Retaliation against physicians reporting EHR flaws that cause use errors? Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

It appears that way to my eye.  First, on use errors (as opposed to user errors from carelessness):

“Use error” is a term used very specifically by NIST to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging, misuse of color-coding conventions, omission of information, etc. From "NISTIR 7804: Technical Evaluation, Testing and Validation of the Usability of Electronic Health Records." It is available at http://www.nist.gov/healthcare/usability/upload/Draft_EUP_09_28_11.pdf (PDF).

Now this:

Becker's Hospital Review
Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks
Jessica Kim Cohen
January 25, 2019
https://www.beckershospitalreview.com/legal-regulatory-issues/physicians-subpoenaed-in-rhode-island-allegedly-after-reporting-ehr-risks.html

The Rhode Island Department of Health reportedly has served at least four emergency room physicians at Providence-based Rhode Island Hospital with subpoenas, according to the Politico Morning eHealth newsletter.

The subpoenas allege the physicians participated in behaviors that fall under the umbrella of medical misconduct, on account of mistakes the physicians reported themselves. The mistakes, which didn't injure any patients, reportedly were meant to draw attention to risks associated with the hospital's EHR.

This is outrageous if accurate, especially considering the issues I raised in my Nov. 4, 2011 post "Lifespan (Rhode Island): Yet another health IT 'glitch' affecting thousands - that, of course, caused no patient harm that they know of - yet" at https://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html.

The RI Dept. of Health owes the public an explanation.

The subpoenas primarily relate to medical scans, such as X-rays, which were mistakenly ordered by the physicians. EHR experts who spoke with Politico said these errors are common because it's easy to click on the wrong icon or patient name in complex system interfaces.

That is classic "use error" and results from poorly-designed, mission-hostile user interfaces of bad health IT as defined by myself and Australian informatics expert Dr. Jon Patrick at at http://cci.drexel.edu/faculty/ssilverstein/cases/:

Bad health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy, lacks evidentiary soundness permitting concealment of alterations, or otherwise demonstrates suboptimal design and/or implementation. 

I covered the issue of 'mission-hostile health IT' at a 10-part series in 2009 at http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-idiots-part-1.html

Physicians and EHR safety researchers have raised concerns over the subpoenas, suggesting that the department's response could discourage future clinicians from voluntarily reporting medical errors.

Not "could." 

Will, and likely by design in my opinion.  The ultimate motive for the subpoenas and those behind them, which may extend outside the DOH, needs to be determined.

"Anyone punishing individual providers for these events is punishing the wrong thing," Jason Adelman, MD, chief patient safety officer at NewYork-Presbyterian Hospital in New York City, told Politico. "These are system issues, not the provider being reckless. The focus should be on things like EHR usability and safety."

I am aware of patient injuries and deaths as a result of mis-clicks due to mission-hostile user interfaces that confuse users and lack appropriate safety alerts and notifications.  This includes ER mistakes.

The corporate response followed the expected boilerplate:

When asked about the subpoenas Jan. 25, Rhode Island Hospital spokesperson David Levesque [Director of Media Relations, Lifespan, https://www.lifespan.org/news-events/news/media-contacts] provided the following statement to Becker's Hospital Review:

"Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital's culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare."

As one colleague of mine observed, "the hospital's culture of transparency remains a point of pride" seems to mean that "you can prosecute staff for being transparent, and it is not a contradiction."

I wrote Mr. Levesque regarding this story:

From: S Silverstein
Date: Tue, Jan 29, 2019 at 10:07 AM

Subject: Re: Physicians subpoenaed in Rhode Island, allegedly after reporting EHR risks

"Rhode Island Hospital is deeply committed to the safety of our patients and the continual improvement of our healthcare environment, including the processes our caregivers and staff follow. Furthermore, the hospital's culture of transparency remains a point of pride and is unwavering. Rhode Island Hospital supports our world-class physicians, nurses and other staff and appreciate their tirelessly work in providing world-class healthcare."

Really? 

After the debacle I documented at https://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html , I think this is an outrage.

I am passing this story on to trial lawyers who will likely pass it to the national trial lawyer's listserv.  I believe these actions are retaliation against the physicians.

