Dr. Robert Wachter, Editor, AHRQ WebM&M: What does the average journalist know about medical mistakes?
Charles Ornstein: There's a real range of knowledge about health care, about medical mistakes in particular, but also just general issues of health policy. And with cutbacks in the news industry, reporters are being asked to handle more and more subject areas, some of which they may have a lot of experience in and some of which they have only brief experience in.
RW: How do reporters gain that kind of specialized knowledge, generally in health care and then specifically in the area of quality and safety?
CO: When you're first starting out on the beat, you ask a lot of questions. You probably spend a lot of time on the phone just making sure that you have the basics and that you understand the complicated alphabet soup that exists out there—the difference between an HMO [health maintenance organization] and a PPO [preferred provider organization] and the difference between AHRQ and HRSA [Health Resources and Services Administration] and CMS [Centers for Medicare and Medicaid Services]. It's very complicated. I think as you begin covering health care more, you probably have areas that you want to focus on. I'm most passionate about patient safety and medical errors. I think the area is really not appreciated by some of my colleagues in the media, and it is very important to patients. For anybody who needs medical care, the potential for error is great, and knowing what goes on and how to be alert is critically important.
RW: Was your interest general, or was there a certain case or a certain story that got you jazzed about this?
CO: As I started on the health care beat, I became familiar with forms that both the state and federal governments use when they're inspecting hospitals, nursing homes, and other health facilities. They're called 2567 forms, which are the statements of deficiencies that the inspectors write when they go into one of these facilities and find a problem. As you start reading through these forms, you start seeing the range of things that happen in health facilities and how things can go wrong. But what really captured my interest were the problems at a hospital in South Los Angeles, King/Drew Medical Center, which I covered extensively for 4 years.
RW: You and your team won a Pulitzer for that coverage. How did you first hear about it and did you have the sense that this would be a huge story when you started out?
CO: We kind of stumbled into the story initially. We actually had been writing about problems and concerns at the bigger county hospital in Los Angeles, LA County-USC Medical Center. Early in 2003, there was a lawsuit that involved some proposed cutbacks at that hospital where they wanted to reduce the number of beds. The head of the emergency department filed an affidavit as part of the suit, citing specific cases in which patients had died because of long waits for care. And that had us asking questions about whether we needed to take a broader look at the county health care system generally to see if the public hospitals had a lower standard of care than the private hospitals. A couple of things happened in the summer of 2003 that caused us to focus on King/Drew. The first was that two women died over the summer. They were both connected to cardiac monitors, but for some reason, they didn't receive prompt help when the alarms sounded. Initially, we were led to believe that this was a problem with the monitors: they had just been installed, and perhaps they weren't alarming properly. But when the state inspectors went into the hospital, they discovered that it was not a problem with the monitors. Rather, it was a problem with the nurses, who ignored the patients and who were pre-charting and post-charting to indicate that they were checking on them and found that they were "fine" at a time when they were dead.
RW: You mentioned that there was a second thing that happened?
CO: The second thing that had us interested in the hospitals was less to do with direct patient care. It had to do with the fact that the ACGME [Accreditation Council for Graduate Medical Education], which is the certifying arm for physician training programs, took steps to remove the accreditation for the surgery training program at the hospital because it had more residents than it was allowed. Most people who are in academic medicine know that it's fairly rare for the ACGME to try to remove accreditation from a training program, but this demonstrated some of the serious problems that existed in the hospital. So those two things together made us open our eyes to what could be serious problems at King.
RW: In the last few minutes, you've mentioned cases that you heard of because of state inspection reports, cases that came from an accreditation review like ACGME or The Joint Commission or something that you heard of through a lawsuit. Are those the main things that you and others like you mine, or are you looking at large datasets or listening for the one anecdote or the whistle-blower phone call? How does information make it across your transom?
