How Well Are We?

GUEST: Dr. Mark Chassin
VTR: 4/11/01

I’m Richard Heffner, your host on The Open Mind. And this is one of a series of programs dealing with a theme that resonates widely and importantly in American life today: namely, the quality of health care in our country.

Of course, when we ask how well Americans are, one way of measuring the quality of our health care might be to compare the mistake rate we live (and sometimes die) with in American medicine with mistake rates that major American businesses find simply unacceptable.

Now this has all been well documented by my guest today, Dr. Mark R. Chassin, professor and chair of the Department of Health Policy at New York’s Mount Sinai School of Medicine, and former Commissioner of the New York State Department of Health, in his role as chair also of the Institute of Medicine National Roundtable on Health Care Quality.

And so I want to ask Dr. Chassin about the Roundtable’s conclusion that, quote, “a national focus on improving the quality of health care is imperative, ”end quote, its reasoning based on these propositions:

First, that quality of health care can be precisely defined.

Second, that at its best, health care in the U.S. is superb. But that, unfortunately, it is often not at its best … and that as a result “Americans bear a great burden of harm … a burden … measured in lost lives, reduced functioning, and wasted resources … [that] call for urgent action.”

Third, that “a few health plans, hospitals and integrated delivery systems have made impressive efforts to improve their quality of care … However, many more institutions have made little, if any, effective effort to improve … [and] there are no available data identifying individual health plans, hospitals or health care systems that deliver care that is uniformly and consistently of the highest quality.”

Which is a pretty grim assessment, particularly since Dr. Chassin adds “Therefore, there are no clear role models of exemplary [health] delivery systems.” Which leads me to ask my guest today just where we go from here? Fair question?

CHASSIN: It’s a very fair question. And I think there are a lot of possible roads to improvement. My own view is that the institutions in the delivery system, who are actually providing care to patients bear the principle responsibility for initiating substantial and major improvements in that care, whether they’re hospitals or medical group practices, or integrated delivery systems, nursing homes … everyone has a very substantial role to play.

HEFFNER: Is that … is that because the problems are institutional rather than personal, rather than the problem of individual medical persons?

CHASSIN: Well, I think it’s because the institutions in the delivery system have the greatest capacity to marshal resources that are necessary to do the investment that’s required to do substantial improvement. It really isn’t possible for a single physician or even a very small partnership of a couple of physicians to make major improvements in care given the need for information systems and for major investments in that kind of infrastructure to really achieve much, much higher quality.

HEFFNER: Since you wrote those grim words that I quoted, has much been done? Strike that. Has enough been done, in your estimation?

CHASSIN: Well … no, not enough. There are some stellar examples of improvement, where mistake rates, serious mistake rates have been brought down by fifty, eighty percent in some instances. But the problem is that they’re isolated. And they tend to be one program that has a very strong impetus to improve and then it stalls. Or even if it continues for a while, it doesn’t spread its effect to other parts of the same delivery system or the same institution and make improvements across a wide array of services. And that’s really what we have not been able to do yet.

HEFFNER: So you’re not talking about a single hospital. You’re talking about a program within a hospital, for instance.

CHASSIN: That’s right. For example, there’s a wonderful hospital program in Salt Lake City, an LDS hospital. Probably the nation’s leader in reducing injuries due to medication errors. And that has developed over the course of 25 years; it’s been extremely effective using the latest information technology to help physicians do ordering in the right way. One of the most difficult problems with all of the new medicines that we have and all of the new interventions that we have, is keeping straight exactly how they should be conducted. So, for example, a lot of very powerful medications need to be, have their doses adjusted based on how old the patient is, how well their kidneys are functioning, whether their livers are functioning. And it becomes very complicated and difficult for an individual physician, thinking by himself or herself to get that right every single time. And that’s where information systems and computer technology come in. LDS has done a great job at that. And a couple of other places. But still, across all of the services that they deliver, that’s where we haven’t seen the uniformity and the commitment over time to the kind of excellence that’s achievable, that has been achieved in one or two areas.

HEFFNER: You know that’s so puzzling because you make mention, in your report of the LDS changes, the efforts. One would have thought that those efforts would have been immediately imitated all over the country.

CHASSIN: Well, here … and I think you’ve put your finger on one of the most important aspects of this problem in general. And that is that it’s very different from the same kind of situation that say, the electronics industry faced, or the auto industry faced, when a major improvement occurred, say when to Toyota showed up in the United States. That got all of the American automobile makers attention. It doesn’t work that way in health care because virtually all health care is local. So if LDS hospital makes a tremendous improvement in the way they take care of patients and reduce medication errors, that doesn’t really affect the market for health care in New York or Chicago because they can’t transport that here. So that’s one reason that progress is slower in health care than in other sectors. The other reason, quite frankly, is that the public hasn’t demanded the kind of performance in health care that it demands out of tires, or aircraft performance.

