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The Silent Treatment 'Just Be Quiet About It'

December 7, 2007
Related Topics: Medical Benefits Law, Corporate Culture, Health and Wellness, Featured Article, HR & Business Administration
New York's Stony Brook Medical Center hired Dr. Irvin Krukenkamp 10 years ago in part to oversee the safety of the Long Island hospital’s cardiac care program. When a baby died of complications from heart surgery in 2003, Krukenkamp, an adult cardiothoracic surgeon, reiterated his earlier concern that Stony Brook did not adequately staff its hospital with doctors who specialized in pediatric heart surgery and who could provide timely care to infants in case of post-operative emergencies.

    Several months later, Krukenkamp was asked to resign as director of the hospital’s heart center, according to a complaint he filed in a federal court in 2004. The experience left Krukenkamp, previously a professor at Harvard Medical School, feeling that the atmosphere at Stony Brook stymied open discussion of issues on the quality of its medical care.

    "Once you are trampled, you have one person fired or retaliated against, nobody is going to open their mouth," he says. "And that is very much the case in a significant amount of health care."

    Wide concern among employers, patients and health care workers regarding the toll of medical errors—which cost an estimated $37.6 billion annually and account for as many as 98,000 deaths a year—has led to increased scrutiny of workforce management practices at hospitals. Some medical centers have focused recently on creating a workplace where problems are openly identified and executives are held accountable for safety issues.

    Yet, these efforts run headlong into what many health care professionals describe as a culture of fear that permeates the health care system. Among the areas under scrutiny as employers and other payers demand improvement in the quality of health care is the extent that working conditions within a hospital affect patient safety.

    Part of the issue, says Dr. Robert Rubin, a New York state-based heart surgeon, is the workplace culture of most hospitals. "There is no free and easy exchange" when it comes to talking about mistakes, he says.

"Once you are trampled, you have one person fired or retaliated against, nobody is going to open their mouth. And that is very much the case in a significant amount of health care."
 --Dr. Irvin Krukenkamp,
cardiothoracic surgeon

    In a study published in April, the Agency for Health Care Research and Quality, which is part of the U.S. Department of Health and Human Services, reported that 65 percent of hospital staff worried that any mistakes they make would be kept in their personnel file. A majority said they had not reported any medical errors in the past year. Taken together, the report concluded the number of medical errors that occur is greater than the number actually reported.

    Even before the death of "Baby Doe," Krukenkamp said the hospital did not operate its pediatric heart service with adequate staffing. This was one reason why Krukenkamp told executives at Stony Brook, one of the largest hospitals on Long Island, that he thought the death of Baby Doe constituted a preventable medical error that would have to be reported to state authorities for investigation. A review was conducted, but the patient’s surgeon—a doctor who moonlighted as the hospital’s pediatric heart specialist since the hospital had none on staff—was not required to attend. When nothing came of the review and no report was filed with the state, Krukenkamp criticized the process as incomplete.

    Soon he noticed that meetings on issues pertaining to the heart surgery center were scheduled either without notifying him or while he was in surgery. Several weeks later, Krukenkamp was told that another surgeon was hired to oversee pediatric heart surgery. He later learned that the hospital also had hired an executive search firm to find doctors to replace him.

    On January 30, 2004, Krukenkamp was asked to meet with hospital executives. At the 6:30 a.m. meeting, the hospital executives, citing a need for a change in leadership at the heart center, told the doctor to resign as head of cardiothoracic surgery and the heart program, Krukenkamp’s court complaint states. Their decision, they said, was final. It was in the doctor’s "best interest not to fight this," he was allegedly told.

    A month later, Krukenkamp sued the hospital.

Institutional Barriers
    Identifying and addressing problems in hospitals is as complex as hospitals themselves. There is often a lack of communication between doctors, nurses and other staff, some of whom may be contract employees; a lack of accountability among executives; fear of lawsuits; and a propensity among doctors to protect colleagues’ reputations. Plus, most problems have multiple causes.

    Even seemingly straightforward problems, like avoiding post-admission infections simply by washing hands, have gone largely unsolved. The Leapfrog Group, an employer-sponsored coalition focused on improving the quality of health care in hospitals, recently asked 1,256 hospitals whether they follow recommended steps to prevent the avoidable infections that kill 90,000 people a year. Leapfrog asked hospitals whether they evaluated the frequency and severity of infections acquired in the hospital and if senior executives and managers were held accountable for reducing infection rates. They also asked whether the hospital educated its staff on these issues. Eighty-seven percent of hospitals do not take the recommended steps to prevent avoidable infections, Leapfrog reported.

