In this episode, we welcome Dr. David Feldman, Chief Medical Officer for the Doctors Company & TDC Group, on part 1 to talk about why a culture of patient safety matters.
Highlights of this episode include:
- Patient safety
- Career passion
- Current state of patient safety in healthcare
- Improving patient safety
- The costs that most impact patient care
- Who stands to lose the most and why
Kelly Wisness: Hi, this is Kelly Wisness. Welcome back to the award-winning Hospital Finance Podcast. We’re pleased to welcome Dr. David L. Feldman, Chief Medical Officer for the Doctors Company and TDC Group. In addition, he is senior vice president and chief medical officer at Healthcare Risk Advisors, or HRA, a strategic business unit of TDC Group. Previously, Dr. Feldman was vice president for patient safety, vice president of perioperative services, and vice chairman of the department of surgery at Maimonides Medical Center in Brooklyn, New York. Under his leadership, HRA provides resources in a collaborative environment designed to minimize claims and lower premiums for HRA clients by preventing patient harm, enhancing teamwork and communication, and improving documentation. Dr. Feldman currently serves on the steering committee of the American College of Surgeons for retraining and retooling of practicing surgeons. Dr. Feldman received a Bachelor of Arts degree and Doctor of Medicine degree from Duke University, completed training in general surgery at the Roosevelt Hospital, now Mount Sinai West, and plastic surgery at Duke University Medical Center. He earned a Master of Business Administration degree from New York University. He’s here to talk about why a culture of patient safety matters. In part one of our discussions today, we will lay out the problem. In a later second part, we will dig into what we do about it. Thank you for joining us today, Dr. Feldman.
Dr. David L. Feldman: Thanks for having me, Kelly. Pleasure to be here.
Kelly: And we’re just going to jump right into it today. How does patient safety touch every stop you’ve made in your career?
Dr. Feldman: Well, thanks for asking. It’s interesting if I sort of think back to even in college and medical school at Duke, I was always interested in understanding how things went wrong in healthcare and what we could do to try and prevent them, and also interested in sort of the personality types of doctors. I was struck by how easy it was to categorize who the surgeons were, who the pediatricians were, who the psychiatrists were. And I wondered often about how that felt to patients. Not just with how they appeared, but how they talked to you and so forth. And then, as I became a physician and as a general surgery resident, I was very involved in initiatives to try and improve operations. Obviously, as a surgical resident, that was sort of my focus. And it became quite clear to me, honestly, that being a surgeon, I like to say that patient safety sort of stares you in the face because it’s a very physical specialty, obviously. And patients can see– as a plastic surgeon, they can particularly see sort of what you do and maybe what you don’t do. And if things go wrong, it’s a little easier for patients and doctors to be able to make that determination. And then as a plastic surgery resident, same kind of thing back at Duke, working in areas of pressure sore prevention, looking at how different beds might actually impact doing that, and published some research on that, and optimizing skin graphs and so forth.
And then, when I became an attendee at my Maimonides, I spent a number of years there as a practicing plastic surgeon. Got involved in the medical staff and became part of the administration running the operating rooms where you really get to see how patient safety impacts the delivery of care. First, in the operating room and observing how my colleagues, again, both behaved and what they did as surgeons. Actually wrote a code of mutual respect because I felt that was such an important message that we as physicians could give to not just the hospital community, but the surrounding community, of the importance of that. And then, got interested in things outside the OR. Became the vice president for patient safety so I could go out and watch people wash their hands and do the things to try and prevent things from going wrong everywhere in the hospital. And about eleven years ago, left Maimonides to come to the current company I’m at, where I really work with a number of different hospitals, big academic institutions in New York, doing the same thing, working with doctors, nurses, other healthcare providers to reduce risk across the continuum of healthcare. And now in the last few years, as part of The Doctors Company and TDC group, really working around the country at all levels of healthcare, from individual practice to big groups to small hospitals and big hospitals, with that same mantra in mind, how do we think about reducing risk by improving healthcare, improving communication and so forth. So that’s kind of a brief tracking of my career.
Kelly: That’s so fascinating. And why or how has this developed as a career passion?
Dr. Feldman: Well, it’s interesting. I remember hearing a former president at Duke talked to incoming students and said, “If I had asked graduates, 20, 30 years after they finished at Duke, if they’d ever would have thought they would be in the position they’re in, most of them would say no.” And I certainly answer to that. I remember my kids asking me when they were late in high school and early in college, like, “I don’t know what I want to do with myself the rest of my life.” I said, “Rest of your life? Look at me. Just think about the next five years. What are you really passionate about? And you need to earn a living, of course, but what are you passionate about that you can really think you can make a difference at?” And that’s kind of been my mantra, if you will. And I would say that I’ve been very lucky, although my father used to say that luck is where opportunity meets preparedness. I’m sure that’s a quote from somebody famous. And so I suppose that sort of characterizes each stop along the way. And it’s not like I left something because I didn’t like it. It was more I got to something else that seemed even more interesting and challenging as I’ve sort of broadened my approach around what is now patient safety, so.
Kelly: Well, it certainly is a very great passion to have there. What’s the current state of patient safety and healthcare, and how common are adverse events?
