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Effective public accountability in health care demands effective communication to the public.
The public release of healthcare performance information can easily turn into a media circus focusing on boondoggles and body counts. Michael Millenson, a former reporter with the Chicago Tribune who went on to become a health services researcher and author, reflects on the minor media storm that accompanied release of a study by the UK's National Patient Safety Agency (NPSA).
Releasing public information on medical errors is a delicate task. Context—or, more cynically, what modern public relations practitioners would call “spin”—is critical. At one extreme there is the “bad is good” approach of The Doctor's Dream, in which the 19th century British physician William Snowden Battles gave this tongue-in-cheek confession of his shortcomings:
And thus I dreamt that round me stood The victims of disease The patients I had failed to cure Though some had paid my fees. One said, “It is a happy place, My bliss is unalloyed; Through your mistakes just ten years more Of heaven I have enjoyed”.
At the other extreme is the minor media storm surrounding a study by the UK's National Patient Safety Agency (NPSA) of the feasibility of a “blame free” national incident reporting system. The agency was established in July 2001 to identify adverse events and “near misses” occurring in the National Health Service (NHS) and then to use that knowledge to improve safety. Its 9 month pilot involved 28 trusts across England and Wales.1
In June Health Secretary Alan Milburn was accused by political opponents and some in the press of trying to “suppress shocking figures” about the “true scale of NHS blunders”.2 His transgression was allegedly refusing to release pilot study results that the government believed underestimated the extent of errors. Logically, this meant the government stood accused of not releasing information that, if the government had trumpeted it as accurate, would make the Department of Health look good (that is, few mistakes). Nonetheless, the hubbub caused the Department of Health to look defensive as it released the study at a press conference held the next day by Professor Liam Donaldson, England's Chief Medical Officer.
It is tempting to see this contretemps as confirmation that public discussion of errors promotes vilification rather than improvement. A more useful course, however, would be to acknowledge that public accountability is here to stay, and then to examine what can be learned from this and similar experiences.
ROLE OF THE NEWS MEDIA
The most important lesson is that the role of the news media is to tell stories. Those print and broadcast journalists whose stock in trade is sensationalism will inevitably sensationalize, whether deploring medical mistakes or glorifying miracle cures. Most journalists, though, are simply trying to “get it right” despite limited knowledge, limited time to produce a story, and even more limited time or space for the final product. Indeed, despite these obstacles, the media have played a helpful role in health care data releases ranging from a comprehensive survey of patient opinion on hospital care in California (personal communication, Ann Monroe, California HealthCare Foundation, 17 March 2002) to the annual release of clinical indicators on hospitals in Scotland. In the latter case, a local newspaper's charts presented the information in a more usable and patient friendly manner than the official version from the NHS (personal communication, Steve Kendrick, Information and Statistics Division, NHS in Scotland, 18 March 2002).
Similarly, when the US Medicare program released hospital mortality statistics during the late 1980s and early 1990s, major newspapers did a better job of presenting the information than the government. One reason may have been that federal officials feared incurring the wrath of powerful physician and hospital groups by making it easy for the public to spot providers with low scores. That leads to a second important point.
PUBLIC INFORMATION IS, INEVITABLY, POLITICAL INFORMATION
Information important enough for the public to care about is important enough to generate a political response. In a system such as Britain's, the government is an easy target. However, even in a private system like that of the United States, the massive publicity given to a 1999 report estimating 48 000–98 000 annual preventable hospital deaths from medical errors quickly generated hearings and proposed legislation both in Congress and in state legislatures.
In the case of the NPSA study, the government answered a political attack with a scientific discussion of data reliability. It should have pointed out the illogic of a cover-up of data that made the government look good (one tenth the error rate of international studies) or the sleaziness of a newspaper attack that relied on unnamed sources (as the initial story did). In the end, the government countered charges of perfidy by providing proof, as one newspaper put it, that “Britain's first attempt to measure the number of errors made in NHS hospitals was almost a complete failure”.3 Speaking to reporters, Donaldson acknowledged that the study's conclusion that less than 1% of patients suffered an adverse incident was unreliable due to an overcomplicated reporting form and various computer problems. When those were fixed, the true level of errors would probably soar to 10%.1
In the US the Agency for Health Care Policy and Research (AHCPR) rudely learned the importance of political preparedness after releasing a guideline on lower back pain in adults that outraged orthopedic surgeons with its critical stance toward surgery. Congressional allies of the surgeons slashed the AHCPR funding in 1995 and almost killed the agency altogether. The AHCPR responded by dropping guideline production, mending political fences, and eventually changing its name to the Agency for Healthcare Research and Quality. This highlights a final point.
DATA POWERFUL ENOUGH TO CAUSE CHANGE ARE INHERENTLY DISRUPTIVE
Quality and safety problems have deep roots. Those who feel that either their wallets or their way of life is threatened will not go quietly—witness the “quality heroes and martyrs” stories featured regularly in this publication.4,5 Distortions and half truths are standard tools of status quo protection. For example, health insurer sponsored TV commercials featuring a putative everyday couple named Harry and Louise talking to each other at the kitchen table are widely credited with helping to fatally undermine President Bill Clinton's health reform proposals.
Ultimately, though, the problem is not the media messengers but the message. The Doctor's Dream notwithstanding, patients are unlikely to welcome an early entry through the pearly gates. Any public discussion of medical mistakes is bound to be complex, political and disruptive. Yet the hard truth is that public scrutiny and even outrage over quality and safety problems has repeatedly proved essential to motivate health system change.6 In order to prevail against those who would undermine their efforts, advocates of medical accountability must learn to couple their efforts on behalf of the public with effective communication directly to that public through the news media.
Effective public accountability in health care demands effective communication to the public.