Gregg Bloche. Perspective: Scandal as a Sentinel Event — Recognizing Hidden Cost–Quality Trade-offs. N Engl J Med 2016; 374:1001-1003.
Excerpts:
..... In 2014, Americans reacted with outrage to reports that personnel at Veterans Health Administration (VA) medical centers had schemed to feign compliance with targeted waiting times for appointments. Whistle-blowers outed miscreants, alleging that clinical delays had caused scores of avoidable deaths.....
...... The prevailing narrative was one of breakdowns of character and culture: dishonesty, callousness, and ineptitude......
........ Several years earlier, a similar scenario played out in Britain’s National Health Service (NHS), which had set waiting-time and quality-of-care targets that many facilities struggled to meet. .....
...... Over the next 5 years, investigations showed pervasive clinical lapses and gaming of systems to meet targets at this and other NHS hospitals.....
...... But closer scrutiny reveals another parallel, with important implications for cost-control efforts. In both cases, performance standards often proved incompatible with resource constraints.....
....... the truth that trade-offs between quality and cost were embedded in budget constraints remained submerged......
...... The Mid-Staffordshire scandal similarly grew from a gap between resources and expectations. Annual deficits and NHS funding cuts forced Mid-Staffordshire to begin borrowing in 2003–2004 to cover costs. Downsizing ensued. Specialized hospital units were replaced by merged units with less-specialized staff......
...... Meanwhile, the British government adopted market-style reforms meant to reward frugality. Local health care networks were invited to bear risk, as “Foundation Trusts,” in return for enhanced autonomy and a share of savings. Waiting-time and other performance targets were introduced. Mid-Staffordshire’s leaders aggressively pursued Foundation Trust status, pressing clinical managers to slash spending to meet approval standards.......
....... A government-commissioned inquiry by Sir Robert Francis revealed how these circumstances combined to create a major health care scandal. Francis’s report describes how Mid-Staffordshire’s leaders imposed cuts without assessing risks, then intimidated staff into suppressing their concerns. Overwhelmed clinicians, Francis concluded, couldn’t remain conscientious and still keep up. Receptionists performed emergency department triage. Meals were left out of reach of bedridden patients. Drug doses were missed. Incontinent patients weren’t cleaned. And impossibility engendered emotional disconnection. One physician told Francis, “What happens is you become immune to the sound of pain” — or “you walk away. You cannot . . . continue to want to do the best you possibly can when the system says no to you.”.....
...... Meanwhile, management insisted that NHS performance targets be met, punishing breaches even when compliance did more harm than good. Emergency department nurses told of delaying the start of antibiotics, pain medication, and other needed treatment to attend to less-needy patients within the 4-hour wait-time limit. Staff who missed targets feared being fired. This fear, Francis found, led to premature discharges and falsification of records......
...... Francis’s investigation showed how failure to address conflict between pursuit of quality and thrift begets frustration, neglect, and worse. Both scandals, moreover, spotlight the limits of deceit. Outraged caregivers, patients, and family members exposed gamesmanship and maltreatment. Impossible expectations led to abuses that proved impossible to hide......
........ “There’s a defined pot of money,” Francis told me last year. “But there’s a public expectation — there’s also a professional expectation — I should be allowed to do everything that’s in my patient’s interest . . . . Politicians promise the same. When that doesn’t work, it’s the fault of the [institution’s] leadership.” The result is a “toxic atmosphere” that “prevents those who are running the show from telling the truth” — and signals caregivers to keep quiet.......
....... This analysis doesn’t let clinicians off the hook for dishonesty or neglect. But it underscores that these scandals are sentinel events — indicators of the risk that caregivers will move from frustration to insensitivity to corruption when put in an impossible bind between demands for frugality and demands for excellence........
...... Cost–quality trade-offs pervade medicine. Studies of the relationship between cost and clinical outcomes at many hospitals, including VA facilities, show correlations between higher spending and better results, especially when spending variation arises from different levels of care. The myth that we can control costs without forgoing therapeutic benefit is belied by mounting evidence......
....... As cost pressures build, failure to admit the need for trade-offs will make scandals more likely. Yet we’ve not begun a public discussion about how to make them. Policymakers keep silent lest they be accused of “rationing.” Professional leaders prefer to cast quality and cost reduction as complementary. ......
...... Outcome and process metrics that more broadly reflect what clinicians do can shrink the space for gamesmanship. But open discussion of how to make real cost–quality trade-offs is essential to stopping the progression from impossibility to the breakdown of professionalism and compassion — a progression that leads to scandal.....