Most hospital administrators are not physicians and have no clinical background.  They are selected as leaders due to expertise in management or finance.  As a result, they don’t know how to respond to concerns about poor clinical care.  They “stay in their lane” and focus on the overall business strategy and how to maintain a fiscally sound budget, protect the reputation of the institution and acquire and retain talented people.  They avoid getting “into the weeds” of direct patient care.  However, an event always happens that, at least temporarily, changes the demands on those in charge.  Like it or not, any hospital in business long enough inevitably endures a crisis in the way its clinical care is perceived.   Even the best hospitals in the country – particularly those with prestigious heart surgery programs – face harrowing moments such as these (I recommend following the links to read the details about these events, its heartbreaking):

  • Consider Duke University in 2003 when a donor heart was transplanted that was the wrong blood type. Federal regulators cited Duke University Hospital (US News hospital ranking 19th) for multiple deficiencies in its organ transplant procedures and the hospital CEO admitted they hadn’t developed systems to be able to catch and prevent errors.
  • Then there was a navy veteran that received a heart transplant in 2018 at Newark Beth Israel Medical Center (US News heart surgery ranking 32) and suffered a devastating stroke. His poor prognosis was evident to all the medical team but the family was kept unaware so that he could be kept alive artificially for a year in a vegetative state.  This was done to improve the program’s mortality statistics and avoid federal scrutiny.
  • Heart transplant at St Luke’s/Texas Heart Institute – arguably the most prestigious program in the country (home of Dr. Cooley and the first heart transplant, US News heart surgery ranking 22) – was closed down in 2018 after an investigation by Medicare. Two years after Dr. Cooley’s death, a CMS review revealed a high mortality rate and multiple problems including the lack of properly functioning defibrillators in the OR.  The review was triggered when it was reported that their most famous surgeon – Bud Frasier – was accused by their cardiologists of implanting LVADs into patients that did not need them and other research violations.
  • Then there is UNC-Chapel Hill (US News ranked as “high performing” in heart surgery) where a high mortality rate and poor team work in cardiac surgery was ignored by hospital administration. Two dozen UNC physicians and nurses spoke about their concerns to a NY Times reporter, usually on the condition of anonymity, for fear of retribution from UNC.  Several cardiologists released secretly recorded conversations they had with hospital administrators who implied they would be fired if they referred surgical patients to other local programs.
  • The pediatric heart surgery program at Johns Hopkins All Children’s Hospital had a sudden increase in mortality and complications after their lead cardiac surgeon was demoted in 2016.  A newspaper report described multiple complaints from staff and cardiologists about the problem that administration appeared to ignore.  Once the program was shut down by outside regulators, their response was “We are currently reviewing the program and recruiting senior surgical talent”.  They did not acknowledge a more fundamental problem: their failure to be proactive in response to concerns.
  • A high-volume cardiac surgery program at Redding Medical Center in California repeatedly performed inappropriate and unnecessary procedures on largely healthy patients. After investigation, it became evident that many hospital staff had been aware of what was going on for many years.  Tenet Corporation paid $300 million in reparations for this scandal.
  • At a hospital in Chattanooga, the Medical Executive Committee gave their hospital administration a vote of no confidence in 2019 due to chronic operational issues (inefficiency, understaffing, poor morale and policies that cause overcrowding). The Board chairman of the hospital dismissed concerns and claimed the issue was merely due to “challenges with relations between the medical staff and administration”.
  • The best-known international example was the failure in pediatric cardiac surgery at the Bristol Royal Infirmary in England. It took 5 years and 35 preventable deaths between the first complaint and when authorities eventually shut down the program.  Only the persistence of whistleblower, a cardiac anesthesiologist (Stephen Bolsin), was able to overcome the inertia trying to prevent this result.
  • Winnipeg, Manitoba, 1994: a series of systems flaws – including poor team building and problems with risk management and quality assurance – were responsible for the failure of their pediatric cardiac surgery program. Specifically, the investigation cited that concerns of the nurses participating in the cardiac surgery program were systematically ignored.

These are only some of the most high profile cases of the recent past.  However, ALL hospitals will eventually face incidents that are so traumatic that they threaten the hospital’s future and its highest priority goals.  It is “par for the course” for any high-profile, high-risk business.  Similar crises have occurred in the airlines (Tenerife crash, 1978), nuclear power (Three Mile Island, 1979), the environment (Deepwater Horizon, 2010) and the financial industry (Enron 2001, subprime mortgage crisis 2007).

We rarely hear about a crisis that resolves OK.  Reports from when things go bad reveal remarkably common themes.  First and foremost: a catastrophic failure of leadership.  It is in times of crisis that leaders are needed the most.  Everyone looks to the CEO to navigate the treacherous waters.  Yet each of the cases listed revealed fundamental flaws in basic leadership.  Leaders were reactive and not proactive.  Problems were known about for years, but those in charge only reacted when were forced to do so.  The only people that never seem to know the truth are the families.

Hospital CEOs typically defend inaction by clinging to the most well-proven defense against culpability: “plausible deniability”.  Its application to a crisis is supported by two underlying premises.  First is the problem of hindsight bias – the impending crisis was not as predictable at the time as it appears to everyone in retrospect.  In other words, it was what Nassim Taleb defines as a “Black Swan Event“.  Bad outcomes happen and nurses, patients and others complain about surgeons all the time.  Separating signal from noise is only easy in retrospect, after the crisis unfolds and becomes clear to everyone. It is the job of leadership to guide learning and avoid overreacting to these rare but high impact events.  Overreacting and blaming the administration can result in further institutional harm, i.e. “throwing the baby out with the bathwater”.

