Of Ocean Liners, Sheep, and Hospitals

When it comes to improving care, hospitals are both ship- and sheep-like.

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Sometimes the work of the patient and professional groups to raise standards of hospital quality and safety reminds me of tugboats hauling and pushing gigantic ocean liners—their ponderous bulk resists changing course, but eventually they come around. On gloomier days, what comes to mind is border collies racing around to move a flock of sheep from one pasture to another, snapping at their heels while the woolly ones scatter this way and that, wondering in their dumb way why they can't be left alone to graze as they would in a world without annoying border collies. Yesterday I thought of both.

The catalyst was "Improving America's Hospitals," the second annual report from the Joint Commission, hospitals' accrediting body, on trends in quality and safety. It's stuffed with numbers showing how well hospitals are or aren't complying with measures that have everything to do with good, safe care, from hand washing to reduce infection and calling a "time out" before an operation or other invasive procedure (to double-check that the target is the right part of the right patient) to taking steps so that look-alike or sound-alike drugs aren't confused.

On the plus side of the ledger, more than 99 percent of hospitals complied in 2006 with a standard requiring that pneumonia patients quickly get their blood oxygen checked; if it's low, giving them supplemental oxygen right away improves their survival odds. In fact, only three states had average compliance rates below 99 percent, and the lowest of those three was 98.9 percent.

Now for some of the low marks: Heart-attack patients in 92 percent of hospitals did not get from the ER door to a table in the cath lab, to have their blockage removed, within the required two hours. More than 82 percent of hospitals did not supply adequate discharge instructions to patients with heart failure. More than one third of hospitals did not have a process in place for finding out patients' medications on admission. And more than one fourth flunked the time-out requirement—far worse than just a couple of years ago.

Putting a new standard in place isn't enough. Even important changes, Jerod Loeb, the commission's executive vice president for research, told me today, "tend to be added on top of existing things, as opposed to redesigning the larger process to include the new piece." When other issues come up, the tacked-on changes get lower priority. And some sheep—ah, physicians—simply don't want to change. Take the use of confusing abbreviations for drugs and dosages, which I've previously addressed. Three of every eight hospitals haven't come up with any kind of standardized list of abbreviations, symbols, and acronyms.

"That's a source of great frustration," commission President Dennis O'Leary said yesterday. "You've got physicians who say, 'excuse me, that's what I was taught to write in medical school.' Unfortunately, when physicians blow off the standards and their writing is illegible, you have a real problem. Even with electronic records, we've seen these abbreviations creep in. You are going to have difficulty making some of these changes. They are behavioral and cultural." In part, says Loeb, it's that many hospitals tolerate deviant behavior: Doctors still call the shots. But he adds that he is "realistic enough to know we're dealing with very complex problems—time pressure, people not believing the evidence, et cetera, et cetera."

Sigh. All true. But I've often wished out loud for every physician-to-be to have to spend at least three days as an inpatient before getting that M.D., and a two-day reminder at five-year intervals wouldn't be a bad idea, either. Some of that stubborn, sheep-like resistance might melt real fast.