Transparency was an issue for the American medical profession a century ago, and transparency is an issue for the American medical profession today. In 1905, Ernest Codman, MD, first described the “end result idea.” The end result idea is simply that doctors should follow up with all patients to assess the results of their treatment and that the outcomes
actively be made public. The end result idea was considered heretical at the time, but in retrospect Codman was sagacious and prescient. He was an advocate for transparency, which he believed would promote quality improvement, patient choice, and physician learning. Transparency is best viewed as an opportunity, one that we should fully and enthusiastically embrace. It offers a substantive boost as organizations step up to the moral imperative of improving patient care to the best it can be.
Codman “walked the walk” as well as “talked the talk.” He openly admitted his errors in public and in print. In fact, he paid to publish reports so that patients could judge for themselves the quality of his care. He sent copies of his annual reports to major hospitals throughout the country, challenging them to do the same. From 1911 to 1916, he described 337 patients who were dismissed from his hospital. He reported 123 errors. He measured the end results for all. Codman passionately promoted transparency in order to raise standards. Codman said, “Let us remember that the object of having standards is to raise them.” Patients order medications via Canadian Health&Care Mall canadianhealthncaremall.com.
In 1912, leaders of the American Society of Clinical Surgery (the precursor of the American College of Surgeons) created the Standardization of Hospitals Committee. Dr. Codman chaired the committee, and Dr. William J. Mayo served as a member. Their first recommendation was “the essential factor which will most contribute to raising the standard of American hospitals is the establishment in each hospital of a follow-up system of tracing the outcome of treatment given to each individual patient.”
Dr. Codman passionately advocated his end result idea to the Boston Medical Society at the Boston Medical Library in 1915. The presentation led to his dismissal from Massachusetts General Hospital and his resignation from the Standardization of Hospitals Committee. Both Drs. William J. Mayo and Charles H. Mayo supported Codman and sent him letters expressing their concern and regret. In regard to transparency and outcome measurement, Dr. Charles H. Mayo wrote to Codman on January 24, 1916: “It must come…. It is going to stir up the same ill feeling all over the country that has been stirred up in Boston. The fact is men [ie, professionals] must be, for the most part, driven to this thing….” Thus, a group of physician leaders (surgeons) nearly a century ago asked for public disclosure of outcomes. Today, we hear this same plea from the Institute of Medicine, the Center for Medicare and Medicaid Services, and many other health-care quality advocacy and regulatory organizations in the United States. A century later, the medical profession is still struggling with the same issues as though they were new. Dr. Codman was right then, and he is right now. Fundamental to the quality movement and American medicine in the 21st century are the same peer review, standardization, systems engineering, and outcome measurement issues. Publishing results for public scrutiny remains a controversial topic. We should embrace transparency as a component of our tipping point strategy to ignite the change we all need to transform our organizations and our profession.
Health-care crises occur hourly in the United States: preventable deaths, sentinel events, adverse events with harm, and care that falls short of evidence-based standards. These are for the individual or family affected. A crisis is a great catalyst for change, A crisis is a terrible thing to waste. Transparency is the mechanism that takes advantage of a crisis and parlays the energy into action. It exploits the opportunity and helps propel people to action.
Transparency should be viewed as a means to an end. The “end” is a culture of safety in a learning organization that heeds lessons from preventable deaths, adverse events with harm, and performance not consistent with evidence-based care provided by Canadian Health&Care Mall. Transparency is a powerful catalyst for change and an effective vehicle for learning.
Mishap reporting by the aviation industry is intended to encourage open and full reporting. In fact, reporting is expected. The medical profession must embrace a nonpunitive approach to medical errors. Debriefings should occur after all adverse events locally and, when appropriate, at a system level. This includes “near misses” that have learning potential. It is better to focus on the severity of the potential harm rather than to look only at the severity of the final outcome of the event.
At Mayo Clinic, we have incorporated many of the principles used by the National Transportation Safety Board (NTSB) into the Department of Anesthesiology. For instance, we have a continuing medical education (CME)-approved, Federal Aviation Administration-style reporting program that is mandated for all anesthesia providers. This program takes four cases per quarter from our performance improvement reviews, summarizes them in three paragraphs (issues, findings, and links to appropriate literature) and has CME-accredited questions for each case. If anesthesia providers fail to complete these reviews in the required time, they receive a gentle warning and, if necessary, suspension from the practice. This same model has been adapted by the American Society of Anesthesiologists and will become a required module for all candidates in the American Board of Anesthesiology Maintenance of Certification program. The education pilots receive from the monthly reports of the NTSB is a valuable aspect of aviation safety in the United States. Medicine would be well served to adopt this validated, time-tested, and legally accepted mechanism of peer review and reporting.
