- Email: [email protected]
Fiduciary What?
Fiduciary What? Bear Stearns, Lehman Brothers. They are Enron, now synonymous with corporate mismanage-
ment and victory of greed over rationality. Whereas a few power- and money-hungry miscreants may have caused our collective suffering, many were complicit. Misgovernance of for-profit corporations robs average citizens of material wealth. Poor governance of hospitals robs them of health or life. Each year, it is estimated that 100,000 preventable deaths occur in America’s hospitals.1 Immense waste of resources is coupled with outcomes that rival those of the underdeveloped world.2 If the “product” is the public’s health, why aren’t those who are misgoverning America’s hospitals held accountable? In this issue of CHEST (see page 171), Goeschel and colleagues3 complement the “Medical Ethics” series with a description of national efforts to help hospital boards of directorsⲐtrustees understand and better discharge their responsibilities. Oddly, despite the fact that lives depend on them, there are no explicit, medically relevant rules for governance of US hospitals. Yet, in the health-care system, boards should be the champions of patient safety and quality of care. Unfortunately, most boards mistake their primary interest as the financial well-being of the hospital.3 Boards have a legally binding fiduciary responsibility to their corporate entity. The word fiducia derives from the Latin, meaning “trust.” Hospital boards are unlike other corporate boards because those trusting them are communities of patients. Whereas finances are sine qui non for operation, a hospital’s “product” is not capital, but rather an abstraction: the public’s health. Boards are most often composed of varying blends of physician-leaders, business people, nonmedical professionals, and community representatives. Assuming they recognize their primary responsibility to the public, how do they educate themselves to understand the intricacies of hospital quality and safety? How do they know the right questions to ask? How do they know whether they are receiving accurate information?3 These questions highlight intrinsic vulnerabilities of hospital boards. First, there is no mechanism for hospital boards to be accountable to the public. Other industries have shareholders to “check” boards (albeit abysmally in recent years). Second, non-health-care-worker members look to clinician members to help decipher medical data. Unfortunately, health-care workers’ philanthropic goals are, to varying degrees, conflicted with concurrent, sometimes competing, financial interests.3 Even the most well-meaning physician has potential financial conflicts, and physicians elected to hospital boards are not necessarily facile with hospital
and public health standards. Finally, boards depend entirely on institutional officers for information. Financial balance sheets are easy to quantify; outcomes are evident in black and white. Safety and quality cost money (to actuate and measure) that many hospitals don’t have. And data are vulnerable to manipulation; it is not difficult to spin unfavorable data favorably to mislead uninformed, novice audiences. Salaries are predicated on favorable data, so hospital officers carry intrinsic conflicts into what they present to boards. Frank malfeasance may be rare, but multiple small insufficiencies can combine to overall failure. Hospital board members are likely well meaning, but may be unaware andⲐor ill equipped to satisfy their obligations. It is untenable that the business people, professionals, and community leaders who compose hospital boards can master, without instruction, patient safety and hospital quality, a discipline unto itself.4 Accordingly, the Institute for Healthcare Improvement5 and National Quality Forum6 have devised explicit guidelines that could enable boards to become robust, vigorous advocates for patient safety. The Saving 10,000 Lives Campaign includes a “Get Boards Onboard” arm that includes educational sessions; more than 100 hospitals have already enlisted. How can boards be compelled to “get onboard?” Unfortunately, doing the right thing for its own sake is not always sufficient. In a simple Google search, I could find no lawsuits in which boards were found liable for medical malpractice in their hospital. But what if a hospital had persistent, systemic safety quality problems, and boards failed to act to force proper management? To the extent that boards have such a responsibility3 and fail to discharge it, subsequent harm—resulting from broken systems that could have and should have been remedied—should be partitioned to board members, especially if they have not undertaken due diligence to perform their fiduciary responsibilities. Tort has been used as the “stick” for punishing doctors who err. When doctors err, one patient is harmed at a time, whereas when boards fail to discharge their duties, all patients are at risk and many are likely to be harmed. What can individual clinicians do, and what is our ethical responsibility? I attend a multitude of meetings where physicians and nurses throw up their hands, feeling helpless and sometimes hopeless about complex problems that require focused institutional attention and money we may not have. But hospitals have a ready source of recruitable energy: the good people who have dedicated their lives to relieving suffering. Turning their attention to safety only requires single-minded focus— an institutional safety fetish. Safety must be championed by hospital leaders to empower every employee— transport personnel, nurse assistants, nurses, respiratory