HEFFNER: Now, how do you account for that?

CHASSIN: Well, I think it’s … there are two factors here. One is that the nature of this problem has increased dramatically over the last, say, fifteen or twenty years. And that also has a set of underlying causes. It hasn’t been that long that we’ve had such a very broad range of effective treatments. In fact if you go back ten or fifteen years, the number of treatments that we had that really worked were many fewer than we have today. So, the stakes are higher today for not doing high quality care every time in the right way. So, the, the public’s perception of this has lagged a little bit. The other part of the problem is that unlike airline safety … when a plane goes down we all hear about it, we all read about it. Those accidents are highly visible, they’re covered in great detail, and over a prolonged period of time. In health care when we make similar kinds of mistakes, that result in injuries, they don’t get reported. In fact, they’re very often hard to identify even within health care institutions. So they’re not as visible. And I think that that’s led to the prevalent attitude among the public that health care is really pretty good. And my doctor, my hospital practice very high quality health care, those mistakes that we hear about sometimes, the individual mistakes, occur somewhere else, they’re in a different city, they really don’t have an effect on me or my family. When the truth is really quite different.

HEFFNER: Do you think it has to do with “it’s too damn scary?”.

CHASSIN: Well, it is scary to think that you do have a risk of suffering from a mistake, and in fact, the trust of patients in their physicians and in the health care system is an important part of the healing process.

HEFFNER: So how do you balance?

CHASSIN: Well, it’s a very important challenge. And I think we need to responsibly get information about the quality problem out to the public, at the same as we try to move the delivery system toward improvement. So that the concern and the improvement occur, if it’s possible, to match this in public policy together.

HEFFNER: Is that why you put your emphasis upon systems? Put your emphasis upon institutions? And, I was going to say “down play”, but I don’t think you do that, but you put your emphasis more there than upon individual fault.

CHASSIN: And this is another very important discussion that we really haven’t had fully yet in the field of quality improvement. I think that both are equally important. And in fact, I think we don’t do a good enough job in either instance. Quality improvement using system improvement, so the kind of system that hospitals try to do to improve medication ordering that’s computer based that can move the entire process toward excellence is the best way to move large systems toward excellence and that clearly has been shown over and over again. But that does not absolve us either as individuals in practice, or individuals in positions of responsibility in institutions, from looking for those very poor providers who can’t improve despite attempts to make that happen. And those situations need to be handled with disciplinary action through the State licensing boards and the other disciplinary actions that, that are possible in a regulatory system. Both of those approaches to improvement are important.

HEFFNER: To what degree, in the second instance, the instance of individual responsibility, in the instance of people who shouldn’t be practicing … what changes have taken place? Has … I was going to shift again to asking you the same kind of question … are you satisfied with the speed with which changes have taken place, if they’ve taken place at all?

CHASSIN: Well, I think that, in fact, in New York we have a system that is much more geared to identifying cases of egregiously poor performance, and in dealing with them in a disciplinary way than in almost any other State in the country. The vast majority of State licensing boards that have this responsibility pursue physicians who, whose mis-conduct is either sexual abuse of patients, drug abuse, either selling drugs or of abusing drugs themselves, or other almost criminal or criminal behavior. And that, of course, needs to be done. But that’s only the very beginning of the kind of disciplinary action that, that is required. New York does more cases of negligence with respect to quality than any other State that I’m aware of. We still need to do a better job in making sure that we identify only those cases that really do represent egregiously poor patterns of care over a period of time that are not remediable, and have a fair and equitable process for bringing those charges, investigating them, having a complete and fair hearing process, and then having a penalty that’s appropriate to those, to those instances. But we have a system in place … it’s not perfect, but it’s better than in virtually every other state.

HEFFNER: Does that system provide ultimately for decisions by the individual institutions, the hospital? Or by the Commissioner of Health?