I am aware of patient injuries and deaths following "wrong clicks" in ER's.

Sincerely,

Scot Silverstein MD

The stated source of the subpoenas, DOH, seems odd.  The hospital should strongly defend its doctors against DOH if the DOH was the sole source of the subpoenas and accusations of medical misconduct, not just provide boilerplate.  If DOH was influenced by some other party to take this action, that needs to be revealed.

I hope I am wrong about the retaliation issue, and that this has all been a misunderstanding.  Perhaps Mr. Levesque will clarify.  Perhaps the subpoenas against the physicians who reported the EHR use error issue were issued by the DOH to gain more information about the alleged EHR problems.  If not, I hope they will be summarily dropped. 

If not, I hope the matter gets wider attention, especially at a time when bad health IT is contributing considerably to clinician burnout per numerous studies and reports (see for instance my Jan. 23, 2019 post at https://hcrenewal.blogspot.com/2019/01/experts-declare-physician-burnout.html).  Burnout increases risk of medical error for everyone.

Supposed accusations of any type of "professional misconduct" are outrageous, and will have a chilling effect on other like-minded, candid clinicians (including nurses) confronting bad health IT.

-- SS

$100 million Epic install dampens Lifespan Rhode Island Healthcare's credit

Lifespan Rhode Island Healthcare System's Siemens EHR was apparently causing thousands of electronically-generated prescriptions to become scrambled, as I posted in Nov. 2011 here: http://hcrenewal.blogspot.com/2011/11/lifespan-rhode-island-yet-another.html.

Due to this "glitch" - and other factors, I surmise - they switched to Epic.

Here are the current results:

$100 million Epic install dampens Lifespan's credit
http://www.modernhealthcare.com/article/20140606/NEWS/306069948

By Bob Herman

Posted: June 6, 2014 - 5:45 pm ET

A multimillion-dollar electronic health-record system installation is eroding the cash flow, and bond rating, of Rhode Island's largest health system.

Moody's Investors Service downgraded the rating of Lifespan, Providence, R.I., to Baa2—only two notches away from junk-level status. The ratings agency also gave the system, which operates four acute-care hospitals and one children's hospital, a negative outlook.

... At the heart of the downgrade is Lifespan's new health IT system. In March 2013, Lifespan chose to implement an Epic platform, a system spokeswoman said. Lifespan expects to go live with Epic's EHR by the spring of 2015. Moody's analysts noted the investment will cost $35 million this year and $100 million total over the next several years.

This has slammed Lifespan's operating performance, Moody's analysts wrote. Lifespan is projecting a 2.8% operating cash flow margin for fiscal 2014, which is far below the Baa2 median of 8.8%. The operating margin is predicted to hover around -1.7%. And it's not likely to get better soon—executives told Moody's they don't expect to post improved results until 2016.

“The thin performance provides little cushion during a period of increased capital spending and the installation of a new IT system with short-term implementation risks that could disrupt cash flow,” the report said

They're a year from going "live" and they've already damaged their financials.  (This does not account for the losses from abandoning an older system.)

$100 million is not an unusual cost for a commercial EHR, as I noted elsewhere, e.g., http://hcrenewal.blogspot.com/2006/10/70-million-for-electronic-medical.html.  An entire hospital or large hospital wing can be built with that much money...not to mention the hiring of quite a lot of human health information management professionals.

Hospital executives have bought the "EHRs will save massive amounts of money, eliminate medical errors, and heal the sick" marketing hype hook, line and sinker (as opposed to the more sober "improve healthcare somewhat when implemented expertly").  They are so eager to have this unregulated technology, NOW, that they will place their organizations - and patients - into jeopardy to get it. (As to patient risk, see http://hcrenewal.blogspot.com/2014/04/fda-on-health-it-risk-reckless-or.html and its hyperlinks).

I find this phenomenon stunning, and even more so the cognitive dissonance and refusal to believe the actual evidence when the starry-eyed predictions of Cybernetic Medical Nirvana just don't come true.