10
Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on July 6, 2010 © 2010 American College of Chest Physicians
therapists, physical therapists, occupational therapists, even janitors—to act on behalf of patient safety. Far more people die needlessly in American hospitals than die in plane crashes because our industry has been ruled by interests other than those of patients. Systemic change is only possible when all these stakeholders insist that patient safety become the primary focus, rather than an afterthought. The excellent review by Goeschel and colleagues3 provides some prescriptions. Specifically, what can we physicians do? 1. Insist that hospital board members become educated, proactive patient advocates. 2. Elect fellow physicians who are patient champions, thoroughly immersed in day-to-day hospital care, and committed to mastering national safety and quality initiatives. When information presented in executive staff and board meetings does not square with clinical reality, clinicians should press for clarification and accountability. 3. Insist that hospital boards consider nationally accepted standards of patient safety, staying abreast of latest developments of the Agency for Healthcare Research and Quality, Institute for Healthcare Improvement, and National Quality Forum. 4. Insist that reports regarding safety and quality be compiled and provided by an institutional (safety) officer whose salary line is determined by the board rather than institutional officers. Private-sector industry has demonstrated the dangers of executives’ conflicts of interest. Because the “product” is human life, the ombudsmen for safety must be unfettered by financial conflicts. 5. Identify safetyⲐquality problems and require accountability—an attribute lacking in many hospitals—to complete a repair. 6. Participate in qualityⲐsafety committees in areas of expertise. 7. Insist on a no-tolerance policy for clinicians who punish or treat rudely colleagues who report or act on behalf of patient safety. 8. Insist on a no-blame policy for clinicians who report errors and participate in efforts to use missteps to create systemsⲐprograms to prevent future, similar errors by others. But I have become cynical; these measures are certainly overly idealistic. If insurers and the government really want to get serious, they might install patient-system ombudsmen in all hospitals.
www.chestpubs.org
If such personnel simultaneously surveyed for patient safety and for wasteful health-care spending practices, the investment in one or two salaries per hospital would reap exponential returns for patients and the state. Many doctors mourn the bygone days when we led communities and governed hospitals, when we commanded respect because we subjugated our selfinterest for the public’s well-being. Good governance, like good medicine, requires selfless stewardship. We can guide our hospitals to prioritize safety above financial concerns, even if those concerns occasionally affect our pockets. The ideology of patient safety doesn’t cost the ethical physician a dime, and we can be the natural advocates of those ideals on behalf of our patients. We can select medical staff committee and board representatives who are devoted to the communities’ health and safety. We can become part of the solution and fully realize our covenant with patients and society.7 Constantine A. Manthous, MD, FCCP Hamden, CT Affiliations: From Yale School of Medicine. Financial/nonfinancial disclosure: The author has reported to CHEST that no potential conflicts of interest exist with any companiesⲐorganizations whose products or services may be discussed in this article. Correspondence to: Constantine A. Manthous, MD, 4450 Whitney Ave, Hamden, CT 06518; e-mail: [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.orgⲐ siteⲐmiscⲐreprints.xhtml). DOI: 10.1378/chest.09-3107
References 1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000. 2. World Health Organization. World health statistics 2009. http:ⲐⲐ www.who.intⲐwhosisⲐwhostatⲐEN_WHS09_Full.pdf. Accessed August 10, 2009. 3. Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Chest. 2010;138(1): 171-178. 4. Jennings B, Gray BH, Sharpe VA, Weiss L, Fleischman AR. Ethics and trusteeship for healthcare: hospital board service in turbulent times. Hastings Cent Rep. 2002;32(4): S1-S27. 5. Institute for Healthcare Improvement. Get boards on board. http:ⲐⲐwww.ihi.orgⲐIHIⲐProgramsⲐCampaignⲐBoardsonBoard. htm. Accessed October 16, 2007. 6. National Quality Forum. Hospital governing boards and quality of care: a call to responsibility. Trustee. 2005;58(3):S5-S8. 7. Tobin M. Medicine is a covenant. Lecture presented at: 2008 American Thoracic Society International Conference; May 16-21, 2008; Toronto, CA.
