Covid-19 may be receding, but it’s leaving a quiet menace lurking in hospitals in its wake.
In a Perspective essay in The New England Journal of Medicine, four senior physicians with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention warned of a “severe” post-Covid decline in patient safety. The Association for Professionals in Infection Control and Epidemiology reached a similar conclusion, warning of a rise in “common, often-deadly” infections.
To help reverse this troubling trend, the federal physician leaders called for “promoting radical transparency.” Though they didn’t detail what that should entail, our years working in safety and quality strongly suggest that “radical transparency” must be radically different from current efforts in both form and content in order to successfully catalyze genuine change.
Medical care is intensely personal; shopping for cancer care isn’t like shopping for a car. That’s why we believe adapting the psychological principles of Maslow’s Hierarchy of Needs as an organizing framework, paired with the principles of information design, can significantly boost both the use and impact of safety and quality information.
Psychologist Abraham Maslow posited in a landmark 1943 paper that human behavior is motivated by an ascending set of needs. His major categories can be roughly mapped to categories used to measure the quality of care. The most basic physiological need is survival (mortality), followed by safety from harm (complications). There’s also esteem or respect from others (patient experience) and, finally, self-actualization (functional status).
Marketers have long known that Maslow’s hierarchy can be harnessed to motivate desired consumer behaviors. Using the framework, noted one marketer, can get customers thinking about a problem causing “stress and anxiety” and “how your product or service can cure it.”
Is there any problem that causes more “stress and anxiety” than illness?
As the Covid-19 pandemic has shown all too clearly, the way in which information is presented is crucial. Numbers alone can be numbing. In contrast, smart information design focuses on organizing and simplifying complex information in ways users can quickly grasp.
A famous health care example is the “coxcombs” chart designed by Florence Nightingale in 1855, which The Economist placed among “three of history’s best” charts. It converted statistics about the deaths of British soldiers during the Crimean War into a graphic demonstrating that more soldiers were dying from infections than from wounds. The impact on military hospitals was immediate.
Compare that with the U.S. government’s Care Compare site on hospital quality. It uses long lists of comparative numerical data on technical indicators that are both complex and confusing; for example, two hospitals near one of us (M.M.) were said to be “no different than national benchmark” on the rate of surgical site infections from abdominal hysterectomy, even though one had a rate of 2.786 and the other was 0.313. The site is capped off by a “star” rating system whose reliability remains controversial. Most online health care report cards are constructed in the same vein.
“Radical transparency” demands something radically different.
Applying Maslow to maternity care
To illustrate what a more powerful portrayal of information might look like, we compared maternity care at three Baltimore-area hospitals based on quality data from the Maryland Health Care Commission website.
To begin, we mapped Maslow categories to categories used by the site: “Will I be safe?” to mortality and complications; “Will I be heard?” to patient experience of care; and “Will I be able to lead my best life?” to functional status. The graphic is meant to show a hierarchy, while the shape and color of each measure indicate better-than-average, average, or worse-than-average performance.
In a dynamic, web-based version, a user could mouse over various elements to get detailed information such as the actual quality score and its statistical significance. For example, the category “Will I be safe?” might use patient videos and a hospital’s Leapfrog letter grade to tell an easily understandable and emotionally resonant story. “Will I be heard?” could incorporate patient comments from Yelp. (Yes, those can be valid.) “Will I be able to live my best life?” could include patient-reported outcome measures about their quality of life after they leave the hospital.
Since we’re not information design professionals or psychologists, we’re certain there are other possible improvements.
The opportunity to use radical transparency to bring about radical improvement in patient safety is a precious one the nation cannot fail to grasp. Before the pandemic, one-quarter of hospitalized Medicare patients experienced some sort of harm, according to a new report from the Department of Health and Human Services. HHS separately estimated that even before the pandemic, preventable medical errors were killing some 200,000 men, women and children across the U.S. every year. With a “severe” decline in patient safety, how much greater is that death toll today?
The playwright Oscar Wilde once observed that a cynic is “a man who knows the price of everything and the value of nothing.” Without quality and safety information to complement health care price tags, the effort to shift toward a value-based system will fail, and the cynicism of “more is better” and “higher price equals better quality” will continue to reign.
The hospital industry has been timorous about transparency since the first large-scale quality survey was conducted by the American College of Surgeons back in 1919. When just 89 out of 692 hospitals met minimum standards, the regents of the college descended to the basement of the hotel where they were gathered and flung the pages into the furnace. A similar recalcitrance has regularly surfaced since then, if not quite so dramatically.
Radical transparency involves rocking the boat. Are the professionals now sounding the alarm about patient harm prepared to urgently push change even if it upsets some powerful groups?
Whether I will be safe, whether I will be heard, and whether my care will leave me able to live my best life are emotional, even existential, questions that have grown more urgent since the emergence of Covid-19. Applying information design principles to a Maslow’s Hierarchy of Needs framework is a deliberately radical effort to provide information that resonates emotionally and intellectually, thereby empowering and motivating every individual to choose the best and safest care.
Michael L. Millenson is president of Health Quality Advisors LLC and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. J. Matthew Austin is an associate professor of anesthesiology and critical care medicine at the Johns Hopkins Armstrong Institute for Patient Safety and Quality.
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