CHASSIN: Well, the system is largely independent of the Commissioner of Health. The Commissioner does have one role in the middle of that system, which is a … and the disciplinary system I’m talking about now is for physicians, not for hospitals. There’s a separate regulatory process that applies to hospitals. And the Commissioner’s role is in … really in the middle of the process. A complaint is investigated, a committee … a physician and lay person committee hears the evidence that the investigation has uncovered, and then decides whether formal charges should be brought against that physician or not. And at that time, before the charges are adjudicated, the committee recommends, may recommend to the Commissioner that this situation “is so dangerous, and so much a potential harm to the public” that the Commissioner should use his or her power to summarily suspend that physician’s license during the time the case is being prosecuted and decided. That’s the place where the Commissioner gets involved. Otherwise the Commissioner does not have a direct role in making decisions about who will be punished and who will not be.

HEFFNER: Of course, as I follow the New York Times, every once in a while, it becomes exorcized about a particularly horrendous instance of irresponsible actions, seemingly on the part of hospitals that will permit doctors to come back to practice because, according to the stories, and you have to say whether generally they’re right or not because they bring in dollars. These individuals are responsible for dollars coming into the hospital.

CHASSIN: Well, the question then, after this disciplinary process is played out, with the particular physician … the question is “what’s the penalty?”. Very often the penalty if permanent revocation of that physician’s license. And in those instances, physicians have no legal right to practice, can’t work anywhere in the State whether it’s in an office or a hospital or anywhere else. Penalties less severe than that typically permit physicians to continue to practice. Sometimes with oversight, sometimes with assistance and other kinds of probationary requirements until a period of time has gone by and presumably the oversight has worked to get rid of whatever the problem was. Those are the instances in which hospitals have to make decisions about whether those physicians may be permitted to join their staffs and continue to practice or not.

HEFFNER: Too large a question. But, are you generally pleased with the decisions that hospitals in New York make?

CHASSIN: Oh, I think most of the time, I think hospitals are making well-reasoned decisions. I think there clearly are some instances where hospitals have given too much responsibility to physicians, too soon after they’ve been disciplined. But I certainly haven’t looked at all of those to make a global judgment. I think hospitals do have a very clear responsibility to weigh the disciplinary action that was taken, the circumstances that surrounded those disciplinary actions, and make appropriate decisions about what procedures and what responsibilities those physicians may continue to have. The State says either “this physician cannot be licensed to practice” or “this physician can be, under these circumstances” and then it’s a, I think, an individualized decisions that hospitals and other delivery system organizations have to make when physicians have been disciplined, but they are permitted to continue to practice.

HEFFNER: If I’m cynical and leery about decisions either that the State makes or that hospitals make, what do I as a recipient of health care by individual practitioners, what can I do?

CHASSIN: Well, I think the first thing that patients need to do is to be much more vigilant about getting information about the physicians and the institutions from whom and from which they receive care.

HEFFNER: Doesn’t that run against our culture?

CHASSIN: Well, I don’t think it does. I think that the American public … not everyone … but there certainly is a large segment of the population that wants to know about the safety record of the cars that they are considering buying, the repair records on appliances that they are considering buying … they look up lots of this information and lots of available sources … Consumer Reports and others.

HEFFNER: Yes, but we know there are no Gods in Detroit. But doctors, after all, we’ve believed for so long, are Gods. That’s what I meant about running against the stream.

CHASSIN: Well there is certainly a, still, very prevalent belief that doctors are god-like, that they make perfect decisions every time. And, unfortunately, that is really not true. Physicians are not any more omniscient than any other humans, they make mistakes at the same rate as others humans. And they’re not given any other kind of powers to avoid mistakes, than any other humans. What we are struggling with in health care is to surround physicians and nurses and other practitioners with systems of care that understand that humans will make mistakes and in fact we know a fair amount the kinds of mistakes that people are prone to make, that anticipate those mistakes and either prevent them or compensate for them before they do harm. And that’s really the challenge for the health care delivery system of the 21st century.

HEFFNER: You know when Karen Davis was here and she spoke about computerization, as you … as you have, that’s such an astonishing notion. But I gather you feel that this is so basic to our institutional change, to make use of technology and not of what we usually consider medical technology, but of computers to help men be … doctors be, if not more god-like, at least more accurate.

CHASSIN: Well, I … computers do some things much better than people. Computers add, subtract, multiply and divide much better, much more accurately, much more consistently than people do. And in those kinds of situations, where that kind of process is important to preventing errors and getting care to people that’s safer, computers are terrific. Now, it is also the case that if you don’t use the computer correctly or smartly, it can cause problems. So, for example, one of the things that hospitals are now struggling with is to put in systems that … where physicians enter orders into a computer, instead of writing them on a piece of paper. It has obvious potential advantages … handwriting is always subject to misinterpretation. Physicians probably more than other individuals, but always subject to mis-interpretation. And the computer can get rid of that. Now, that’s a potential source of a benefit. But, if the order is incorrect …

HEFFNER: “Garbage in … garbage out.”