CO: Good reporters have a variety of sources of information. Reporters who routinely cover the hospitals in their communities should be constantly looking at state inspection reports, lawsuit data about payouts, their Joint Commission accreditation, and how they're doing with their training program. All these types of things should be on the radar screen and monitored regularly. But nothing can replace talking to employees in the facilities and the patients that receive care there—trying to get an on-the-ground perspective. It's important to be out there as a reporter. You need to get to as many people as you can, handing out your business card and urging people to call you. Even the best hospitals in the country have problems, and there are problems that they can fix. But if employees have raised their concerns internally and the problems are not fixed and they feel like they cannot get traction, that's really the time to start calling the media. There's nothing like a call from a reporter to get things moving.
RW: When you show up at a hospital door or you call the CEO or the PR Department and you've heard of something that sounds like a problem through any of these avenues, what is the usual response and what advice would you give hospitals in terms of what the usual response should be?
CO: It depends. It's variable. And that's a source of frustration. In my mind, the response should be forthright and honest. I've seen too many institutions that have tried to cover things up, and I can assure you that it blows up in their face. There is nothing to be gained by trying to cover things up. Ultimately, the truth comes out. Then, not only is the problem what actually happened, but the problem is that you tried to cover it up. If you're a hospital leader, sometimes you have to face up to the harsh reality that a mistake was made, patients may have died, and the key thing is to be honest about it, explain how it happened, what changes you're making, and face up to it. But if you try to lie about it, it will come back to you.
RW: Can you think of an example where this was done poorly and an example where it was done well?
CO: There was a case, an outbreak of Pseudomonas at a neonatal unit in Los Angeles, and when we asked questions about it, the hospital was responsive to it, had answers to the questions, was working with the health department, and did not try to cover it up. I think they tried to ensure that they were as open as possible about what was going on. That's one example. The second was when a very prominent hospital in Los Angeles gave an overdose of heparin to the twins of an actor. The hospital was fairly forthcoming about the fact that they had made pretty terrible mistakes in the past, and about what they were doing to fix it. Certainly there were additional details that came out when the state report came out, but generally the institution did not make an effort to cover it up or to try to say it didn't happen.
RW: Putting aside the ethical correctness, would you say in those cases the hospitals did better in the press because of how they handled it?
CO: Certainly when you are caught in a lie, there's nothing good that can come of that. So if you're up-front and you try to reveal the information you can while respecting the limits that are placed on you by HIPAA [Health Insurance Portability and Accountability Act], I do think that, if nothing else, you help kind of control where the story goes. It may not be a 5-day story because the next 4 days are spent trying to track down why you lied. It may be more than a 1-day story, but at least you won't be accused of not being up-front.
RW: Can you talk a little bit about the tension between being sensationalist in reporting medical errors that are almost inherently sensational stories and being accurate and sober? How do you balance that? Does every paper or media outlet do that well or do some do that poorly?
CO: There is a fine balance. Part of the job of the media is not only to explain when these events happen but to try to put them in perspective. So, going back to King/Drew Medical Center, one of the things that we thought was really important was to present the story in context and not just as a string of anecdotes. We did a lot of statistical analysis—looking at data from the state inspection surveys, analyzing information from The Joint Commission, looking at quality scores, looking at lawsuit settlements and payments, and trying to determine where the hospital stood compared with its peers and other public hospitals around the state. It takes a lot of time, it takes money, it takes data analysis skills, but it pays off because you are able to, in a sense, immunize yourself from charges that you took things out of context or that every hospital has medical errors. The other thing that's important for reporters is not just to say when a particularly bad case happens, but also to take a step back from time to time and tell patients what they can do to protect themselves, the types of questions they should be asking of their hospitals and doctors to make sure that they are not a victim of a medical error. If reporters are thinking along those lines—first, providing perspective and some numerical context and, second, offering suggestions to consumers about how to be better patients—you take a step away from being just sensational.
RW: You and I know very well that the paradigm in the safety world in the last 10 years has shifted from it being about bad people to it mostly being about bad systems. Do you think that's right?
