Excerpts from an interview with Lucian Leape – an adjunct professor of health policy at Harvard School of Public Health – in a 2007 issue of Health Affairs.
[Buerhaus, Peter I. Is Hospital Patient Care Becoming Safer? A Conversation with Lucian Leape. Health Affairs. 26;6 (2007):687-96.]
Dr. Leape is well known for his ground-breaking research and thinking about patient safety, particularly on the need to focus on systems of care to prevent injury to patients, and, more recently on the need for full, open disclosure and apology when things go wrong.
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On reducing medical error to 0:
The most exciting thing that has happened recently in patient safety--something that has truly changed our agenda--is that it is now apparent that we can use perfection as a benchmark. This means that we can stop talking about reducing medication errors by 50 percent or improving hand washing by 30 percent, and so forth. We now have convincing demonstrations that when the effort is made and new practices are implemented, we can actually eliminate certain adverse events. There is no reason to think that this cannot be expanded to the whole universe of adverse events.
On disclosure of medical errors and patient safety:
The need for full disclosure and compensation is finally on the patient safety agenda. Acknowledging mistakes when they occur, fully explaining what happened, apologizing for errors, and providing compensation for the cost of the injuries we cause are things that we have to do. Patients too often do not get the truth, the whole truth, and nothing but the truth, and it is time to stop that.
There are many reasons why physicians have been reluctant to be open and apologize after accidental injury, but a major factor has been bad advice from liability insurance carriers and hospital counsels, who have perpetuated the myth that informing the patient will increase the likelihood of being sued. There is not a shred of evidence to support this assertion--not a single study--yet the myth dies hard.
Although fear of litigation is very real, and understandable, I believe that a more powerful reason that doctors sometimes do not communicate fully with patients after a serious error is their sense of shame and guilt. Physicians hold themselves to high standards of performance. As a result, they find it difficult to deal with failure. And they get very little support, either from their colleagues or from risk management personnel. It turns out that full disclosure and apology when there has been an error are important for the physician as well as for the patient. We need to provide them with support to help make it happen.
On Pay for Performance (P4P) models of health care:
Essentially, it suggests that you can get quality by paying for it. The idea seems sound, but whether the results will confirm it remains to be seen. It certainly is a concept worth trying, given that our current system of paying for health care is rife with perverse incentives. As some wag observed, health care is the only industry where you get paid more for a defective product! But, it's true: Hospitals and doctors receive more income when things go wrong than when they go right. And it works both ways: You get paid less for good care. That is clearly not what we want.
Here is a classic example: A doctor does a good job treating patients with asthma, teaching them to manage themselves, and the end result is exactly what we want--patients have fewer attacks. They are not going to the doctor's office as often, they are not going to the emergency room, and they are not being admitted to the intensive care unit and being intubated. But the net result is that both the doctor and the hospital lose money. That does not make any sense, and we need to change that. Our fee-for-service system also emphasizes providing services rather than providing care, and that also needs to be changed. We should pay for good-quality care.
On the major flaws of current - and potentially all - P4P proposals:
Pay-for-performance, though, has some major problems that we have to sort out. I do not know how they are going to be resolved, but let me at least briefly mention a few. The first is whether you should pay for process or for outcomes. Second, how do you pay: Do you pay a bonus for good care, or do you punish people who fail?
Let us say you pay a bonus for somebody who does a better job of making sure that all patients who have a heart attack get beta-blockers afterward. We have pretty good data that this makes a difference in outcomes, so one thing to do is say, "If you achieve a high level--say, over 90 percent of your patients get beta blockers--we will pay a premium." Or do you not worry about that and focus on outcomes?
I am also concerned about the possibility of perverse effects. Any time you change payment, you change behavior, and that often has unintended consequences. If we concentrate on paying for outcomes, will we in effect devalue and direct attention away from the "soft stuff" that means so much to patients: time spent listening to them, caring about them, communicating with them? If we do not pay for that, then is it going to be diminished? I would hope not, but one must be aware of that possibility.
On the power of data collection as an engine of change in health care settings:
The second [effective] approach [to progress in healthcare quality and safety], which is even more powerful, is data and feedback. Everybody in medicine, perhaps everybody in health care, thinks they are from Lake Wobegon--that they are "above average." It is very hard for any doctor, for example, to be called average. And when they find out from the data that they are below average, they begin to do something about it.
And finally, on one of the major shortcomings of the current state of medical education:
The third barrier is that students in medicine, nursing, and pharmacy receive insufficient basic education in quality and safety. At a minimum, in the first year of school, all of them should learn the basics of error theory, why people make mistakes, and how to prevent them. Later, they should learn how to analyze systems, how to identify systems' failures, and how to redesign systems. As we mentioned, they need to learn how to work in teams by doing it, and doctors especially need to learn the basics of leadership. They need to learn much more about how to communicate more effectively, how to handle their own feelings and concerns, and how to handle the shame and guilt they will feel when things go wrong, so that they can still be effective caregivers. They need to learn how to apologize. These are things that are currently not being taught to our budding doctors. That has to change.
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Oh man -- Dr. Leape presents puts forward so many outrageously smart and forward-thinking ideas in this interview. I hadn't come across his work until I started working with the Patient Safety and Risk Management teams at this hospital, but some very similar thoughts have been fermenting in my brain (albeit, phrased far less articulately) since my time in South Africa - especially after my experiences working alongside members of the Institute for Healthcare Improvement's developing countries team.
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