CHASSIN: … it gets to patients very quickly. So what LDS and other hospitals that have used computer in the most effective way possible, have done is to build rules into those ordering systems, that judge the order that the physician has entered, and make sure, for example, that it’s adjusted correctly for the patient’s age and organ function and other things. And then say to the physician, “No, I think you missed this, this is what we think the dose should be, reconsider this before you send the order on to the patient”. So, it’s a little more complicated than just buying a computer and putting it in to a hospital.

HEFFNER: Are there other indications … I didn’t mean indications … are there other institutions that are following the Latter Day Saints’ example?

CHASSIN: Well, there are certainly probably half a dozen hospitals, big hospitals in the country that have emulated that kind of approach with computer order-entry systems that have rules that look for the most common kinds of mistakes. And that’s an important trend that I hope will continue and will permeate the health care system. But that really is only one kind of improvement that we need to see.

HEFFNER: Medical schools. What’s their responsibility?

CHASSIN: Well, medical schools have a big responsibility. One of our problems in dealing with the idea that systems require improvement is that we have trained physicians for a couple hundred years using very old models of medical education. We’ve thought that a medical school faculty knew all the facts that medical students needed to know in order to be good doctors and that the four years of school were necessary to get those facts into those students heads. And that really couldn’t be further from the realty today. There are too many facts, nobody can learn them all. The facts change on an annual basis. And what we need to be teaching medical students how to be is life-time learners, how to get information when they need it to make good decisions. And equally importantly, not to think of themselves as doctors as the only source of decisions for patient care. Doctors function best today as part of interdisciplinary teams of care givers, where a pharmacist has an important role, a physical therapist, a respiratory therapist, a critical care nurse has a very important role to play in patient care. And we don’t teach team work as, as effectively as we should.

HEFFNER: How come? It’s, as you suggest, so obvious today, in the 21st century, why don’t we?

CHASSIN: Well, I think in part … again I go back to what we touched on a little bit earlier. This problem of having so much information …

HEFFNER: Yeah.

CHASSIN: … to marshal, to provide high quality care in the year 2001 is really a very recent phenomenon. I, I tried to look at this a couple of years ago, and put a number on this problem. And what I looked at was the amount of … the number of articles that we have to read to be good doctors. And I only looked at the number of articles that come from the most rigorous, the most scientifically valid research study … the randomized trial that really tells us the gold standard of what works and what doesn’t . If you go back to the 1960s only about a hundred such articles were published annually. Now, not every physician had to read every one spread across a lot of specialties … that’s manageable. In addition to the other articles that were less, less valid. But today ten thousand such articles come out every year. And the curve is going up at an increasing rate. So this phenomenon is rather recent and we haven’t accommodated our old institutions and our old ways of thinking about decision-making to this really recent and very important new phenomenon.

HEFFNER: Indications? Are there any indications that there is recognition of these problems on … well, on the source … on the level of the source of funding? That’s always the best place to put the pressure.

CHASSIN: Well there are some indications. There is a little bit more funding available for research in quality and how to make it better. But, there’s not enough and one of the reasons I think … to go back to it, is that there really has been a lack of demand from the public, from the representatives of the public through employers and other purchasers of care who … organizations that buy health care on behalf of the public, for excellence as measured across the entire spectrum of quality. One of the other ingredients is that, it’s only a narrow part of the quality problem that has really come to the public attention, particularly the problem about mistakes. But, for example, we have an equal problem in terms of the harm that’s done with overuse of services. Where people get health care that can’t possibly benefit them. And that, in general, is not recognized by the public as a quality problem that does harm. An example of that is that 24 million Americans get antibiotics for colds and other viral infections. And nobody can benefit when they take a antibiotic for a cold, and in fact, they’re put at great risk of an adverse affect from the drug … getting an infection with a resistance organism and in general the public appears to believe that more health care is always better health care. And until we get that part of the quality equation communicated well, we’re still going to have problems in dealing with all of the aspects of quality effectively.

HEFFNER: So that a little scare might go a long way. Too much might be quite damaging.

CHASSIN: That’s right.

HEFFNER: Thank you so much for joining me today, Dr. Chassin.

CHASSIN: It was my pleasure.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again next time. If you would like a transcript of today’s program, please send four dollars in check or money order to: The Open Mind, P. O. Box 7977, F.D.R. Station, New York, New York 10150

Meanwhile, as an old friend used to say, “Good night and good luck”.

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.