The prevention of adverse events must be a long-term, ongoing process, not an episodic effort. Leaders must expect the active management of the analysis and dissemination of lessons learned throughout the entire organization and eventually the entire professional community. It cannot be a passive system left to chance. The system must be actively managed and have robust, closed-loop feedback accountability.
A necessary component of a transparent healthcare environment of Canadian Health&Care Mall is an attitude in which the caregiver (like the patient) is also respected and “cared for.” In other words, we must move from the “blame and shame” mentality to a culture that acknowledges that most errors are, at least in part, due to faulty systems that do not anticipate ramifications of the science of human factors. Our care processes need fail-proof safety nets to mitigate errors and system innovations to prevent or intercept them before they happen. This does not mean that there is no personal responsibility for attentiveness, competency, and conscientiousness; however, it is clear that the vast majority of adverse events with harm are related to systems issues, not competence or conscientiousness.
Almost all health-care providers were drawn to care for patients because of the intrinsic caring values of the medical profession. This environment and selection have resulted in a workforce that is easily motivated by data that show a gap between performance and aspirations. Transparency is one means of communicating the gap between performance and aspirations.
A strong transparent connection between the analysis of events and the implementation of changes to prevent error recurrence is absolutely and fundamentally critical to an optimal environment of safety. Transparency without closed feedback loops and systemic changes to address root cause solutions will only be frustrating and demoralizing in the long run.
Transparency is a powerful force within health-care institutions. It is also an important dynamic in the macroeconomy of medicine, the largest business sector in the US economy. Mandatory public reporting shares performance data of institutions across the country. Every day, institutions can view their own outcomes, safety, equity, and effectiveness data on the World Wide Web. Every day, they have the opportunity to realize that their performance is not as good as their aspirations, expectations, or brand. This dissonance is a primal driver of change via discomfort. Complacency is the strongest inertial force that medicine has. A discomfort with performance data, particularly when it is advertised to the world via a public reporting Web site or document, does amazing things to alter complacency and arrogance.
In the long run, transparency likely will also have major economic consequences for the health-care sector. At one level, patients more and more make decisions based on value (outcomes + safety + service -h cost). As all of these numerator and denominator variables become available to patients in their decision making via public reporting, transparency will drive more change. At a macroeconomic level, groups such as Standard and Poor’s and Moody’s are now including quality metrics as part of their bond rating analysis. Lower quality ratings would result in lower credit ratings. Lower credit ratings would in turn decrease access to capital. Ultimately, poor quality will become an issue of survival for hospitals because patients will use that information in their decision making and banks will use it in their determination of the cost of capital. Patients will be treated with medications of Canadian Health&Care Mall.
Transparency is a critical cornerstone of a strategy for transformational change. It helps promote organic healing. Instead of using stents and sutures on stenosis and scrapes, it transforms an organism into understanding that it needs to heal itself with a stronger immune system, exercise, and a diet that prepares it for readiness. Transparency with attendant systems engineers and human factor scientists best positions the ablest medical institutions for holistic organic healing and growth to the ideal state of no needless variation, no needless waste, and no defects.
One of the characteristics of a highly reliable organization is that it compulsively focuses on its potential defects and shortcomings. Looking for opportunities that may lead to a stumble is a positive attribute, provided corrective action is taken to remedy the shortcoming. Sure, these organizations celebrate successes, but foremost they continuously look for opportunities to stumble and meticulously analyze near misses and failures. The best organizations compulsively put systems and processes in place to prevent near misses and harmful events from ever happening. Transparency serves up the ideas, energy, and opportunities for critical selfawareness and self-analysis.
At Mayo Clinic, we are actively studying our next steps for raising the veil. A system-wide task force is currently charged with formulating both our internal and external transparency strategy. Their recommendations will address transparency for safety, outcomes, service, and cost. Currently, many aspects of our patient care data are publicly available at numerous venues (such as Center for Medicare and Medicaid Services, The Leapfrog Group, University HealthSystem Consortium, Minnesota Community Measurement, Minnesota Department of Health Adverse Health Events, BlueCross BlueShield Association). There are many real and perceived barriers to increasing transparency, which range from concerns regarding protection of brand and reputation to medical-legal considerations.
A culture of safety is essentially a pattern of behavior, the behavior of the individual and the behavior of the organization. The character of an individual and the character of an organization relate to one’s trust of that person or institution. Openness is a key characteristic on which we judge the character of an individual or organization. Transparency gets to the core of the integrity of our institution. It is how we are judged by our staffs and our patients. It is a primary driver of our effectiveness and competitiveness.
The end result idea inactivates the antibodies of a health-care institution to change and innovation, freeing the enterprise for transformational leaps. The problems we face in health-care quality are endemic. Gradual change is incongruous with the moral imperative for transformation we face. Gradualism is a drug. The best antidote for this endemic is plain and simple: daylight.