"A culture of disclosure is not prevalent in our provider community. Transparency has not been a standard that has been upheld."
--Rachel Weissburg, program associate, the Leapfrog Group, an employer-sponsored health care coalition

    The practical challenge of reducing hospital-acquired infections is difficult enough—much harder than simply imploring workers to wash their hands. But attacking the problem first requires the hospital to admit there is a problem and allow outside scrutiny and comparisons with other hospitals, something they are loath to do. "A culture of disclosure is not prevalent in our provider community," says Rachel Weissburg, program associate for Leapfrog. "Transparency has not been a standard that has been upheld."

    Most hospital administrators say they prefer to handle problems internally. They implement their own controls to manage risk and assure quality. And they fear that greater openness would invite lawsuits, despite a federal law—the Patient Safety and Quality Improvement Act of 2005—that protects those who report incidents to third-party patient safety organizations from having the information used against them in court, unless the medical error is deemed criminal.

    Other health care experts believe workplace issues that may contribute to medical errors—the training of medical residents, the understaffing of nurses—also create the conditions that keep workers from voicing concerns.

    In another study from the Agency for Healthcare Research and Quality, this one released last month, researchers said errors committed by medical residents were caused in large part by lack of supervision and poor teamwork among staff members. "Despite the growing body of evidence that links poor teamwork and preventable medical errors, graduate school medical education programs continue to pay insufficient attention to teamwork-based training and communication skills," the authors of the study wrote.

    Researchers have tried to determine how hospital working conditions affect patient safety, but the data so far is incomplete. Again, the agency concluded in a 2003 report that staffing shortages and increased nursing workload are associated with higher rates of nonfatal adverse outcomes as well as medication errors. The opposite was true for physicians: Higher caseloads were associated with fewer deaths.

    The study said there wasn’t enough data to properly address whether workplace culture affected the rate of medical errors or the recognition of medical errors by hospitals, leading the authors to conclude, "The cumulative evidence demonstrates that working conditions are important in influencing patient safety and deserve careful attention from health care professionals."

'An aura of secrecy'   
    Tricia West has been a nurse in Los Angeles for 34 years and has also consulted on malpractice lawsuits. She says she has experienced several occasions when, as a nurse, she reported "significant risks" to hospital administrators but was told to "just be quiet about it."

    "Every facility has a risk manager or an internal process for process improvement," she says. "Part of the problem is, how far is that information [about a safety issue] taken and what is done with that information?"

"As long as you don't outright kill somebody, the attitude is, 'Don't tell; we'll take care of it amongst ourselves.' So the problem never gets fixed."
-- Diana Iversen, former per diem nurse, fired after reporting a dosing error
she committed

    West says the ability to freely communicate safety issues varies among hospitals and even within hospital departments. Intensive care unit staffs, which usually operate as self-contained departments, tend to be tightly knit groups, she says. Problems, therefore, are more openly discussed.

    In an analysis of medical errors in New York state hospitals from 2002 to 2004, the state Health Department concluded that "communication issues" contributed to 39 percent of errors; 36 percent of mistakes were attributable to not having an effective policy or process in place to prevent and communicate errors; and 17 percent of errors were caused by "human resource factors and issues."

    The nursing shortage may make things worse. Contract nurses may be less inclined to voice safety concerns for fear of losing their jobs, West says. "If you are working per diem," she says, "you come in, you do your job, you leave."

    The challenge of managing contract nurses is growing along with the nursing shortage. By 2020, the Department of Health and Human Services projects a shortage of 1 million nurses.

    Diana Iversen, who has 30 years of nursing experience in California, was a per diem nurse when she committed a medical error seven years ago by giving a patient the wrong medicine. She confused the abbreviation for Hespan, a drug that expands a person’s circulatory volume, for Heparin, a blood thinner. She immediately reported the incident because the patient required an antidote, and the patient was saved. Yet Iversen was fired the next day, she says. As a result of the error, her nursing license was put on probation, she says.