The second defense of hospital leaders is that they trusted their surgeons that told them nothing was wrong. The surgeons involved in the cases listed above– Jeff Jaggers, Mark Zucker, Bud Frasier, Michael Mills and those in Redding, Bristol and Winnipeg  – were not run-of-the-mill surgeons with no talent. They were all highly respected in the field and had been at their institutions for decades.  It is believable that a CEO that has no specialized knowledge of cardiac surgery would not challenge or overrule these powerful authorities.  This tactic turns a disadvantage (no clinical knowledge) into a political advantage.  Once a crisis starts to emerge, it is even more reasonable to think that a CEO would trust the experts to its management, at least as a default position.  They see their role as stepping in at the end of the crisis and employing the politically expedient solution: hiring and firing the lead surgeons.

There is a major downside to plausible deniability: failure of accountability.  It is best in the crisis to act early when the problems are treatable.  Hospital leaders have a disincentive to do so because it limits their ability to claim deniability.  This scenario plays out even in the best hospitals.  Johns Hopkins – a top 5 hospital ever since US News started publishing its rankings – performed an internal investigation and found “fear at every level”.  This included top level administrators afraid to act against senior surgeons that they called “chronic untouchables” due to their long-established system of hierarchy and associated political power.  They followed-up on reports of bullying and ended up disciplining 55 physicians and removing 9 from positions of power.  I have seen no other hospital take such a courageous look into the collateral damage of failed accountability, must less publish an article to let others know about it.  But the story behind the story is that it took a brave “bottom-up” investigation triggered by anesthesiologist Peter Pronovost to get administrators to act.

This leads to the second theme of bad management of crisis: poor treatment of informants.  At best, dissenters from these stories were ignored and treated like the skunk at the garden party.  At worst, they were fired or themselves blamed for the problem.  Even when staff were genuinely exposed to poor or dangerous practice there was a strong tendency to criticize the way they spoke up.  This leads to staff that are disempowered and silent.  I’ve written about this dilemma in the past (see past posts about Sophie’s choiceWhy the Cardiac Team Fails to Speak Up).  If you still don’t think speaking up is a serious problem, you aren’t paying attention.  It is all so tragic because those that speak up should be celebrated, not punished.

A third theme is a poor culture of patient safety.  Hospitals always seem to be reacting to problems, well after the horse has left the barn.  The right culture requires a proactive, unwavering commitment to safety, which starts with open communication.  Everyone on the team (not just the surgeons) must feel obligated to raise any and all concerns and those in charge must listen.  This process comes to a halt the first time a credible allegation is not investigated.  Leaders that fail in this duty cross the line from plausible deniability into the arena of “willful blindness”.  At that point, they are no more innocent than I would be if I delivered a package of illegal drugs and claimed I never looked inside.  Failure to acknowledge a duty does not make it cease to exist.

According to Taleb, organizations do not prepare for their next Black Swan Event by trying to predict exactly what and when it will be.  By definition, they are unpredictable and inevitable.  The core competency is an ability to mitigate its negative effects.  There is one thing that – more than anything else – hospitals can do to facilitate this: take away control from leaders with no clinical experience.  I expand on this point in a prior post.  The bottom line is that the only one qualified to lead in a crisis is a physician.  They have credibility and legitimacy with other physicians, which are precious commodities during the most harrowing times.  No credibility/legitimacy = no trust.  Hospitals with nonclinicians in charge are usually able to work around this equation when the times are stable, but ultimately discover its impact during a crisis.

Leaders that accept a future crisis as inevitable gain a better appreciation of the business case for safety.  The downside risk of a Black Swan Event is that years of profitability, growth and goodwill are instantly wiped out.  Building redundancy in safety systems appears far more profitable within this broader context.  The best example of taking a hyperconservative approach to safety are the high reliability organizations, teams that have minimized the risk and impact of errors despite working in hazardous environments.  They are characterized by complete transparency, deferring to expertise, showing resilience and a reluctance to simplify answers to complex problems.  The above cases studies of crisis events shows that hospitals today often act the exact opposite way.  They are places of secrecy, that defer to authority (not experts).  Their leaders focus on avoiding blame via politically expedient and oversimplified answers.

I will close by addressing the “baby out with bathwater defense”. Hospital leaders (the baby) claim they should not be held accountable for a crisis (the bathwater) because that would be an overreaction to an unpredictable event.  If we fire the CEO everytime a bad event happens, we will have no one around to implement the lessons that were learned.  This defense requires hospital leaders to present evidence that they have actually learned from their mistakes. Unfortunately, that does not appear to be the case.  As a cardiac surgeon, the result of every decision I make on behalf of patients is fully available for the world to see.  Hospital administrators are virtually never transparent about their decisions, particularly those that go wrong.  The crisis events over the last two decades show the same repeated mismanagement errors.  When your instinct after making a bad decision that hurts patients is to skirt accountability, you are the bathwater and not the baby.  The time for us to recognize that difference is now.  To paraphrase candidate Barak Obama in 2007, we are entering a defining moment in history where we’ve lost the faith that our leaders can or will do anything about it.