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Hospital, or Hilton? Ashish Jha says too often patient safety takes a backseat to marketing efforts. In this photo, the main atrium of the Henry Ford West Bloomfield Hospital is seen in West Bloomfield Township, Mich., Wednesday, Feb. 25, 2009. The $360 million, 300-bed hospital features a bevy of perks for patients, including private bedrooms with wireless Internet access and feng shui designs; tasty cuisine cooked up by a high-profile local chef and a main street of small specialty retail shops. (Carlos Osorio/AP)

Did you hear about the hospital that spent $100 million to eliminate medical errors? Or the large healthcare system that guaranteed patient safety, fully compensating any patient who was harmed?  You might have missed these stories because, as far as I know, they didn’t happen. But as hypothetical scenarios they make an interesting contrast to two recent real news stories.

The first, reported in The New York Times, describes how hospitals are investing tens, sometimes hundreds, of millions of dollars upgrading their amenities: nail salons, around-the-clock room service, spas, concert pianists in the lobby, etc. The article includes a photo quiz, testing the reader’s ability to tell the difference between a hospital and a hotel. (I didn’t fare very well.)

The second story, from NPR and Propublica, focuses on the number of Americans killed each year due to medical errors. A decade ago, the Institute of Medicine estimated that the number was around 100,000 each year. Now, a new paper in the journal Patient Safety estimates that between 210,000 and 440,000 Americans die each year, at least in part, due to medical errors. That would make medical errors the third leading cause of death in the U.S., behind heart disease and cancer.

To be sure, many patients were already sick. The error either made their condition worse or created new problems (such as hospital-acquired pneumonia for the patient undergoing hip surgery).

So while there is some debate about how to account for those patients, there is no controversy about this: Medical errors are a major cause of suffering and death across America (and the world). These errors are often preventable but get little attention.

How did we end up with a system where hospitals make big investments in nail salons and flat screen TVs but little on making care safer?

So how did we end up with a system where hospitals make big investments in nail salons and flat screen TVs but little on making care safer? Simple. It’s the sensible thing for hospitals to do. As businesses, hospitals have to meet payroll, maintain facilities, and attract top talent. Investing in patient safety is not a financial winner. People have called on hospitals to “do the right thing” and invest in patient safety, but understanding why hospitals behave the way they do, and what we can do to change their behavior, would be far more effective.

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.

The mezzanine of Bumrungrad Hospital in Bangkok, Thailand. (Kate Raynes-Goldie/flickr)

The mezzanine of Bumrungrad Hospital in Bangkok, Thailand. (Kate Raynes-Goldie/flickr)

Investing in hotel-like amenities, on the other hand, can pay off handsomely. The Medicare Value-Based Purchasing program puts a small amount of money (currently, 0.4 percent of Medicare payments) on the line for hospitals that have poor quality healthcare. Although it pays minimal attention to the epidemic of deaths from medical errors, it does include hospital performance on patient experience surveys. It has even gotten some hospitals to pay attention to customer service. But the bigger payoff comes when negotiating with insurance companies. Hospitals want to keep their beds full and extract the highest prices they can. The fanciest facilities become the “must have” in any insurance network. Insurance companies have a hard time getting and retaining customers if their network excludes the hospitals with beautiful lobbies, nice salons, and great food. So, we now have an arms race — who can be the fanciest hospital in town. There is no race for who can be the safest hospital in town.

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.

We now have an arms race — who can be the fanciest hospital in town. There is no race for who can be the safest hospital in town.

So what’s our bottom line? Until we make it financially smarter to reduce medical errors, we are not going to make serious progress. Unfortunately, neither insurance companies nor the biggest payer in America, Medicare, is signaling any meaningful efforts in this area.

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. Businesses generally don’t send you a bill when they screw up and nor should hospitals. Until this happens, we shouldn’t expect to see any headlines about the millions being spent to ensure that when you go to the hospital, you get the care you need and make it home safely — with or without a pianist playing in the lobby.

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  • afbrat1117

    Third leading cause? How SHAMEFUL for the entire medical community, although I suspect admin vs practitioners account for this. Thank you doctor for writing an honest commentary. I am a cancer pt and it is enough to fight the disease, I don’t need the additional risk factor of poor care due to mislaid priorities of admins (financial trumping pt safety). Thank you to all practitioners speaking up, and SHAME on admins/insur for conspiring against us/parients. Every time you undermine patient safety in the name of finance, you should be charged w conspiracy to commit murder. You are conspiring against the very ppl you are supposed to be serving, the most helpless and weakest among you. I think admins need to take, and be held litigiously liable for, the Hippocratic oath. Mistakes will happen, but willful disregard of improved pt safety options is SHAMEFUL and should be litigiously viable. But of course, it is cheaper for them to pay out the one in ten who will sue instead of pay upfront on improved pt safety standards. You don’t think we know your game, admins & insur cos? FOR SHAME! I for one will be evaluating & referring F&F based on true hospital quality stds: rate of infection, post op readmit etc. A nail salon or 24 hr rm service can’t counter those statistics. You don’t need a manicure if you’re dead.