CO: I don't think one or the other is right. It's probably somewhere in the middle. Sometimes bad systems allow for bad people to do bad things. Correcting the systems will not necessarily correct the people. One of the things Tom Garthwaite, who is the former head of the Los Angeles County health system, said was that you can teach people what the right thing is, you can make sure that they have the skills, but the bottom line is you cannot always teach them ethics. So even if you have systems in place to prevent problems, if a nurse is going to falsify a chart or a doctor is going to spy on a patient record and violate HIPAA and share that information with the news media, even the best systems may not protect them. So I think it's a combination of both people and systems.
RW: How do you balance that when you get into an individual case?
CO: I think it is incumbent upon health care reporters when they're writing about these topics to talk to patient safety experts to provide that level of context and to help differentiate between the situations when it is about the people who have a track record and then when it is about the system. And helping to explain those things together. It is a challenge, but there are plenty of people who study this and have more expertise than we do as reporters, and we should be turning to them and seeking their guidance. That's one of the areas where I think the L.A. Times does a really good job, in terms of analyzing patient records and state regulatory reports. We don't believe we necessarily are the experts. But we know what we want to look for in an expert to help us assess that.
RW: In some ways, it's a little bit luck of the draw that a hospital gets a lot of media attention for an error because they happen to be in a media market where there are good reporters focused on this issue. You could easily envision that if King/Drew Medical Center was in another part of the country without the L.A. Times, it would not have had the same kind of scrutiny.
CO: I hear that a lot as an excuse from hospitals, and I don't fully buy that. There are good hospitals and there are average hospitals and there are bad hospitals. We all need to recognize that not every hospital is a good hospital. The excuse that it's just that you're looking at us and that's why we look bad and that these problems exist everywhere, I don't know if I get that. If a hospital has been reviewed by The Joint Commission and has been put on preliminary denial of accreditation, that does not have to do with the fact that the media is looking at it. That has to do with the fact that Joint Commission reviewers went in and found that the hospital didn't meet minimum standards of care. And when CMS inspectors go in and find that a hospital doesn't meet the Conditions of Participation or puts patients in immediate jeopardy, that does not have to do with the fact that the media has reported on it. So I think it's an excuse to try to say that it's just the media attention, that these problems happen everywhere, but we're just the unfortunate figures who draw all the media attention because I don't think that's a justification for the errors that have taken place.
RW: If a hospital that had the same deficiencies and the same Joint Commissioner or state reports happened to be in a market that didn't have a paper like the L.A. Times—as you say, most papers don't have specialized health care reporters, don't have the ability to drill into the stories in the same way—do you think they're getting a free ride?
CO: Probably so, and that's why I'm on the board of the Association of Health Care Journalists. One of the things we do at every conference is hold a training session about how to cover your local hospital and discuss the available resources, such as how to get your hands on 2567 forms or how to get information from The Joint Commission or ACGME. I try to tell people what tools and resources are available, so that a bad hospital in any part of the country will be known to the people who depend on it for care and so that the public pressure will be brought to bear on them to fix it.
RW: The media is in some ways one tool to bring pressure on organizations or individuals to improve through transparency. There are others; you've mentioned some of them, like accreditation and the state public reporting of data. What's the relative role of the media, and how do you see all of these other tools and stakeholders? How are they doing in this regard?
CO: Regulators and accreditors play critical roles. In many ways, they have access to information that the media doesn't have access to. But the media has the opportunity to take what some others may be identifying and amplify it, so that people are asking the questions they need to be asking. There's a fundamental distinction between the role of the media and the role of accreditors and regulators. In many ways, organizations like The Joint Commission and state regulators are interested in trying to work as collaboratively as possible, not to punish but to prevent things from happening in the future. There's a view that they need to work together. It's not the role of the media to necessarily "work together" with you to improve your care. It's the role of the media to spotlight if there's a problem and to ensure that you actually do fix that problem. And it's the role of the media to spotlight those organizations that do it right.
RW: When you see a health care organization that has real deficiencies, when do you say it cannot get better and patients should not go there and in fact, it should close? Is the goal to make it better or at some point do you just say this is not going to happen?
