Public reporting of patient harm is a potent force

By Marshall Allen

Rod Davis was incensed when he read the first installment of our series, “Do No Harm: Hospital Care in Las Vegas,” in the Las Vegas Sun. For the first time, we had identified cases of preventable harm that occurred in each of the city’s 13 hospitals.

Davis, CEO of the three St. Rose Dominican Hospitals, was understandably unhappy. He and his colleagues at the Nevada Hospital Association had lobbied for years to keep the information secret. Davis shot off a letter to every legislator in Nevada and every doctor on his staff denouncing the Las Vegas Sun. He said we, “grossly oversimplified hospital billing data. The result was an inaccurate, incomplete and negative view of hospital care in Southern Nevada.”

Our analysis of hospital billing records on file with the state showed 3,689 cases of preventable infections, injuries and surgical accidents over a two-year period. It also exposed how the hospitals had resisted public reporting of their performance for almost a decade. And it spotlighted individual cases of egregious harm: a woman whose kidney was mistakenly removed, a patient who died when her wind pipe was ripped with a breathing tube, a man whose chemotherapy port was improperly installed in his chest, resulting in the toxic chemicals charring his flesh, and more. Few of the patients I interviewed had the hospital acknowledge the harm. Almost none received an apology. And almost all of them were billed for the complications.  

Our series was rooted in the belief that people have a right to know about the quality of care provided by their local hospitals. That seems like common sense, but it’s considered revolutionary in American health care. Hospitals, nursing homes and doctors are accustomed to operating with little outside accountability for their performance. In most states, you can’t find out an individual hospital’s rate of deadly infections or injuries to patients. Or, what you can find out is carefully controlled by hospital lobbyists.

Our analysis at the Sun made big waves, and it barely scratched the surface of the patient safety crisis nationwide. A study of the medical records of 780 randomly sampled Medicare patients found that 1 in 7 of them suffered harm such as medication errors, bedsores, falls resulting in bone breaks, infections and other injuries while hospitalized in October 2008. But in most states it’s impossible to identify where such cases occurred. That’s one reason the Sun‘s investigation created such a stir – just making the information public was new. But the stories also highlighted additional truths about transparency.  

Transparency touches a nerve, and that’s a good thing

Dr. Mitchell Foreman, president of the Clark County Medical Society, made critiquing our reports the topic of several columns in the group’s newsletter. He seemed most offended that we made the data so personal:

“…the authors exploit the ‘facts’ by presenting sensational and distorted case reports that tug at the heart strings of those who read these accounts. The accounts bring to life the individuals who have presumably been impacted by the incompetent, uncaring or malpractice acts of doctors and the medical profession. It takes the raw data and connects it to people.”

Publicly reporting harm caused by medical providers is sensitive. Doctors, nurses, and yes, probably even hospital administrators, go into medicine because they want to help people. The public revelation that they’re harming them, or killing them, bears uncomfortable implications. Namely, once it’s acknowledged it can’t be ignored – and that leads, hopefully, to improvement.

Transparency improves patient care

Paul Levy, then-CEO of Beth Israel Deaconess Hospital, one of three Harvard-affiliated facilities in Boston, was trying to encourage his staff when he published the facility’s declining hospital-acquired infection rates on his blog. But he also became an instigator. Levy trumpeted his commitment to patient safety and openness with the public, and challenged his fellow Boston hospital CEOs to do the same. He goaded them in private and called them out in public, until in 2009 administrators at the two other facilities, Brigham and Women’s Hospital and Massachusetts General Hospital, published their record of infections and injuries suffered by patients.

The AHCJ Media Fellowship on Health Performance, supported by The Commonwealth Fund, allowed me to go to Boston, where the hospital leaders pressured by Levy said they wrestled over the decision, worrying it would cause a media bloodbath or an increase in malpractice lawsuits. But now that they have public reporting in place, they say the fears were unfounded and they would never turn back. It provided the accountability managers and administrators needed to bring about improvement. Dr. Tejal Gandhi, director of patient safety for Partners Healthcare, the umbrella organization for Brigham and Women’s and Massachusetts General, said transparency “drives leadership to take action more immediately.”

The malpractice myth

Over the course of our investigation, I spoke to at least 100 patients or their families who were harmed in hospitals, most who seethed because the incident was covered up, kept secret, denied, ignored, excused or explained away. Many lawsuits are rooted in a quest for information or a demand for acknowledgement.

The AHCJ fellowship allowed me to travel to the University of Illinois at Chicago Medical Center, to write about its “seven pillars” patient safety program. The pillars of the program include apologizing for harm, waiving bills and offering compensation when necessary, and it is becoming a national model. Many hospitals and doctors resist acknowledging harm because they’re afraid it will lead to lawsuits. That’s not what research shows, and it hasn’t been the case at the University of Illinois at Chicago Medical Center. Since its seven pillars program started, malpractice claims have dropped 30 percent and overall malpractice costs have been cut by $3 million a year to about $40 million. In the same time period other Illinois hospitals reportedly saw a rise in their malpractice costs.

Dr. Tim McDonald, one of the architects of the program, said the openness eliminates frivolous lawsuits. Plus, the hospital conducts open investigations into each incident, so patients would never sue just to find out what happened. They also get to see improvements implemented that prevent other patients from becoming harmed.

Transparency is a change agent

Days after hospital CEO Rod Davis sent his letter criticizing the Sun, he had what could only be called a conversion. He went on the Sun‘s website and examined our findings in detail. Then he requested a meeting with us, where he said our investigation was “worthwhile,” that we had done an “exceptional job,” and if he had it to do over again he would not send the letter. (He later sent a retraction.)

Furthermore, Davis agreed to post the previously undisclosed sentinel event information on the websites of his three hospitals. The CEO of the city’s public hospital agreed to do the same. That was more transparency than Nevada legislators had accomplished in a decade.

There was no going back once we published the information. The Nevada Hospital Association didn’t have a leg to stand on. They couldn’t deny the problem. And they couldn’t say the sky had fallen once it was acknowledged. In the end, the association did not stand in the way of five new patient safety laws passed in Nevada in June.

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Marshall Allen reported Do No Harm with Alex Richards at the Las Vegas Sun. Allen,  who has since moved to ProPublica, completed part of this series while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund. The series won a 2010 Award for Excellence in Health Care Journalism, the investigative reporting category in the 2010 Scripps Howard Awards, best in show for the print category of the National Headliner Awards and the 2011 Goldsmith Prize for Investigative Reporting.