  • Osman

    Nice piece , we need to make safety projects more attractable to the market. Other professional on media and marketing. Like hotels groups showing their facilities we need to show real safety projects given for the customers in a good way.

  • SafePatientProject

    Great blog – gets right at the heart of the problem: hospitals choose every day how to spend their profits and way too many of them repeatedly choose amenities that fail to significantly impact patient safety. This recommendation at the end – which is right on – was obviously meant to say [caps added]: “Second, payers should NOT pay for any hospitalization where a patient is hurt from a preventable medical error.”

  • Skeptical Scalpel

    Well said. But isn’t it a fact that when hospitals self-report, they miss over 90% of errors and complications? How would you deal with that?

  • Michaelm

    Ashish, as you know, there are studies showing that poor care (injuring patients, not killing them) can be profitable. The hospitals invest in the flat screen TVs on purpose, as you say. But while they don’t harm anyone on purpose, it should be mentioned in your article that the financial bonus of bungling plays role in the lack of safety. Everyone in the industry knows it; it’s just not mentioned publicly very often. This is a good place to do so.

    See my Health Affairs blog: “Why we still kill patients: Invisibility, inertia and income.” http://healthaffairs.org/blog/2010/12/06/why-we-still-kill-patients-invisibility-inertia-and-income/

    Regards,
    Michael

  • JEngdahlJ

    Have preventable medical errors led to higher preventable death rates in the U.S.? http://www.healthcaretownhall.com/?p=5931

  • ceblen

    What is not understood is that Medical Errors are NOT Reimbursed by Medicare and Private Insurance but the innocent Medicare/Medicaid patients have NO IDEA that an error has occurred because Hospitals/physicians don’t have to, under Medicare Law and reimbursement protocols, notify patients that their Medicare/Medicaid insurance isn’t reimbursing the hospital/physician because of the error.
    Innocent patients, the elderly on Medicare and Medicaid, have NO idea that they are “charity” patients for the hospital and in a hostile environment. The physicians/hospitals have to EAT these costs of treatments that are not reimbursed. They are not above burying these elderly Medicare/Medicaid patients on whom errors have been committed with unilateral DNR code status that allows them to limit any further life-extending/life-saving treatments that they KNOW will not be reimbursed by CMS, and its private partners, Big Insurance —-because of error and/or because of complications that exceed the Medicare Diagnosis Related Group Cap for the cancer/disease being treated that are also NOT reimbursed..
    As a direct response to reimbursement protocols, hospitals/physicians HIDE errors whenever possible from the insurers with the use of the hospital chart. But, of course, it isn’t always possible what with audits and some honest personnel, and the insurers, Medicare/private insurers, do discover the errors and refuse to reimburse but they have no duty under Medicare law to report this to the Medicare patients whom they insure!
    When a Medicare eligible citizen looks at his/her “Medicare and You” handbook that describes the legal rights of the Medicare patient, Medicare does tell you on page 56 “some” of the items and services that Medicare doesn’t cover and of course, errors and exceeding the DRG Cap isn’t included. Medicare also advises in this same handbook on Page 118 ” if you have Original Medicare, your doctor, other health care provider or supplier may give you a noticed called an “Advance Beneficiary Notice of Noncoverage” (ABN). This notice says Medicare probably (or certainly) won’t pay for some services in certain situations”
    Then! further on down on page 118, Medicare advises that “Doctors, other health care providers, and suppliers don’t have to (but still may) give you an ABN for services that Medicare never covers. See page 56.”
    This is NOT a political thing and has been developed under administrations of both the Republicans and the Democrats because of budget constraints —but isn’t it disgraceful and un-American???

  • Adam Joseph

    “Second, payers should not pay for any hospitalization where a patient is hurt from a preventable medical error. ”

    Wouldn’t this make doctors simply cover-up their errors? Paul Levy makes a good point: http://www.nytimes.com/2013/10/20/opinion/sunday/sunday-dialogue-handling-medical-errors.html?_r=0

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