CHEST / 138 / 1 / JULY, 2010
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on July 6, 2010 © 2010 American College of Chest Physicians
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ment and victory of greed over rationality. Whereas a few power- and money-hungry miscreants may have caused our collective suffering, many were complicit. Misgovernance of for-profit corporations robs average citizens of material wealth. Poor governance of hospitals robs them of health or life. Each year, it is estimated that 100,000 preventable deaths occur in America’s hospitals.1 Immense waste of resources is coupled with outcomes that rival those of the underdeveloped world.2 If the “product” is the public’s health, why aren’t those who are misgoverning America’s hospitals held accountable? In this issue of CHEST (see page 171), Goeschel and colleagues3 complement the “Medical Ethics” series with a description of national efforts to help hospital boards of directorsⲐtrustees understand and better discharge their responsibilities. Oddly, despite the fact that lives depend on them, there are no explicit, medically relevant rules for governance of US hospitals. Yet, in the health-care system, boards should be the champions of patient safety and quality of care. Unfortunately, most boards mistake their primary interest as the financial well-being of the hospital.3 Boards have a legally binding fiduciary responsibility to their corporate entity. The word fiducia derives from the Latin, meaning “trust.” Hospital boards are unlike other corporate boards because those trusting them are communities of patients. Whereas finances are sine qui non for operation, a hospital’s “product” is not capital, but rather an abstraction: the public’s health. Boards are most often composed of varying blends of physician-leaders, business people, nonmedical professionals, and community representatives. Assuming they recognize their primary responsibility to the public, how do they educate themselves to understand the intricacies of hospital quality and safety? How do they know the right questions to ask? How do they know whether they are receiving accurate information?3 These questions highlight intrinsic vulnerabilities of hospital boards. First, there is no mechanism for hospital boards to be accountable to the public. Other industries have shareholders to “check” boards (albeit abysmally in recent years). Second, non-health-care-worker members look to clinician members to help decipher medical data. Unfortunately, health-care workers’ philanthropic goals are, to varying degrees, conflicted with concurrent, sometimes competing, financial interests.3 Even the most well-meaning physician has potential financial conflicts, and physicians elected to hospital boards are not necessarily facile with hospital
and public health standards. Finally, boards depend entirely on institutional officers for information. Financial balance sheets are easy to quantify; outcomes are evident in black and white. Safety and quality cost money (to actuate and measure) that many hospitals don’t have. And data are vulnerable to manipulation; it is not difficult to spin unfavorable data favorably to mislead uninformed, novice audiences. Salaries are predicated on favorable data, so hospital officers carry intrinsic conflicts into what they present to boards. Frank malfeasance may be rare, but multiple small insufficiencies can combine to overall failure. Hospital board members are likely well meaning, but may be unaware andⲐor ill equipped to satisfy their obligations. It is untenable that the business people, professionals, and community leaders who compose hospital boards can master, without instruction, patient safety and hospital quality, a discipline unto itself.4 Accordingly, the Institute for Healthcare Improvement5 and National Quality Forum6 have devised explicit guidelines that could enable boards to become robust, vigorous advocates for patient safety. The Saving 10,000 Lives Campaign includes a “Get Boards Onboard” arm that includes educational sessions; more than 100 hospitals have already enlisted. How can boards be compelled to “get onboard?” Unfortunately, doing the right thing for its own sake is not always sufficient. In a simple Google search, I could find no lawsuits in which boards were found liable for medical malpractice in their hospital. But what if a hospital had persistent, systemic safety quality problems, and boards failed to act to force proper management? To the extent that boards have such a responsibility3 and fail to discharge it, subsequent harm—resulting from broken systems that could have and should have been remedied—should be partitioned to board members, especially if they have not undertaken due diligence to perform their fiduciary responsibilities. Tort has been used as the “stick” for punishing doctors who err. When doctors err, one patient is harmed at a time, whereas when boards fail to discharge their duties, all patients are at risk and many are likely to be harmed. What can individual clinicians do, and what is our ethical responsibility? I attend a multitude of meetings where physicians and nurses throw up their hands, feeling helpless and sometimes hopeless about complex problems that require focused institutional attention and money we may not have. But hospitals have a ready source of recruitable energy: the good people who have dedicated their lives to relieving suffering. Turning their attention to safety only requires single-minded focus— an institutional safety fetish. Safety must be championed by hospital leaders to empower every employee— transport personnel, nurse assistants, nurses, respiratory
