OPERATING THEATER: MAGNIFICENT NEW HOSPITALS DO NOT EQUAL QUALITY CARE
By Jessie Gruman
April 2, 2014
On Monday morning at 8:30, the pianist was playing Chopin etudes in the beautiful but deserted four-story lobby of the new hospital where my father was being cared for.
“I bet my dad would have traded this music and this lobby for breakfast on Saturday and a check-in by the nurse more than once per shift for the past two days,” I mused. The hospital is short-staffed on the weekend, the nurse had told him, so her time is in short supply. Mix-ups in meals for patients are common then too.
The contrast between that lovely lobby and the minimal attention my dad received over the weekend, combined with a report about the architectural whimsy of a new hospital at Johns Hopkins (‘a football-field-size front entrance’ with manicured gardens and a rectangular water feature’), make me cranky, especially in light of the new RWJF/Harvard poll reporting that two thirds of sick people in the U.S. are concerned about the quality of their health care and 87 percent are concerned about its cost.
Every day we read or hear in the news about the poor quality of U.S. health care, the high number of dangerous medical errors, staff shortages, avoidable tests and treatments, the incomplete implementation and adoption of EHRs, tepid patient satisfaction ratings and the absolutely unsustainable price of care.
The majority of us who have been sick enough to be hospitalized in the past year have experienced and are concerned about all of these. What are we to make, then, of these expensive new edifices, that appear like a hotel wrapped around a high-tech factory? How do we make sense of the buckets of money spent on an ad campaign featuring a hospital’s new proton therapy center or stories of patients whose cancer has been ‘kicked’ or ‘beat’ due to their treatment at this hospital?
We should probably just grow up and recognize that our naive notions of the beneficence of health care generally and hospital care specifically are outdated. Health care is big business, and these new fabulous facilities and all this advertising constitute the cost of doing that business. By competing for private payers and touting boutique services, hospitals try to stand out by offering 5-star type amenities (overlooking, in my father’s case, that 24/7 room service is a hallmark of such ratings). They aim to cement their stellar reputations in the minds of the public; they seek to attract us to the affiliated specialist physicians who maintain a steady flow of sick people.
A new physical plant and advertising blitzes ‘signal’ to us that this hospital provides excellent care. Adam Davidson in the NYTimes Magazine, describes how paying a fortune to get our attention sends a subconscious signal that their product is so successful that, well, they can afford it’It also sends the signal that the company is too heavily invested to turn out a shoddy product.
Davidson also notes that according to classic economic theories, signaling ‘thrives when consumers don’t have access to reliable information. Many claim that this describes thecurrent sparse quality information landscape for hospitals, despite government and entrepreneurial efforts to populate it.
When my dad rates his experience of care, the grand piano in the lobby will not be part of his assessment. Rather, he will focus on the respect and attentiveness he was shown by his doctors and nurses and the cleanliness of his room.
If he returns to the hospital with a raging infection six days after he is pronounced well enough to go home, it won’t be because he longs for the Chopin recital in the lobby. It will likely be because he and my mom weren’t given sufficient guidance or support to care for him when he was discharged.
And months later when he contemplates his portion of the hospital bill, his memories of his stay won’t be of gourmet menu choices or the art on the walls. He will think about whether he will have to go into his savings or take out a loan to pay for his care.
Don’t get me wrong, I would far rather have surgery and be cared for in a clean, modern hospital than in a dingy old one. And there is legitimate evidence that people do a little better when there is light and air and art around in the hospital. But such arrangements will never compensate for the medical errors and erosion of quality caused by nurse staffing shortages, underused EHRs and the lack of thoughtful, personalized discharge planning.
It is my great hope that the plans for greater accountability pay for performance and shared savings for ACOs, for example will continue to drive serious attention to the quality and safety of the care hospitals deliver and to measuring and reporting it to the public in ways people easily understand in places they can easily find.
But I’d really prefer that hospitals wouldn’t treat me like Goldman Sachs treats its clients an ignorant muppet who can be manipulated for its own profit. These high-rolling hospitals are betting that I’ll be dazzled by the ‘rectangular water feature’ and the ads promising to cure my cancer. They hope I’ll overlook quality ratings or other relevant factors, such as the good care available close to home or the ability of my local cardiologist to manage my garden-variety arrhythmia. All these efforts are aimed at getting me to seek care at this hospital.
Being ill enough to be in the hospital is a serious business for us. It doesn’t involve much whimsy; there is little place for Chopin. At best, investments such as these appear unseemly. When so many of us are challenged to pay for our care, such conspicuous spending shows profound tone-deafness to the public’s most urgent concerns. At worst, we become cynical: Are these cathedrals to medicine really about better health for me and family and my neighbors? Or shouldn’t I worry about this? After all, it’s not personal. It’s just business. Right?
Original blog post by Jessie Gruman. Updated by the GW Cancer Institute June 2016.