Will the Ebola Crisis Expose the Managerial Changes Required in Health Care?

The finger pointing has begun in earnest: who is responsible for Ebola coming to the US and Europe? It's got to be someone's fault! So the media and the politicians won't rest till they place the blame somewhere, preferably on a public figure.

But the reality may be that it is not a government or a public official, per se, as disappointing as that will be to some.

Rather, it may well be, as the following article explains, that the 'value' oriented mindset often associated with MBAs, their training and ambition is largely responsible. Not because they lied so they could get out of Africa, but because twenty years of cost-cutting and austerity budgets and placing profits above people and prevention have reduced the relevant systems' ability to respond to crisis too weak to deal with anything out of the ordinary.

All of the statistical analyses and planning exercises have supposedly reduced the risks to their mathematical optimization points. Until, of course, they dont. Which usually happens when something outside of those quantified inflection points throws all of the calculations off kilter.

There is a reason why redundancy gets built into risk management programs. We are now learning the cost of eliminating them. JL

Yves Smith comments in Naked Capitalism:

Making hospital leaders feel entitled to make more money regardless of  their institutions’ performance seems to be a recipe for “CEO Disease,” leading to unaccountable, self-interested leaders.  Hospital leaders may be particularly willing to countenance suppression of facts that raise doubts about their brilliance.

This discussion from the BBC gives a damning picture of the performance of the supposedly “best of all possible worlds” US health care system has been in dealing with Ebola:

The Dallas Presbyterian Hospital treated one Liberian, Thomas Duncan, who died. From caring for him, two nurses have now contracted the disease.
Nearly 80 health workers are under observation. It is claimed by the biggest nursing union that those charged with his care did not have the right protective clothing, flesh was exposed, there were no clear guidelines of what to wear, how to wear it, and how to disrobe.
The US Centers for Disease Control and Prevention (CDC) concedes that it is possible flesh was left exposed when treating Duncan. And that is why among those nearly 80 still under observation, no one can rule out the possibility that there will be further cases.
This is a crude, and damning, statistic but so far Medecins sans Frontieres (Doctors without Borders) has treated thousands of people in West Africa with Ebola, and has seen 16 medical workers contract the disease. This hospital in Dallas has treated just one patient, and has two sick healthcare staff.

Note how the BBC contacted an organization with actual experience in treating Ebola. How many US news organizations have interviewed Medecins sans Frontiers? Lambert and I haven’t seen a single mentions of them in the large number of Ebola-related stories we’ve read between us. Given how deeply embedded exceptionalism is in the American psyche, odds are high that the CDC hasn’t talked to them either.
This sorry performance looks even worse when you read a New York Times story on how the hospital handled the outbreak. Even with thin details and image-burnishing efforts by PR giant Burson Marsteller, staff clearly had no idea what to do and their improvisations often increased risks. Ironically, Presby, as it is called locally, is also described as the Neiman Marcus of hospitals, with a stellar local image and a Margaret Perot wing. But while it does well with treatments for the affluent, like heart surgeries, emergency care is another matter:

In Medicare’s most recent ratings, the hospital scored well on surgery, obstetrics, and cardiac and stroke care. But it did less well, below state and national averages, on assessments of its emergency department. For instance, it took an average of 52 minutes for an emergency patient to be seen by a doctor or nurse, twice the state and national averages.

One of the things we’ve mentioned occasionally about the short-sightnedness of the “crush ordinary workers and squeeze government so that it becomes incompetent and no one will want to pay for it” is public health risks. Wealthy people can’t avoid contact with people at the bottom of the economic food chain: servants, yard men, hospital orderlies, service staff in restaurants. They might be able to insulate themselves from bad economic and political results of their looting schemes, but they can’t escape the ravages of infectious diseases. Remember, FDR was a polio victim. And this has been brought home earlier than we might expect by a medical facility that caters to the well-heeled becoming the American ground zero for a disease from poverty-stricken West Africa.
The article below goes into considerable, damning detail about the considerable mismanagement of Duncan’s case and how it demonstrates how short-sighted it is to have MBAs run hospitals. These details have become public despite a gag order having apparently been put in place on the staff of the hospital that treated the first patient, hospital, Texas Health Presbyterian. Imagine what we don’t yet know.
By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website
Introduction 

News and opinions about Ebola virus are swirling around the US, fueled by a tragic epidemic in West Africa, and fears that more infections could appear here.  On October 6, 2014, I posted my concerns that despite a tremendous amount of confidence expressed by government officials and health care leaders, our dysfunctional health care system might have trouble containing Ebola virus.  Less than two weeks later, my concerns do not seem so extreme.  The first patient to be diagnosed with Ebola virus in the US has died.  Two nurses who cared for him now have the virus.

