Learning from Stafford Hospital

I think there are some lessons to be learned from a recent scandal involving poor quality and safety failures at Stafford Hospital in England.

The problems were serious and the causes complex. Among the many problems described in the investigative report, two major factors were identified which should give American policy makers and hospital leadership teams pause:

  • A focus on externally imposed and often arbitrary metrics that distracted attention and resources from actual quality.
  • Budgeting was from the top down, rather than from the bottom up.

What do these mean and do they apply elsewhere?

Metrics. Insurers, CMS and institutions like mine classically pursue quality by picking a metric that may be indirectly associated with (but is never causative of) quality, and using financial incentives to reward or punish based on that metric. The result is the medical version of teaching to the test, and the result is predictable. Instead of focusing on patient care, members of the care team from the clinician on down are forced to  focus on checking the correct boxes. When hospitals and clinicians are judged by readmission rates, documentation of advance directives, or adherence to scheduled lab surveillance, these tasks are more reliably done, but potentially at the expense of more important aspects of care. Imagine what would happen if you brought your car to a mechanic whose pay was determined, not by whether or not he fixed your car, but by whether or not he checked the tire pressure and changed the oil.

Budgeting. Instead of examining and engineering the care process to ensure quality and safety, then identifying what resources are needed, and finally budgeting up from there,  a budget is generated based on historical information and/or external standards (like the MGMA) and departments and clinicians are expected to do the best they can within that budget.

These are both staples of the US approach to hospital management, and the Stafford Hospital experience shows they are not without risk.



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