Rethinking Never Events
It’s a lot more fun to write about exciting new technologies, or companies in other industries that healthcare could learn from, than to pick on healthcare for its many, well-known shortcomings, but there was an article in JAMA Forum last week that I had to note and perhaps expand on: A New Category of “Never Events” — Ending Harmful Hospital Policies, by Dave A. Chokshi, MD, MSc and Adam L. Beckman, BS (he is also an MD/MBA student).
The concept of a “Never Event” is well known by this point. Coined some twenty years ago by Ken Kizer, MD of the National Quality Form (NQF) and soon widely adopted and expanded, it recognizes that healthcare sometimes has egregious errors that shouldn’t happen: the wrong foot is amputated, the wrong drug/dosage is given, surgical instruments are left inside a patient, and so on. Organizations like The Leapfrog Group exist largely to try to measure and compare hospitals on such patient safety issues.
Never Events still happen, but hopefully less often. However, Dr. Chokshi and Mr. Beckman argue that clinical events are not the only ones that should never happen, that there are several other categories that should be included as Never Events. “Hospitals should be places for healing,” the authors say, “not agents of harm — and there is precedent for addressing harm in hospitals. Now, another category of hospital behaviors should be rendered unacceptable — a different set of never events. Five are especially harmful.”
1. “Hospitals should never pursue aggressive debt collection tactics against patients who cannot afford their medical bills;
2. A hospital should never spend less on community benefits (such as providing care to uninsured; patients or funding public health programs) than it earns in tax breaks from its nonprofit status
3. Hospitals should never flout federal requirements to be transparent with patients about the costs of their care;
4. Hospitals should never provide compensation worth less than a living for hospital workers;
5. A hospital should never deliver racially segregated medical care, whereby it systematically underserves its surrounding communities of color;”
The authors acknowledge that other healthcare organizations (they mention insurance companies and medical device makers, but could have easily included pharma, dialysis centers, certain physician practices, etc.) are similarly at fault, but felt hospitals deserved particular attention because “the fact that the majority of hospitals are engaged in 1 or more of these 5 behaviors…necessitates attention.”
I’ve written before about shady hospital billing practices, those faux community benefits, issues with price transparency, inadequate wages for healthcare workers, and inequities in health care, so I feel pretty good about their list. I hope the article gets the attention it deserves, and that “visionary hospital leaders” and thoughtful policymakers take appropriate action, as the authors call for. I hope that it doesn’t take another twenty years for these five things to be seen as Never Events.
But they’re not enough.
I don’t minimize the challenges of ending, or at least lessening those five practices, but I don’t want us to lose sight of other health-related events that we, as a society, should not tolerate. The complete list is longer than I have room, time, or energy to fully enumerate, but here are some of the ones that should have highest priority:
Hunger: No one in America should go hungry. Yes, we have SNAP, school lunch programs, and other efforts to make food more affordable/available, but an estimated 34 million people — including 9 million children, are still “food insecure” — never quite sure when or what their next meal might be.
Housing: No one in America should go homeless, or live in housing that poses risks to their health. Estimates for both are tricky, but there is thought to be at least a half million homeless at any point in time, and another 6 million homes (with 16 million living in them) considered severely or moderately substandard housing (some estimates put the number as high as 30 million homes).
Clean air/water: No one in America should lack clean water/air. We like to think we live in a developed country, but some 2 million people are estimated to lack clean water (and sanitation); think Jackson (MS) or Flint (MI). Even more shocking, 135 million Americans are forced to breath polluted air.
Hiding errors: No one in America should be subject to medical errors that could have been prevented. How many medical errors are there? Who is committing them, and why (e.g., incompetence versus situational)? We don’t know. Due to concerns about medical malpractice, professional autonomy, and other factors, we don’t have solid mechanisms to report errors, analyze and act on them, or to ensure that problematic healthcare professionals either get better or get out the profession.
Ineffective/harmful care: No one in America should receive care that is unlikely to actually help them. We don’t like to admit it, but most of the care we receive is not based on solid research. We don’t like to admit it, but even when such research is available, it may take years, if ever, for practitioners to adopt it. Too much care is based on “this is how I was trained” (whenever, wherever that was) or “this is how others around me practice” (whomever, wherever that is). “How much will I make from this?” also plays too much of a factor.
Limiting care: No one in America should be prevented from receiving care they need. “Rationing” healthcare is universally denounced by politicians, but anyone working in healthcare or receiving healthcare knows it happens all the time. It happens when people can’t afford it, it happens when tests or procedures are denied, it happens when patients are forced to only use network providers. Not all care is appropriate (as noted above), more care isn’t always (or even usually) better, and some healthcare professionals cause harm, but here’s the thing — the goal of everyone in healthcare should be: how do I help get this patient to the right person/place for the right kind of treatment?
All of these should be Never Events in a civilized society and in a healthcare system that we’re proud of. Sadly, they’re not, and I’ll bet that Dr. Chockshi and Mr. Beckman see their list accomplished before I see mine. But that doesn’t mean we shouldn’t be working on both.
Kudos to Dr. Chokshi and Mr. Beckman for broadening the issue, and it’s on all of us to make Never Events — of all kinds — never happen.