There seem to be millions of words on paper and on the internet about Ebola appearing every day.  So I certainly do not want to try to deal with the problem in all its aspects.  I do want to revisit a particular set of issues from my October 6 post: the hazards posed by generic management deluded by business school dogma running health care institutions in the time of Ebola.  In particular, my focus is the management of the US hospital at which one patient died, and two nurses were infected, based on what has come out since October 6.

The Incoherence of Hospital Leaders 

On October 6, we noted that the hospital, Texas Health Presbyterian, part of the Texas Health Resources hospital system, had issued conflicting and confusing statements about why the first Ebola patient, Mr Thomas Eric Duncan, was sent home from the hospital when he first presented.  The first specific statement by hospital managers was that there had been a problem with the hospital’s electronic health record (EHR), as had been suspected by my fellow Health Care Renewal blogger, InformaticsMD.  Then the hospitalretracted that statement, but provided no explanation with which to replace it.

Since then, there have been more inconsistencies in statements made by hospital managers.

Fever or No Fever?

First hospital managers said Mr Duncan arrived without a fever, but then review of his medical records indicated his temperature was as high as 103 degrees F while he was in the hospital, a fever high enough that it might reasonably have prompted admission given his other symptoms, even if Ebola was not a concern.  (See this Dallas Morning News story.)

Readiness for Ebola Patients?

Hospital managers assured the public they were ready for Ebola virus patients, e.g., in the Dallas Morning News story of September 30, 2014,  

When Ebola arrived, they were ready.
The staff at Texas Health Presbyterian Hospital of Dallas did a run-through just last week of procedures to follow if the deadly virus landed in Dallas.
‘We were prepared,’ Dr. Edward Goodman, an epidemiologist at Texas Health Presbyterian, said Tuesday in a news conference. ‘We have had a plan in place for some time now in the event of a patient presenting with possible Ebola. We are well-prepared to deal with this crisis.’
Presbyterian said it is following recommendations from the U.S. Centers for Disease Control and Prevention and the Texas Department of Health in responding to the patient, described as being ‘critically ill’ at the hospital in northeast Dallas.
All precautions are being taken to protect doctors, nurses and others in the hospital, officials said.

Sadly, this statement soon seemed, as one politician once said, inoperative. an October 14 Washington Post article described how hospital health professionals had to essentially make up their procedures as they went along.

The hospital that treated Ebola victim Thomas Eric Duncan had to learn on the fly how to control the deadly virus, adding new layers of protective gear for workers in what became a losing battle to keep the contagion from spreading, a top official with the Centers for Disease Control and Prevention said Tuesday.
‘They kept adding more protective equipment as the patient [Duncan] deteriorated. They had masks first, then face shields, then the positive-pressure respirator. They added a second pair of gloves,’ said Pierre Rollin, a CDC epidemiologist.

Also,

He said the hospital originally had no full-body biohazard suits equipped with respirators but now has about a dozen. Protocols evolved at the hospital while Duncan was being treated, he said: ‘Collecting samples, with needles, then you have to have two people, one to watch. I think when the patient arrived they didn’t have someone to watch.’

Worse, in the last 24 hours, there have been reports by anonymous people said to be nurses at Texas Health Presbyterian that the hospital was clearly not ready, per the Los Angeles Times,

The nurses’ statement alleged that when Duncan was brought to Texas Health Presbyterian by ambulance with Ebola-like symptoms, he was ‘left for several hours, not in isolation, in an area’ where up to seven other patients were.  ‘Subsequently, a nurse supervisor arrived and demanded that he be moved to an isolation unit, yet faced stiff resistance from other hospital authorities,’ they alleged.
Duncan’s lab samples were sent through the usual hospital tube system ‘without being specifically sealed and hand-delivered. The result is that the entire tube system … was potentially contaminated,’ they said.
The statement described a hospital with no clear rules on how to handle Ebola patients, despite months of alerts from the U.S. Centers for Disease Control and Prevention in Atlanta about the possibility of Ebola coming to the United States.
‘There was no advanced preparedness on what to do with the patient. There was no protocol. There was no system. The nurses were asked to call the infectious disease department’ if they had questions, but that department didn’t have answers either, the statement said. So nurses were essentially left to figure things out on their own as they dealt with ‘copious amounts’ of highly contagious bodily fluids from the dying Duncan while they wore gloves with no wrist tape, flimsy gowns that did not cover their necks, and no surgical booties, the statement alleged.
‘Hospital officials allowed nurses who interacted with Mr. Duncan to then continue normal patient-care duties,’ potentially exposing others, it said.

