not about cutting staff and making people figure it out (or letting them struggle). I don't know much about “Lean” efforts at MedStar, but Christina Saint Martin, who is well known in Lean healthcare circles, formerly of Virginia Mason, was there at MedStar from 2015 to 2017 and recently left to join Baylor Scott & White in Texas). It's far from the most important aspect of this situation, but I hope nobody there would blame Lean for their problems. It wasn't mentioned in the article.
Lean should be part of the solution to situations like this, of course.
Even at full and proper staffing levels, poor processes and systems can lead to medical error and harm. Understaffing is like throwing gasoline on a fire.
From the article:
“Sewage that leaks down the walls and on the operating room floors is among the many problems at the go-to hospital for Congress and the White House, according to interviews and documents obtained by USA TODAY.”
Sewage leaks aren't the typical problem I see or hear about. That makes patient safety risk seem like a rare event. Not every hospital has sewage leaks. But, I'd say most every hospital has daily risks that are less visible (or harder to smell).
It seems that the hospital and its leadership failed in addressing the sewage problem quickly and effectively. It smells like there were more workarounds than root cause solutions.
“Buckets have been used to catch water leaks from ceilings at least twice during surgeries. These were the same ceilings through which sewage leaked.”
A bucket to catch the leak is, at best, a “short-term countermeasure.” There might have a been a bad system design choice to put some ORs in the basement below bathrooms, but not every bathroom leaks sewage. Was that a construction issue, as suggested by the surgeon in the video, or was maintenance not done properly?
In another example:
“Portable fans were used to eliminate strong “porta potty” odors in the operating rooms and to dry them more quickly, even though federal studies show fans can spread bacteria in the air.”
That sounds, again, like firefighting instead of good problem solving. And, it seems like an example of a countermeasure that caused at least the risk of another problem.
Quite literally, the shit hit the fan…
The hospital now says:
“all pipe issues have been corrected.”
I hope that means, then, that the sewage problem has been corrected.
Other than sewage leaks, the article describes the type of process breakdowns and poor problem solving that you might see more frequently in other hospitals:
“Employees in “protective” foot coverings scurried back and forth between sewage-soaked operating rooms and surgical instrument storage areas into hallways as patients passed on gurneys and lined the halls.”
This is something that bothered me since the very first time I was able to spend time in a surgical area. I was taught and shown “proper” protocol about changing into scrubs and what to do with head and foot coverings. I was told not to wear shoe covers out of the surgical area.
But, I constantly saw experienced O.R. staff wearing their head and foot covers throughout the hospital, including the cafeteria. What were they tracking out of the O.R. with them? Did they always change into fresh covers when they re-entered the surgical area? There was an apparent breakdown of process and standards. Who was managing that?? Who was responsible for maintaining standards?
I'd call that a “leadership problem” not a “bad staff” problem. A “Lean” organization would have better adherence to process. When they see a standard not being followed, they'd start by asking “why?” instead of blaming staff. They'd work together to ensure staff can do the right things the right way.
Back to MedStar:
“Flies are a regular problem in operating rooms and the insects landed on open wounds at least twice and often elsewhere on patients.
“This describes a hospital that is out of control,” says Lisa McGiffert, director of Consumer Reports‘ Safe Patient Project.”
The surgeon in the video talks about their reputation. Is that really a patient-focused mindset?
You hear the pride in the CMO's comments:
“In an interview, the chief medical officer, Gregory Argyros, described MedStar Washington as “the most important hospital in the most important city in the most important country in the world.”
Pride cometh before the fall, as they say?
This “most important” hospital gets very bad scores from CMS Hospital Compare (2 stars out of 5) and Leapfrog Group (a “D” grade). That hasn't harmed their reputation?
MedStar Georgetown scores worse with CMS:
Some of their surgical quality measures are “no different” or “worse” than the national rate and a lot of the infection rate data seems missing.
The Leapfrog Group page for the hospital says they declined to participate, so I'm not sure where USA Today gets the “D” grade from. Maybe that was from previous years when the hospital DID participate?
The hospital has been in cost cutting and layoffs mode. And, nurse turnover is pretty high… not a good indicator for quality and safety:
Against this backdrop, Washington Hospital Center was grappling with a $16 million shortfall after the most recent fiscal year ended in June, which prompted a memo alerting department heads that they need to cut millions from their budgets. Physicians, including anesthesiologists, left the hospital under confidential agreements although Argyros denied layoffs affected anyone involved in direct patient care.
About 400 nurses out of 1,780 left their jobs last year — up from about 300 a year between 2010 and 2015, according to data compiled by National Nurses United, which represents them. That comes to about a 22% turnover rate, compared to the 14% rate provided by hospital spokeswoman Donna Arbogast.”
Hospitals always say “patient safety is our top priority” and they always say layoffs “won't affect patient care.” Do those statements always ring true?
Hospital “defenders” (some might use the word “apologists”) say it's unfair to blame them for high infection rates. But, I'd say you CAN blame a hospital for bad process.
“In an internal memo to staff after an earlier USA TODAY story about the hospital, MedStar's David Mayer, the vice president of safety and quality, said it is improper to link in any way someone shot with a “dirty bullet from a dirty gun on a dirty ball field” with a hospital's high overall infection issues with a hospital.”
Referring to Congressman Steve Scalise, who was shot on a baseball field. Scalise did get an infection. Who knows why.
The “our patients are sicker” argument is a pretty common excuse in healthcare.
Leapfrog has a different view on the hospital:
“Our data suggests that patients are more likely to be harmed or die unnecessarily from an infection at this hospital than most other hospitals in the country,” says Leapfrog CEO Leah Binder.
The CMO talks a better game about aiming for zero harm:
“Argyros, who says the hospital is on a “high reliability journey,” confirmed the four retained foreign objects and said they included a sponge, a rubber retractor, a piece of a catheter and a “tiny piece” of a drill bit.”
“We need to accept no less than no patient harm,” Argyros said in a recent interview at the hospital. “It's really all about the outcomes. If outcomes are not good, we haven't met the mission.”
He says it's about the outcomes. Sure… but maybe focusing more on the process and better problem solving are some of the keys to achieving better outcomes?
The article mentions many examples of process breakdowns:
“A 102-page D.C. health department inspection report from last September highlighted examples of nurses failing to wash hands after treating wounds and not wearing protective clothing. Under a negotiated corrective plan, the hospital was required to develop a policy to prevent infections, including guidance for employees on things including how to keep their hands clean, use gloves and carry trays into patient rooms.”
I wonder how effective the “policy” countermeasure is.
The article also alludes to a culture of fear, which, again, is not good for quality and safety:
“As Scalise's operating room was being closed off for sterilization two days after his last surgery this summer, a doctor who asked to remain anonymous for fear of retribution said he saw liquid stool mixed in with other sewage on the floor. That suggested to the physician that the leak didn't just happen. As the room was being cleaned, a surgical procedure was taking place about five feet away in room No. 12, the doctor added and a document reviewed by USA TODAY indicates.”
Does anyone know how to get a copy of the 102-page report that the USA Today reviewed?
What are your reactions to the article and the situation? To me, it seems like a pattern of a splashy headline that asks “what's wrong with THIS hospital?” instead of “what's wrong with hospitals, more generally?”
As an aside, some of you might remember that I did a podcast interview with a filmmaker who was working with MedStar to make a documentary about IMPROVING patient safety.
I contributed to the Kickstarter campaign for the film. The film has not yet been completed. They are trying to get more funding, now from PBS. They might need to update their film, you know, because of the hospital's “reputation?”
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