10
Editorials
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on July 6, 2010 © 2010 American College of Chest Physicians
therapists, physical therapists, occupational therapists, even janitors—to act on behalf of patient safety. Far more people die needlessly in American hospitals than die in plane crashes because our industry has been ruled by interests other than those of patients. Systemic change is only possible when all these stakeholders insist that patient safety become the primary focus, rather than an afterthought. The excellent review by Goeschel and colleagues3 provides some prescriptions. Specifically, what can we physicians do? 1. Insist that hospital board members become educated, proactive patient advocates. 2. Elect fellow physicians who are patient champions, thoroughly immersed in day-to-day hospital care, and committed to mastering national safety and quality initiatives. When information presented in executive staff and board meetings does not square with clinical reality, clinicians should press for clarification and accountability. 3. Insist that hospital boards consider nationally accepted standards of patient safety, staying abreast of latest developments of the Agency for Healthcare Research and Quality, Institute for Healthcare Improvement, and National Quality Forum. 4. Insist that reports regarding safety and quality be compiled and provided by an institutional (safety) officer whose salary line is determined by the board rather than institutional officers. Private-sector industry has demonstrated the dangers of executives’ conflicts of interest. Because the “product” is human life, the ombudsmen for safety must be unfettered by financial conflicts. 5. Identify safetyⲐquality problems and require accountability—an attribute lacking in many hospitals—to complete a repair. 6. Participate in qualityⲐsafety committees in areas of expertise. 7. Insist on a no-tolerance policy for clinicians who punish or treat rudely colleagues who report or act on behalf of patient safety. 8. Insist on a no-blame policy for clinicians who report errors and participate in efforts to use missteps to create systemsⲐprograms to prevent future, similar errors by others. But I have become cynical; these measures are certainly overly idealistic. If insurers and the government really want to get serious, they might install patient-system ombudsmen in all hospitals.
www.chestpubs.org
If such personnel simultaneously surveyed for patient safety and for wasteful health-care spending practices, the investment in one or two salaries per hospital would reap exponential returns for patients and the state. Many doctors mourn the bygone days when we led communities and governed hospitals, when we commanded respect because we subjugated our selfinterest for the public’s well-being. Good governance, like good medicine, requires selfless stewardship. We can guide our hospitals to prioritize safety above financial concerns, even if those concerns occasionally affect our pockets. The ideology of patient safety doesn’t cost the ethical physician a dime, and we can be the natural advocates of those ideals on behalf of our patients. We can select medical staff committee and board representatives who are devoted to the communities’ health and safety. We can become part of the solution and fully realize our covenant with patients and society.7 Constantine A. Manthous, MD, FCCP Hamden, CT Affiliations: From Yale School of Medicine. Financial/nonfinancial disclosure: The author has reported to CHEST that no potential conflicts of interest exist with any companiesⲐorganizations whose products or services may be discussed in this article. Correspondence to: Constantine A. Manthous, MD, 4450 Whitney Ave, Hamden, CT 06518; e-mail: [email protected] © 2010 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.orgⲐ siteⲐmiscⲐreprints.xhtml). DOI: 10.1378/chest.09-3107
References 1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000. 2. World Health Organization. World health statistics 2009. http:ⲐⲐ www.who.intⲐwhosisⲐwhostatⲐEN_WHS09_Full.pdf. Accessed August 10, 2009. 3. Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges. Chest. 2010;138(1): 171-178. 4. Jennings B, Gray BH, Sharpe VA, Weiss L, Fleischman AR. Ethics and trusteeship for healthcare: hospital board service in turbulent times. Hastings Cent Rep. 2002;32(4): S1-S27. 5. Institute for Healthcare Improvement. Get boards on board. http:ⲐⲐwww.ihi.orgⲐIHIⲐProgramsⲐCampaignⲐBoardsonBoard. htm. Accessed October 16, 2007. 6. National Quality Forum. Hospital governing boards and quality of care: a call to responsibility. Trustee. 2005;58(3):S5-S8. 7. Tobin M. Medicine is a covenant. Lecture presented at: 2008 American Thoracic Society International Conference; May 16-21, 2008; Toronto, CA.
CHEST / 138 / 1 / JULY, 2010
Downloaded from chestjournal.chestpubs.org by Kimberly Henricks on July 6, 2010 © 2010 American College of Chest Physicians
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