CO: Well, I do want to talk specifically about King/Drew in this regard because it's one of the most challenging and vexing questions that faced everyone who was involved with the story. Is it better to have a hospital that may not be as good as private hospitals—or even the other public hospitals—but at least provides an access point for tens or hundreds or thousands of people to seek care? Or is it better to have no hospital and to avoid some pretty horrific medical mistakes, but certainly have situations where access to care is reduced? At what level or at what point do you cross the threshold between the two? Nobody has a good answer there. I said repeatedly as we were covering King/Drew that the goal of my team and myself was never to close the hospital. Our goal was to ensure that the residents of South Los Angeles had access to the same quality of care that they could get in other parts of the city. It seemed to me that it was racist to say that it was acceptable for residents in a poorer area of the city with more health conditions to be subjected to a lower quality of care than residents in other areas just in order to preserve their access. How unfortunate to say, okay, you don't have to meet minimum standards of care because the alternative—which is no access—is worse. It's a horrible situation. But we felt continuously from the moment we started writing about the hospital that there had to be a way to fix it while they kept it open. And in fact, after we wrote a big five-part series about the hospital in 2004, we ran a big, long piece about solutions. And, unfortunately, solutions that medical experts from around the country proposed for L.A. County to take, the county did not take.
RW: Was there some moment when you shifted on your thinking and felt like the best thing to do was to close the hospital?
CO: I don't think I had that moment. The federal regulators gave them many, many chances. They felt like at some point they had to enforce their minimum standards, otherwise they would be meaningless to any other hospital in the country. I certainly asked the question of a lot of people, probably including you, is it better not to have a hospital open than to have sub-par care? I think that is a legitimate question, but I don't think that equates to advocating for the hospital to close. I don't think I ever suggested that they had to do that in order to improve. I always held out hope that they would be able to improve while they remained open.
RW: Before it did close, there were lots of statements from many quarters talking about the problems that would occur if it closed and the access difficulties. What have we learned about that since it closed?
CO: There have been access difficulties and there have been problems, people have waited longer for care in neighboring emergency departments and people have not gone to get care that they probably needed. There hasn't been a quantification of how many people may have died because of these issues. It is really difficult to quantify that, just as it's difficult to quantify how many patients have died at a hospital because of poor care. But without question, waits are up, ambulance wait times are up.
RW: What did you learn about patient safety and medical errors from covering King/Drew that you didn't know when you started that story?
CO: I think I understood a lot of context. I understood about safety problems. I understood about system problems. I understood the role that personnel play within that, and it really helped me understand the balance between the role that systems play in problems and the role that people play in problems, and the interplay between the two. While most of the employees at King/Drew were good employees who cared deeply about their jobs, there were a fair number who didn't do their jobs well. One of the final tallies that the county provided indicated that more than 600 of the hospital's 2400 workers were disciplined in a crackdown on employee misconduct in the hospital. That's an awful lot of people. If you look at some of the disciplinary reports, the number of things that people did over and over again shows that some of the people may not have been right for their positions. However improved the systems were, they may not have been able to compensate for the poorly trained staffers.
RW: What is it like to win a Pulitzer?
CO: It's a great feeling, but it's tempered by the fact that when you do investigative reporting you hope that there are positive results that come from what you do. It was a real shame that after the amount of time that we spent covering King and uncovering the problems, the county was never able to fix them. If anything, they seemed to just get worse over time. It pained me considerably when we would be writing stories about nurses who were accused of turning down the volume on patients' cardiac monitors so as not to be bothered. And you'd write that story and then 3 or 4 months later, another nurse would be accused of doing something similar and you'd just wonder, how can this happen? How can this still go on when there's so much scrutiny and so much tension and we're devoting so much time to writing about these things? So as exciting as it is to be recognized for the quality of the journalism that we produced, it's also upsetting that the results couldn't have been more positive, so that I would have been able to write a front-page story saying, King/Drew has overcome its problems and the threat of sanctions is lifted. We never got a chance to do that.