Monday, September 08, 2008

"I'm Not a Hospital Guy Anymore"

Some of the issues most important to us at Health Care Renewal are how bad leadership and governance of health care organizations threaten physicians' core values, and thus help fuel our continuous health care crisis of rising costs, decreasing access, stagnant quality, and demoralized health care professionals. These issues are not often discussed in the "main stream medical media," but have been creeping in more often lately.

An important cri de coeur just appeared in the Cleveland Clinic Journal of Medicine, by Thomas F Lansdale III MD [Lansdale TF. A medical center is not a hospital. Cleveland Clinic J Med 2008; 75: 618-619. Link here.] Dr Lansdale dealt mainly with poor leadership of teaching hospitals that threatened the core clinical and academic mission.

The leadership was poor in that it was ill-informed about health care and its values, and perhaps incompetent:

Now the medical center, riddled with 'centers of excellence' instead of departments, answered only to administrators who cared nothing about medical education, except for the Medicare dollars they would lose if they cut the training programs. They spent enormous amounts of money marketing the centers of excellence, and they cut everything else to manipulate the bottom line.

Poor hospital leadership was abetted by poor leadership of accrediting agencies and insurance companies.

We struggled to keep up with the unending deluge of arcane demands from the accreditation organizations watchdogging our teaching efforts.

we capitulate to the for-profit insurance industry that informs us they won’t pay for day 4 of Mr. Jones’ hospitalization because he has failed to meet some arbitrary criteria in their manual.

The effects of the poor leadership were mediated through a stifling bureaucracy that ignored the health care and educational mission.

Nurses now cared for their patients by managing their own support staff, and spent much of their time entering useless information in the computer.

I couldn’t stand the management retreats in which we obsessed about 'customer service' while the waiting time in the emergency department ballooned to 12 hours because there were 'no beds.' There were plenty of beds, but no nurses to staff them.

Furthermore, as we have seen time and time again, managers were quick to suppress any criticism of their power.

I was marginalized when I protested the budget cycles bleeding out support of medical education in favor of the annual purchase of new scanners and surgical gizmos.

The results were:

Medical education slowly slipped from being a calling to folks like me, finally succumbing to bureaucratic lunacy. The pace of teaching and caring for acutely ill patients became intolerable.

The biggest casualty, of course, was the nursing staff. Underpaid, depleted of leadership and morale, they simply disappeared. They were replaced by agency nurses who worked their shifts and didn’t know the doctors or the patients.

We lurch toward physician computer order entry, clinging to the false belief that software programs will prevent adverse drug reactions and delivery of the wrong dangerous drug to the wrong patient. We understaff our pharmacies so that they can’t get the medications to the patients on time or alert us to our own prescribing errors. We burn out our nurses despite years of loyal service

So finally,

My real job is to do everything in my power to keep my patients out of the medical center. I walk the halls now and don’t recognize the institution I grew up in and came to love. Everywhere I look, I see not magic and promise, but dirt and danger.

I'm not a hospital guy anymore.

Read the whole thing, and weep.

So I get to say again: health care is reeling under poor leadership of increasingly large and dominant health care organizations, enabled by poor governance structures. We need to make health care governance more representative of its constituencies, accountable, transparent, and subject to ethical standards. We need health care leaders who are informed about health care and understand its values, are committed to the mission ahead of personal gain, and are unfailingly ethical and honest. Meanwhile, demoralized doctors and nurses succumb to foolish bureaucracy piled up by self-interested managers, and it is the patients finally who suffer the most.


Gregg Masters said...

Could not agree with you more! An articulate and qualitative indictment of the prevailing hospital "empire building" and "silo oriented cultures" that assure an addictive recreation of processes and systems that do not work, dehumanize its participants and progressively compromises an institution in service to its patient care mission.

"They (leadership) look but do not see."

"They listen but do not hear."

"They talk, but do not speak."

So, where is the accountability? Why does hospital senior management routinely turn over only for the next crop to introduce nuanced variants prior failed management initiatives?

There is precious little vision in the hospital management industry.

PharmacistMike said...

You hit the nail on the head with this one. One problem is that we have replaced hospital administrators that have worked their way up the ladder and personally understand health care with accountants with Masters in Health Care Administration.

Anonymous said...

Timing is everything. Today's Akron Beacon Journal (9/9/08) highlights The Cleveland Clinic spending $680M on two new medical centers for it's campus. And what do we get for only $680M: First Dr.M. Bridget Duffy, Cleveland Clinic's chief experience officer:
"A new tree-lined street called Cleveland Clinic Boulevard with six reflecting ponds "provides a sense of calm and peace to families before they ever enter the space."

The combined buildings cover over 1.3M square feet, over 200 exam rooms, 95 procedure rooms, 232 physician offices, 278 patient rooms, 16 operating rooms, 10 cath labs, 110 specialized ICU beds for the heart area, and lets not forget the obligatory helipad.

Per the Clinic staff the object of this expansion is so that patients can get all their test and doctor visits done in one day. Along with this formerly procedures that required an overnight will be done on an outpatient basis.

As a businessman I can tell you, you do not build it hoping they will come. The Clinic plans to fill this space, offices, and patient rooms, with paying customers. The Clinic is a machine.

Steve Lucas

Anonymous said...


Thanks for a compelling article. Hope you sent it to our presidential candidates (or their policy advisors).


MedInformaticsMD said...

Nurses now cared for their patients by managing their own support staff, and spent much of their time entering useless information in the computer ... We lurch toward physician computer order entry, clinging to the false belief that software programs will prevent adverse drug reactions and delivery of the wrong dangerous drug to the wrong patient.


Clinician skepticism of the "miracle of health IT" often results in clinicians labelled as "resistant to change" and "technophobes."

Perhaps they should be called "resistant to ill-conceived change" and "critical thinkers about technology."

The executive and IT ignorazzi in hospitals and payer organizations who don't know their a**es from their elbows where healthcare and social issues in informatics are concerned are the last people we need to push their "cybernetic miracles" on clinicians.