The purpose of this report to our team is to extract lessons from a recent safety concern at UNC-Chapel Hill that could be useful for improving our new hospital. UNC-Chapel Hill Medical Center has been ranked for many years by US News as “high performing” in heart surgery. However, several physicians and other staff recently became concerned about a high mortality rate and poor teamwork in cardiac surgery. They raised these concerns on several occasions but were ignored by hospital administration. With no other avenue available to enact change, two dozen UNC physicians and nurses spoke anonymously about their concerns to a NY Times reporter (Gabler 2018). To gather evidence for the reporter, several cardiologists secretly tape-recorded conversations they had with hospital administrators about their lack of confidence in the cardiac surgery program. These conversations documented that it was implied by the hospital that those making the complaints would be fired if they referred surgical patients to other local programs.
This issue put the whole hospital in a crisis. Bad publicity in a program like cardiac surgery that is critical to the financial well being and reputation of a hospital, amplified by the inability to cope with its impact, are triggers for a crisis (Keown‐McMullan 1997). Similar high profile disasters have triggered crises 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). Investigations of these catastrophes in all fields reveal remarkably common themes. First and foremost is an acute failure of leadership when it was needed the most. In times of crisis, everyone naturally looks to the CEO and the administrative team to navigate its treacherous waters (Boin 2010). The fundamental failing of the leadership at UNC was that their response was reactive and not proactive. It was evident that problems in the CT program were known about for years at the hospital, but those in charge only responded when were forced to do so by a few whistleblowers who were forced to go to the press.
Another leadership problem at UNC and elsewhere has been a failure of accountability. Hospital leaders often have strong political instincts but limited clinical knowledge, a combination of attributes that afford them “plausible deniability” about the bad clinical programs at their hospital. This creates a disconnect between leadership and problems with clinical quality that plays out even in the best hospitals. Johns Hopkins – a top 5 hospital ever since US News started publishing its rankings – performed a broad internal investigation of its clinical services and found a culture of “fear at every level” (Dixon-Woods 2019) Top level administrators were afraid to act against senior surgeons that were disruptive. These surgeons were 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. Clearly, the heart surgeon at UNC-Chapel Hill established himself as an ‘untouchable’.
Another common theme is poor treatment of informants. At best, the dissenters from these adverse safety stories were ignored and treated like the skunk at the garden party. At worst, they were fired or themselves blamed for the problem. The culture of hospitals is often highly political. The most politically expedient solution is always simplest answer to the problem (e.g. “get rid of the bad apple”). This dreaded “bad apple” label creates a chilling effect on staff, which makes them unwilling to speak up about errors. This culture of silence is often tacitly fostered by those in charge because it creates an illusion of control, stability and security. Even when staff at UNC courageously spoke up about poor or dangerous practices, there was a strong tendency for the hospital to initially respond by criticizing the way they spoke up (e.g. a “disruptive physician” label is often used on whistleblowers). The result was staff that were disempowered and silent, which is what set the stage for the crisis.
A final theme is evidence of a poor culture of patient safety. A safe culture has 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 was stopped by the police while delivering a package of illegal drugs and claimed I never looked inside. Failure to acknowledge a duty does not make it cease to exist.
A hospital CEOs and other leaders typically deflect blame using two common defenses. First, the crisis was not their fault. Not every problem that happens in a hospital as the result of poor decisions or inaction by the CEO. The leadership team at UNC-Chapel Hill appropriately trusted and deferred the clinical decisions to their clinical experts. At UNC, the surgeon involved was Dr. Michael Mills, who is not a run-of-the-mill doctor with no talent. He was highly respected in the field of cardiac surgery and had been at his institution for decades. A CEO with no specialized knowledge of cardiac surgery is not expected to quickly challenge or overrule this powerful authority even after the crisis started to emerge.
The second defense is that we can’t hold hospital leaders (the baby) accountable for a crisis (the bathwater) that was not foreseeable. This amounts to “throwing the baby out with the bathwater”. A crisis is never as predictable at the time it unfolds as it appears in retrospect. When a bad outcome happens, it is natural for nurses, patients and others complain about those in leadership positions (including surgeons). That comes with the job of being a leader. Trying to separate “signal from noise” so that we uncover those complaints that are legitimate is easy only in retrospect, after the details of the crisis become clear to everyone. Leaders guide learning from these errors and help avoid overreacting to these rare events, which can aggravate the harm done to the hospital. If we fire the CEO every time a bad event happens, no one will be around to implement the lessons learned.
The take home lesson for our team is that we need to be prepared for this type of event to happen at our institution. ALL hospitals will eventually face a Black Swan Event – which is an incident so traumatic that it threatens the hospital’s future and its highest priority goals. Its par for the course for any high-profile, high-risk business (Fraher 2011). We prepare for this by creating a vision for what strong leadership looks like during a crisis. This starts with developing a strong culture of safety well beforehand. This emphasizes treating those that speak up with the respect they deserve, thereby creating the trust and excellent communication necessary to survive a crisis. Unfortunately, few hospitals have this type of culture, which leaves them doomed to respond to their next crisis with the same mismanagement errors. The time to change this is now. To paraphrase candidate Barak Obama in 2007, we are entering a defining moment in the history of healthcare where much of the public has lost the faith that our leaders can or will do anything about these repeated errors. We should start by understanding the fundamental principle of being a leader: take accountability for your mistakes. Those that don’t are the bathwater, not the baby.