-- SS

Lifespan (Rhode Island): Yet another health IT "glitch" affecting thousands - that, of course, caused no patient harm that they know of - yet

There's been yet another health IT "glitch" that, of course, caused no patients to be harmed. See other "glitches" here, here, here and at other posts which can be found by searching this blog on the banal term 'glitch'.

I note that when a clinician makes a mistake, it's called "malpractice."

When health IT causes errors that can injure or kill, it's commonly referred with the banal, now-standard euphemism for computing malpractice:

Presenting the latest healthcare IT "glitch", affecting thousands:

Computer glitch led patients to receive wrong meds
Senator calls for review of Lifespan

WPRI.com (Providence, RI)
Updated: Thursday, 03 Nov 2011, 5:47 AM EDT
Published : Wednesday, 02 Nov 2011, 11:56 PM EDT
Reported by Steve Nielsen

PROVIDENCE, R.I. (WPRI) - Rhode Island State Senator Jamie Doyle says he is shocked to hear a Lifespan computer glitch caused thousands of patients to receive the wrong types of medication. [Appx. 2,000 across five Lifespan hospitals according to the Providence Journal, see below, and the WaPo - ed.]

Doyle is now calling for an independent review of all the hospitals Lifespan runs, and a review of the Rhode Island Department of Health.

The DOH is investigating after learning patients who were supposed to receive medications taken once a day instead received medications meant to be taken more than once per day.

Health IT, of course, is unregulated by FDA or anyone, and vetted for safety only so far as the seller wishes to spend money on such tasks - which cuts their margins.  Ultimately, debugging is on live patients.

[11/5/2011 note: As an anonymous commenter pointed out, the 2,000 or so errors at Lifespan should probably be multiplied by the number of organizations using the same software ---> "The entire country may have suffered 25,000-50,000 errors from this one glitch alone", the commenter astutely notes - ed.]

Of course, the customary "we did feel lucky today, and the gun was empty" disclaimer follows:

"Lifespan has not reported any adverse events or situations where patients required additional medications, but the information gathering and investigation is still ongoing," said DOH spokeswoman Annemarie Beardsworth.

In other words, there could have been adverse events, we just at the Dept. of Health don't know yet with certainty, because none have been reported yet.

In addition, some patients who were meant to get a medication with a coating did not receive a coating. The coating can help with stomach pains of other problems.

"I just don't feel comfortable right now with some of the things that are coming out of there," Doyle said, "I really don't want to point fingers in any direction. but what we need to do is we need answers." Senator Doyle wants to have the review started in the next two to three weeks.

Mr. Doyle, see my academic site on HIT failures here and an account of repercussions here from an EHR-related medication error.

Lifespan released the following statement Wednesday:

"Lifespan is actively contacting 2,000 patients affected by this issue to ensure they receive the correct form of their medications. So far, we have reached out to more than 90 percent of the patients, many of whom were already taking the correct medication."

Lifespan expects to finish contacting patients by Thursday.

It will be interesting to understand the nature of this particular "glitch" and who the software vendor is.

All it takes is a single "glitch" to seriously reduce a patient's lifespan.

Siemens software may be involved. See this mutually self promoting, marketing-style Siemens document "Newport Hospital - a Lifespan Partner - At the Forefront of EMR Adoption" (PDF), also cached here. (As an aside, one wonders if the hospital and/or its leadership received special financial or other "incentives" in allowing their name to be used in corporate promotions.)

Also, Siemens was a company that apparently did not listen to an internal informatics specialist physician's concerns that their health IT for critical care was endangering patients (link). They terminated the whistleblower.

Also see my Aug. 2009 post "Why Siemens Healthcare Fails" which I had emailed at the time to the Siemens Healthcare CEO Hermann Requardt.

-- SS

Nov. 4, 2011 addendum:

Felice Fryer of the Providence Journal sent me a link to the story of Nov. 3, 2011 she wrote with a few more details, here. Excerpts:

Flaw found in hospitals’ prescriptions

Some patients discharged from Lifespan hospitals got right drugs in wrong form due to software error

By FELICE J. FREYER JOURNAL MEDICAL WRITER

Some 2,000 patients of the Lifespan hospital group were discharged with incorrect prescriptions over the past 9 to 15 months because of a software glitch.