In response, the official hospital statement (authored by one Wendell Watson, “a Presbyterian spokesman,” according to the AP) contained vague assurances, but no specific responses to the allegations, 

‘Patient and employee safety is our greatest priority, and we take compliance very seriously,’ the hospital said in a statement. ‘We have numerous measures in place to provide a safe working environment, including mandatory annual training and a 24-7 hotline and other mechanisms that allow for anonymous reporting. Our nursing staff is committed to providing quality, compassionate care, as we have always known, and as the world has seen firsthand in recent days. We will continue to review and respond to any concerns raised by our nurses and all employees.’

So while hospital officials (and local and national politicians and government leaders) kept up reassuring statements that our sophisticated, high-technology hospitals were totally ready to deal with a disease like Ebola, the reality appeared far different.  

Other Inconsistencies

According to a USA Today story, other inconsistencies included hospital statements about the date Mr Duncan’s diagnosis was confirmed, and whether or not the hospital was diverting ambulances.

Were Health Professionals Silenced?

Of course, given the suddenness of the arrival of Ebola in the US, the acuity of the first patient, and the general atmosphere of panic, initial confusion in public statements however critical the information they were meant to contain may be, is understandable.

However, there are now allegations that hospital management was not merely confused, but trying to keep critical information secret, and the allegations do not seem incredible. 

In a Washington Post story on October 12, about how many US hospitals seem not well prepared for Ebola infected patients, appeared this from Bonnie Castillo, director of Registered Nurse Response Network, part of the union, National Nurses United,

Castillo said the union has been trying to contact nurses at Texas Health Presbyterian Hospital, where Thomas Eric Duncan, the Liberian man diagnosed with Ebola, died Wednesday.
‘That hospital has issued a directive to all hospital staff not to speak to press,’ Castillo said. ‘That is a grave concern because we need to hear from those front-line workers. We need to hear what happened there. … They have them on real lockdown. There is great fear. This hospital is not represented by a union. Our sense is they are afraid to speak out.’

The Los Angeles Times story included,

The Dallas nurses asked the union to read their statement so they could air complaints anonymously and without fear of losing their jobs, National Nurses United Executive Director RoseAnn DeMoro said from Oakland.

The October 14 Washington Post story noted

the labor organization National Nurses United read a statement that it said came from nurses at the hospital who ‘strongly feel unsupported, unprepared, lied to and deserted to handle their own situation.’

The AP story of October 15 stated,

The Presbyterian nurses are not represented by Nurses United or any other union. DeMoro and Burger said the nurses claimed they had been warned by the hospital not to speak to reporters or they would be fired.
The AP has attempted since last week to contact dozens of individuals involved in Duncan’s care. Those who responded to reporters’ inquiries have so far been unwilling to speak.

 Covering up information vitally needed by health care professionals, other institutions, the government, etc to better manage a potentially fatal disease that is already epidemic in other countries appears completely unethical.  Doing so to preserve the reputation of managers seems reprehensible.  But the implication of the recent stories is that is what happened.  

Why Hospital Managers May Not Deserve Our Trust 

The US has had no recent experience with any disease like Ebola.  So that mistakes, sometimes very serious ones, were made in the management of the first Ebola patients is not a big surprise.
  
What may be a big surprise to many Americans is how untrustworthy health care leaders, and in particular the managers of Health Texas Presbyterian hospital and its parent system, Health Texas Resources now appear.  After all, USA Today published on October 14, “Texas Health Presbyterian was a respected, renowned hospital.”  While even people at respected, renowned institutions make mistakes when confronted with sudden, unfamiliar problems, should not the institution’s leaders at least be trusted to in their public pronouncements?

Instead, it appears that the leaders appeared tremendously overconfident, and worse, may have silenced employees from raising concerns that could have reflected badly on leadership.  This occurred in a context in which transparency was imperative so that other people who might have to deal with Ebola patients might be better prepared.

