That Strength Which in Old Days Moved Heaven and Earth

Last week, I ended an 11 month role supporting quality and safety at a large academic medical center. It was the worst job of my life.

I worked with an amazing team of talented, compassionate individuals. The clinical and medical staff were among the most competent in the region. The hospital had cutting edge technology, bountiful resources, and top-tier researchers. It earned $100 million last fiscal year on net patient revenue of almost $1.3 billion.

And every day it failed its patients.

This weekend, my friend, Jess Jacobs, died after a long struggle with Ehlors Danlos syndrome, postural orthostatic tachycardia, and the U.S. healthcare system. She documented her struggles valiantly, heroically, and hilariously. Her death was a preventable medical error in the most complex of ways.

Over the past year, I’ve seen the same thing happen over and over. I experienced similar frustrations trying to receive care for my own increasingly debilitating chronic illness and as a family member/ patient advocate during my mother’s recent hospitalization. I saw countless examples of shortcuts, mistakes and poor service. But worse than the errors themselves was the steady, predicable lack of leadership in addressing the failures, the lack of commitment to making hard choices to improve the patient experience, and the lack of accountability in enacting meaningful change. Instead, leaders spent most of their time in meetings about meetings, while the organizational inertia dragged on everything and everyone.

Just weeks after spending 22 hours with my mother in the ED, waiting for an inpatient bed, I sat in a board meeting where emergency medicine faculty presented abstract graphs showing an alarming trend in “ED boarding” (itself a sanitized term for how long a patient stays in a bed and on a unit not equipped for anything other than quick triage and stabilization). The group agreed that something needed to be done, and that “something” was simply to adopt the statement that something needed to be done. There was no actual plan, no resources allotted, no direction or reporting or accountability for improvement — just an ethereal agreement that something needed to be done.

Over and over again. A Joint Commission survey two months ago found several conditional level findings (serious lapses that threatened accreditation), yet individual departments and practices pushed back. Infection control issues were not their problem; surgical pause requirements didn’t fit their unit’s workflow; medication dispensing policies were outdated. The executive staff mandated improvement rounds and frequent audits, but the underlying cultural impediments and systemic failures remained.

The organization measured ambulatory assess by how quickly a patient was contacted following a referral. By this measure, they scored well when I received a call less than an hour after my doctor sent in a referral. No matter that the appointment itself was 10 weeks away. Or that the initial visit with the specialist was just to review what I had already told my primary care physician, and the diagnostic test I needed would be scheduled for six weeks later. Or that the follow-up to the diagnostic test would have to wait yet another 12 weeks. Meanwhile, the organization was so proud of their patient access success.

I am a firm believer in the power of lean to transform an organization into a patient-centered, employee-empowered, value-focused healthcare system. Unfortunately, this is rarely the outcome. The AMC was almost five years into its “lean journey” and suffered from the typically failings of most lean endeavors: widespread adoption of lingo, partial use of tools and methodologies, and little attention to underlying enabling philosophies or the failure of leaders to understand their ongoing role in sabotaging meaningful improvement through traditional management practices, dysfunctional alignment, and frequent conference-room quarterbacking.

In discussions about what ails American healthcare, a number of barriers are frequently raised: health IT systems that don’t talk with one another; payment systems that aren’t aligned with quality and service; onerous administrative requirements from regulators and insurers; rampant waste due to tradition and stupidity and greed. There is truth to all of these charges, but not enough to explain the failures that I, and Jess, and millions of other patients face every day. Nor can the failure be pegged on the backs of individuals, on a lack of care or concern or competence.

The central failure is one of leadership. Not of individual leaders, again, but groups of leaders, collectively. Leaders who refuse to be present in the places where care occurs, leaders who fail to align their teams towards a True North, leaders who don’t hold each other and their teams accountable for performing better today than they did yesterday.

Integrity, as its most basic level, is doing the right thing in an honest manner. And surely most people in healthcare would say that’s what they try to do every day. But what is “the right thing?” Indeed, it’s this very question that lies at the heart of most struggles within organizations: individuals, operating from a guarded perspective, try to maximize their own view of what is right. It starts at the top in board rooms, moves down to the administration offices and conference rooms, and continues on the floor of operations. Because of this limited perspective, individuals push organizations towards realities very different from stated goals. Instead of a culture of continuous improvement, we end up with a culture of competition. Instead of a culture of patients-first, we end up with a culture of not-my-job. And instead of a culture of advancing excellence, we end up with a culture of as good as it gets.

Henry Cloud, in his book Integrity, takes the concept a little farther, and usefully so: he defines character as the ability to meet the demands of reality, and integrity as the courage to do the same. Looking at the concept of integrity to include wholeness, completeness, Cloud argues that the primary question to answer is not, “Am I doing the right thing?”, but rather, “Am I getting the right thing done?”

It’s time for healthcare organizations to stop focusing on whether they are doing the right thing (most, for the most part, are), and start focusing on whether they are getting the right thing done (most, for the most part, aren’t). Some organizations, like The Cleveland Clinic and Thedacare and Iora Health are making some progress. But there is much more work ahead.

When I first began managing food service in long-term care, I walked around the dining rooms introducing myself to residents and asking what the biggest challenges were. The complaints rolled in. “The food is always cold.” “They serve too many brussels sprouts.” “The fish is dry.” “Why can’t we have melon?” One gentleman had a particularly lengthy list of concerns. As he finished, I told him, “That sounds like quite a bit to fix. It may take some time, but I’m sure we can make things better.” He stared me straight in the eyes, and said slowly, “I don’t have a lot of time.”

None of us do.

So let’s get to work.