[It took a year or more to discover these mounting errors? This is beyond the "red flag" warning signs I used to write about. This is crossing the chasm into the territory of "asking for catastrophe" - ed.]

The prescriptions listed the right medications, but in the wrong form: people who were supposed to get time-release pills received prescriptions for short-acting ones.

The error affected dozens of generic medications for a variety of conditions. Lifespan discovered the problem on Oct. 25 and had fixed the software by Friday, according to Dr. Mary Reich Cooper, Lifespan’s senior vice president and chief quality officer.

The hospitals have placed calls to nearly all the affected patients, although not all have called back, Cooper said. Most patients reached had already obtained the correct medication because the error was noticed by someone at the hospital, or a pharmacist or doctor outside, she said. So far, Cooper said, there is no evidence that anyone was harmed.

But Dr. Michael D. Fine, state Health Department director, said that the incident is an example of how electronic medical records, which normally help reduce errors, can sometimes amplify them by quickly affecting large numbers of people. “It’s the flip side of what has otherwise been a process that has improved accuracy and reliability,” he said.

[I don't notice mention of a "flip side" to health IT in the aforementioned glossy hospital/IT company marketing brochure - ed.]

The Health Department is investigating the incident. Fine also plans to examine whether the department should regulate the safety of electronic systems in health care. [Readers of this blog know my opinion on that matter - ed.]

Asked whether he was worried there may be other as-yet-unrecognized software glitches, Fine said, “I’m reasonably concerned about the accuracy and integrity of electronic medical records.”... The software in question is not in use at other hospitals in Rhode Island, and the software vendor, Siemens, is notifying hospitals elsewhere in the country, according to Cooper.

[In the interests of public health, I believe it incumbent on Siemens to make this "glitch" widely known not just to the hospitals but to the public in areas served by those hospitals, especially with the admission that "the (RI) hospitals have placed calls to nearly all the affected patients, although not all have called back." To not do so reflects negligence in my opinion - ed.]

... The errors arose from the process known as “medication reconciliation,” in which the physician compares the medications a patient was taking before hospitalization with those prescribed during hospitalization, and ensures that the patient goes home with a correct set of prescriptions. The Lifespan hospitals recently adopted an electronic system for this process.

Doctors were correctly prescribing medication, and the prescriptions looked right on the computer screen, Cooper explained. But when printing out the prescription list, the software was cutting off a two-letter abbreviation that indicated certain medications should be in long-acting form or coated to protect the stomach.

[As at Case 9 from FDA's MAUDE database at the post "Our Policy Is To Always Have Unabashed Faith In The Computer". Do these vendors robustly validate their products? The current errors, in fact, were only peripherally related to medication reconciliation. They were primarily related to computer errors impairing (sabotaging?) the clinicians. It would seem med recon now needs to include comparing what the doctor enters to what is output to the nurses and other healthcare personnel who provide written instructions to patients. Is such a task performable by healthcare personnel when the computer cannot be trusted? Further, do the doctrine of the "learned intermediary" and "hold vendor harmless" clauses seem appropriate here? - ed.]

... Cooper said the risk of harm from taking a short-acting medication instead of a long-acting one was “very, very minimal.”

[Cooper misses the point, and IMHO such nihilistic attitudes have no place in healthcare - ed.]

But Fine, the health director, said such mistakes “can be scary.” People taking medication for angina or high blood pressure would find their medication wearing off over the course of the day, putting them at risk of heart attack or stroke, he said.

Medical errors that might seem innocuous or minor to health IT amateurs can prove catastrophic.  I've seen it happen, leading to injury and death.

-- SS

More Repeats of Talking Points Supporting Making Non-Profit Hospital CEOs Into Millionaires

I have found even more cases of non-profit hospital leaders for whose generous compensation the only support was the usual talking points, without clear evidence on their behalf, and despite obvious concerns based on publicly available data.  In chronological order,

Wellstar

After the firing of its last CEO was later justified by contentions of misconduct and a "special relationship," but countered by accusations of insiders' financial "improprieties," (see this story in the Atlanta Journal Constitution), Wellstar, a non-profit hospital system in Georgia, hired a new CEO, Reynold C Jennings, for hefty price, per the Cherokee Tribune,

He received a five-year contract composed of an initial term of three years and two one-year renewal options.