On the other hand, based on what we have been posting on Health Care Renewal for nearly 10 years, the conduct of the Texas Health Resources leaders should have come as no surprise.  On Health Care Renewal we have been connecting the dots among severe problems with cost, quality and access on one hand, and huge problems with concentration and abuse of power, enabled by leadership of health care organizations that is ill-informed, incompetent, unsympathetic or hostile to health care professionals’ values, self-interested, conflicted, dishonest, or even corrupt and governance that fails to foster transparency, accountability, ethics and honesty. 

We have seen many examples of hospital executives who seemed vastly impressed by their own brilliance, egged on by board members who were themselves executives of other organizations, and by marketing and public relations functionaries dependent on these executives for their own career advancement.  In particular, we have posted examples of hospital CEOs and other top executives making millions of dollars a year based on their supposed “brilliance,” or “visionary” capacity, at least according to the board members who supposed to be exercising stewardship over their institutions, and the public relations people they hired.  Such brilliance has often been asserted, but rarely been explained or justified  (The latest example was here, and much more discussion is here.)

Most such ostensibly “brilliant” hospital executives had no direct experience in clinical care, public health, or biomedical science.

Making hospital leaders feel entitled to make more and more money regardless of their or their institutions’ performance seems to be a recipe for “CEO Disease,” leading to disconnected, unaccountable, self-interested leaders.  Hospital leaders suffering from the CEO disease may be particularly willing to countenance suppression of any facts or ideas that might raise doubts about their brilliance.  

So the leadership of Texas Health Resources may in fact be very typical of that of large non-profit hospital systems.  THR is such a system.  A Dallas Morning News article about Mr Doug Hawthorne, the Texas Health Resources CEO who just retired in September, 2014, stated

In 1997, Doug Hawthorne helped reshape the health care industry in North Texas by leading the creation of Texas Health Resources, an alliance of Presbyterian Healthcare Resources, Harris Methodist Health System and Arlington Memorial Hospital.

By 2014,

 With more than 22,000 employees in fully owned and joint venture operations, Texas Health is one of the largest care providers in North Texas. For its 2012 fiscal year, it had $3.7 billion in total operating revenue and $5.3 billion in total assets.

For leading this system, Mr Hawthorne made a lot of money, although apparently no recent data is available on his compensation,

He was among the most highly compensated not-for-profit CEOs in the region. For 2012, the most recent information available, his base salary was about $1 million and his bonus was about $1.1 million.

It should be no surprise that to justify this compensation, Mr Hawthorne was proclaimed a visionary.  According to the Dallas/ Fort Worth Healthcare Daily, Mr Hawthorne was inducted in 2014 into the Texas Business Hall of Fame.  At that time,  

‘A healthcare visionary, Mr. Hawthorne is at the helm of one of the largest faith-based, nonprofit health care delivery systems in the United States, Texas Health Resources,’ the Hall said in a release announcing the induction.

Yet Mr Hawthorne had no direct patient care experience, public health experience, or biomedical or clinical science experience.  Mr Hawthorne is on the board of directors of the LHP Hospital Group Inc, a for-profit that provides capital and services to non-profit hospitals.  The official bio, posted by LHP stated his educational background only included

B.S. and M.S. degrees in healthcare administration from Trinity University in San Antonio.

Furthermore, as we mentioned earlier, the current CEO of Texas Health Resources, Mr Barclay E Berden, who has only been on the job since September 1, 2014, also was hailed by system board of trustees for his “unique leadership strengths.”  His current compensation is unknown, but I would guess is likely over $1 million/year.  He highest degree is a MBA, and like his predecessor, had much experience in hospital management, but apparently none in clinical care, public health, or biomedical science. 

Summary 

Texas Health Resources’ recent CEOs have been paid millions, and hailed for their brilliance, despite a lack of any direct experience in health care, public health, or biomedical science.  Leaders convinced of their own brilliance may live in bubbles that prevent penetration of any ideas or facts that may challenge that brilliance, making them thus susceptible to hubris. 

So should we have been surprised that the leadership of the first US hospital system to directly confront Ebola de novo seemed more concerned with polishing their supposed brilliance than with transparently providing the information that other people who have to confront Ebola in the future so greatly need?

No, but one tiny silver lining to the time of Ebola is that it may make it glaringly obvious that we need true health care reform that focuses on reforming the leadership of big health care organizations. In particular, we need leadership that is well-informed about health care and public health; that upholds the values of health care professionals, specifically by putting patients’ and the public’s health ahead of their own remuneration; is willing to be held accountable; and is honest and unconflicted.

Allowing the current dysfunction to continue, while it will be very profitable to the insiders who run the system, will continue to enable tragic outcomes for patients and the public.  

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