    The fear of making another mistake and losing her license carried over into future work. Iversen eventually quit her most recent job as a nurse at Northbay Regional Medical Center in Fairfield, California, over concerns of being associated with what she felt were instances when nurses and doctors weren’t following the hospital’s protocols for practicing safe medicine. She says her concerns were not adequately addressed.

    "As long as you don’t outright kill somebody, the attitude is, ‘Don’t tell; we’ll take care of it amongst ourselves,’ " she says. "So the problem never gets fixed."

    After Iversen left, she sent a letter to the hospital’s human resources manager detailing what she said were examples of unsafe nursing practices.

    The hospital would not discuss Iversen’s personnel record, citing her right to privacy.

    "This nurse’s concerns were listened to and responded to appropriately and, despite her assertions, the incidents she has detailed are not medical errors but appropriate medical care that is consistent with well-established standards," Northbay spokeswoman Joanie Erickson says.

"I think there has been an aura of secrecy over the years and walls thrown up when something
happens, and in some places that continues to happen. But there is a groundswell of hospitals saying
that is not acceptable."
--Dopanl Denmark, VP for medical affairs, Northbay Regional Medical Center in Fairfield, California

    The hospital’s vice president for medical affairs, Donald Denmark, outlined a series of programs in place at Northbay to improve communication and reduce medical errors.

    Denmark also explained the hospital’s protocol for the incidents detailed by Iversen. In an example Iversen gave of a doctor using the anti-coagulant Lovenox in a way in which it was not intended, Denmark said the hospital’s computerized pharmacy would not allow it to be dispensed that way. He added, however, that it was a challenge to get doctors who work in private practice but are affiliated with the hospital—in California, hospitals do not have staff doctors—to get involved in process-improvement efforts.

    "From our perspective of administration, there is an encouragement to report the events because we want to improve the process of care," Denmark says. Employees are instructed during orientation to report issues involving quality of care.

    "I think there has been an aura of secrecy over the years and walls thrown up when something happens," Denmark says, "and in some places that continues to happen. But there is a groundswell of hospitals saying that is not acceptable."

    Denae Powers, a State College, Pennsylvania, doctor who used to be on the board of the state patient safety organization, refers to a "culture of silence" surrounding the discussion of medical errors in hospitals. She believes hospitals interested in bringing medical errors to light should focus on creating an open culture.

    "If someone comes across with a concern, how they are treated goes a long way to sending a message to others who might come forward," she says.

    Concerns about lawsuits are only part of the problem, Powers says. "It’s more than lawyers and lawsuits; it’s a culture," she says. "And it’s a culture that’s not getting better."

    Those who do step forward to report mistakes and shortcomings risk professional and financial harm.

    "If you tell the truth, then people can deal with it and you can have processes set up to make sure these things don’t happen—but there are ramifications," West says.

Hosptital faulted
    In 2005, Krukenkamp settled his lawsuit with Stony Brook for $3.3 million. The hospital denied charges that Krukenkamp was asked to resign after he voiced safety concerns regarding the heart program. Krukenkamp is on staff at Stony Brook hospital, but he is no longer chief of cardiothoracic surgery or director of the heart center.

    William Greene, chief quality officer at Stony Brook, said in a statement: "Staff is encouraged to report patient safety concerns, and the person making a report can elect to do so anonymously. Consequently, we promote a blame-free environment because that is the only way to make people feel comfortable about reporting events; by reporting these concerns, it promotes patient safety and quality of care."

    Last year, though, trouble resurfaced at the hospital. Three children died as a result of post-operative complications following cardiac procedures. Again, Krukenkamp spoke out about concerns he had with the hospital’s safety.

    The New York state Department of Health launched an investigation, and in November announced it had found a number of problems, among them high post-surgical infection rates and deficiencies in the hospital’s quality assurance efforts. The hospital was cited for allowing doctors to practice outside their scope of expertise and for not having a full-time pediatric cardiac surgeon on site to ensure that the hospital could respond to emergencies and to perform timely surgeries on pediatric patients.

    The Department of Health ordered the hospital to "immediately cease and desist" its pediatric cardiac service, calling it an "imminent danger to the health and safety of its pediatric patients."

    The pediatric cardiac service remains closed.

Workforce Management, November 19, 2007, p. 1, 16-20 -- Subscribe Now!

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