The contract pays an annual base salary of $975,000, in addition to a bonus that could range from 35 to 65 percent of his annual salary, depending on his performance, [board of trustees chair Randall] Bentley said.

By comparison, Bentley said WellStar’s last CEO, Dr. Greg Simone, earned a base salary last year of $900,000.

Other benefits included in Jennings’ contract are:
Thirty annual paid vacation days, in addition to six holidays.
Payment for time lost from a serious health condition with proper medical certification.
Annual automobile allowance: $12,000.
Annual cell phone allowance: $2,400.
Annual physical exam allowance: $800.
Annual financial planning/tax preparation services: $3,000.
Because Jennings has existing medical and dental coverage and did not want to participate in the benefits plan offered by WellStar, WellStar will also pay him an annual $12,000 allowance for this reason.

The contract also provides for life insurance, a retirement savings plan and long-term disability benefits.

His total compensation thus would have to be more than $1 million, any additional bonus notwithstanding.

The board gave the usual justification for making Mr Jennings a million-dollar plus baby:

'We’re very excited to have someone of his talent and his capability, someone that’s within our community, someone that understands what it takes to take our system to a new level,' said Randall Bentley, chairman of WellStar’s board of trustees. 'We’re very, very excited.'

The WellStar board did not elaborate on Mr Jennings' "talent and capability," or to what "new level" he was expected to take Wellstar. The Cherokee Tribune did note he had a 10 year career in management of Tenet Healthcare, ending in 2007 as Vice Chairman.

Neither the news article nor the board noted Tenet's troubles during Jennings' tenure there, culminating with financial woes and a $395 million settlement of the Redding Medical Center unnecessary heart surgery scandal in 2004 (look here), and a $21 million settlement of US government charges of kickbacks (look here), a $7 million settlement with the government of Florida of charges of fraudulent billing (look here), and a $900 million settlement of federal over-billing complaints (look here, and see our post here), all in 2006.  At least Mr Jennings had experience dealing with allegations of financial improprieties, but if anyone raised questions about hiring someone who lead a for-profit hospital corporation at a time when it seemed steeped in a culture of dubious ethics, they were not reported.

University of California - Davis

The Sacramento Bee noted that:

Last week, UC regents approved a $259,000 raise to $960,000 a year, money paid by hospital fees, not state money or student tuition

for UC Davis Medical Center CEO Ann Madden Rice, justified because,

that another academic hospital was recruiting Rice and offering $1.5 million.

Katehi told The Bee's editorial board today that it was 'not an easy decision' to support the salary hike.

While no one is irreplaceable, she said, the cost and time of replacing Rice would be far greater than the raise.

Just hiring an executive search firm would cost $500,000, Katehi said. Then the search would take a year, and UC Davis would almost certainly end up paying more for Rice's successor. That's just the way the market is, she said.

Rice, the chancellor added, is a great leader.

One wonders whether the decision was informed by Rice's leadership earlier in this year of a lawsuit against the University of California by a group of top university executives who sought a large increase in their pensions at a time that the university was under great fiscal stress (see our post here). That lawsuit drew responses using words like "outrageous," "despicable," and "greed," (not taken out of context) from a variety of people at the university. 

Lifespan

This last story is regrettably local, about Lifespan, the Rhode Island based hospital system, published by the Providence Business News,

A release of Lifespan’s executives’ salary, bonuses and supplemental retirement contributions has been met with great consternation by the Rhode Island Hospital union.

The forms - the U.S. Internal Revenue Service 990 forms for non-profit organizations - show that Lifespan’s nine highest-paid executives received $9.4 million in total compensation in the last reported year, including $1.8 million in bonuses and $2.6 million in supplemental retirement contributions.

Lifespan President and CEO George A. Vecchione received a total of $2.9 million in salary and benefits – including $853,024 in base salary, $522,051 in bonuses, and $1,485,197 in retirement or deferred compensation.

Dr. Timothy J. Babineau, president and CEO of Rhode Island Hospital and The Miriam Hospital, received $1.1 million in salary and benefits – including $573,675, in base salary, $379,376 in bonuses and $92,035 in retirement or deferred compensation.

The defense of these million dollar plus compensation packages was predictable:

Alfred Verrecchia, chairman of Lifespan’s board of directors, said that because of the hospital system’s significant size and complexity, the board places a priority on recruiting and retaining a highly skilled leadership team who can manage in both good and bad times, with the goal of providing the highest quality care to patients. 'The process for setting leadership compensation is undertaken by a board committee and is informed by national surveys provide by the The Hay Group, an independent compensation consultant,' Verrecchia said.

Over the past several years, Verrecchia continued, 'base pay for executives has been relatively flat. A significant portion of the executive pay is at risk and is only paid out if quality, service and financial performance goals established by the compensation committee are achieved.'

Verrecchia praised the current leadership team at Lifespan, saying: 'Lifespan hospitals are fortunate to have a stable, sound leadership team with a proven track record of addressing significant financial challenges in order to continue to fulfill our mission of providing the best and safest care to our patients.'

The system's employees did not all agree:

'We are angry, we feel disrespected,' said Helene Macedo, president of the United Nurses & Allied Professionals which represents 2,200 employees at Rhode Island Hospital.

'It’s not justified, when we see the sacrifice that those of us who are working at the bedside are being asked to make,' she told Providence Business News.

Macedo, an operating room nurse who has been at Rhode Island Hospital for 20 years, was further irked by the fact that Lifespan had just announced a decision to cutting the matching contributions to employee’s 403(b) Fidelity plan for 2011 and eliminating the matching contribution for 2012.

'It looks like another example of corporate greed,' she said, 'when you look at their executives’ salaries, bonuses and supplemental retirement, compared to that of what employees are making – and the sacrifices we’ve been asked to make during the last several years.'

The atmosphere in the hospital, Macedo said, 'is one where we’re counting every penny and cutting every corner. But there doesn’t appear to be any corner-cutting or counting in the corner office.'

Summary

Here were three more examples of million dollar (more or less) non-profit hospital system CEOs. As we have noted frequently, even non-profit hospital systems that are supposed to put their patient care and academic missions, when applicable, first somehow seem increasingly unable to function without yearly making their leaders instant millionaires.

It was striking that the justifications, by boards of trustees or hospital spokespeople, for these indulgent pay packages followed the talking points we have identified before:
-  We pay what everyone else pays
-  CEOs work hard and are brilliant, so they deserve high pay
-  High pay is needed to attract and retain competent, if not brilliant people

Yet in these cases, as in nearly all cases we have discussed before, there were no logical, fact-based arguments why
- the particular CEOs deserved at least what supposedly comparable CEOs got, if not more, and how the comparator group were judged to be comparable;
- why the CEOs were so brilliant, (or in this case, had such "talent and capabilities," was a "great leader," or was "highly skilled," and "stable and sound") when there were at least reasonable but unanswered questions about their leadership based on publicly available information

So despite their hospitals' financial challenges, and despite questions about their previous leadership, more non-profit hospital leaders are becoming million dollar babies, encouraged by boards of trustees who seem to be basing their "stewardship" on the same talking points, rather than reasoned arguments.  One can only wish that the boards who supposedly exercise stewardship over our formerly revered health care institutions actually had to answer some tough questions about the leaders they continue to uncritically endorse.

So ad infinitum, I repeat.... health care organizations need leaders that uphold the core values of health care, and focus on and are accountable for the mission, not on secondary responsibilities that conflict with these values and their mission, and not on self-enrichment. Leaders ought to be rewarded reasonably, but not lavishly, for doing what ultimately improves patient care, or when applicable, good education and good research. On the other hand, those who authorize, direct and implement bad behavior ought to suffer negative consequences sufficient to deter future bad behavior.


If we do not fix the severe problems affecting the leadership and governance of health care, and do not increase accountability, integrity and transparency of health care leadership and governance, we will be as much to blame as the leaders when the system collapses.