Dr. Feldman: Well, that’s an interesting question. I’m not sure that anybody can really give you a straight answer, and that’s part of the problem. Patient safety as an endeavor, if you will, has really began– the modern era people say it began with the Institute of Medicine report in 1999. And here we are some 22 years later, and some would say we’ve made very little progress. Others would say we’ve made a lot of progress, but we still have a ways to go. I suppose the truth is somewhere in the middle. One of the issues, I guess, is how do we even measure this? As physicians, most of us really look to the science, and it’s very difficult to do that when there really isn’t a lot of data or accurate data about adverse events and when they occur. Part of that is because, for hospitals, most of the way we do that is Adverse Event Reporting System, which relies, as its name implies, on people reporting these things. And self-reporting is tricky. If you’re involved in events, you worry about what your role might be and whether you might be punished for reporting this, which is very different, say, from the airline industry or other higher liability industries. We’re trying to get there. Recent events in healthcare have not helped. The conviction of a nurse for a medical error as a criminal doesn’t really help the cause for encouraging people to speak up. We’ve also gotten a little more sophisticated in trying to understand how we cannot rely on humans to understand why things go wrong.
And there are a number of different tools out there, technologies that allow us mostly to dig into the electronic medical record to try and find out where there are things going wrong. Sometimes they call them trigger tools. So, it’s using, really, technology to try and identify where things are potentially going wrong. You do need some human input into deciding whether these things really are something that goes wrong. And as an example, a patient has an operation and goes back to the operating room within 24 hours. On the surface that would sound like, well, something must have gone wrong. Why are they going back to the operating room? On occasion, during an operation, something happens and the surgeon will say, “I need to close the patient now. I’m going to come back in a day and take another look.” It’s not very common, but it does happen. And that wouldn’t necessarily be considered an adverse event necessarily. In fact, if you didn’t do that, maybe that’s the adverse event. But it means that we need to sort of adjudicate some of these things. But at least you’re getting a good part of the way there in understanding, is this really an adverse event? So, we have a long way to go, I think, to really have a sort of full-proof, bulletproof way of really knowing when things are going wrong. Without that measurement, it’s hard for someone to give you a straight answer, even though there is some interesting data that’s recently been published in JAMA and some other places that would suggest we’re doing better at reducing the number of things going wrong. But I think all of us would agree we have to head towards zero. That’s the only acceptable way of doing it.
Kelly: You make some really good points, definitely. Is there something all hospital providers can agree we must do to improve patient safety? What does that look like?
Dr. Feldman: I guess in my mind, I think of– and I’ve given talks about this, what I think the four critical elements to creating what I like to think of as a culture of safety, right? That’s what we’re trying to develop in healthcare, make it part of the culture so that it’s not an initiative, it’s not what some healthcare providers call the flavor of the day, right? So, you bring some consultant in, they talk about some great thing, and then they leave. And then people go back to what they usually do. Healthcare folks, and I’m as guilty of it as anybody, are creatures of habit. And change is not so easy. People talk about changing culture in healthcare as a long-term endeavor. Most of the time, people think about changing culture as a five to seven-year project. In healthcare, it’s probably longer. And in operating, it’s even longer than that, because we are creatures of habit. So, to create this culture, in my mind, requires four sort of critical elements. And the first piece relates to what I mentioned earlier in our discussion about mutual respect. I don’t really believe that anything you try and do in healthcare to improve safety and to create that culture is going to work if people don’t respect each other. People don’t want to talk if they don’t respect each other, they’re afraid to say things. And the environment becomes somewhat toxic if people are worried when they go to work that someone’s going to yell at them or treat them poorly. So, I think that’s the first necessary ingredient in a world of patient safety is having people respect each other. And healthcare is an interesting place. There are people with very different backgrounds, very different training. There’s often an analogy with airlines. It’s not like an airline cockpit where you’ve got a pilot and a copilot, usually have pretty similar backgrounds, often in the military and flight school and so forth. And most of the differences relate to their years of experience. Walk into an operating room or walk into an ICU and you’ve got multiple healthcare providers, some of whom went to nursing school, some went to medical school, some may not have even gone to college. But they all have a different approach to understanding how best to take care of that patient.
And everybody’s opinion needs to be valued regardless of their background. I think that’s really an important step. That’s how I start thinking about patient safety. The other pieces of it really relate to the things we can control, which are the system and the people in it. And the people in it is about teamwork, and there’s lots of data– and I can talk a little bit more as we go on about some of the things we’ve done to help our institutions develop team training approaches, optimizing how people work together as a team. And then, the other side of it is how we improve the system, creating a system that makes it very difficult for us as humans to make mistakes since, as humans, we’re prone to making mistakes. Part of being human, and we can talk about some examples of that. And then overriding all of this, the beginning of mutual respect, the teamwork training, the piece about keeping the system safe, what we call human factors engineering, above all of that is what we call a just a culture where, getting back to what I mentioned before, people are not punished for human error or even what we might call risky behavior. That really requires education. And the only people we really punish, truly punish, are people doing things that are reckless with intent. And that really is pretty unusual. So those to me are the four critical ingredients to creating a culture of safety. And when I talk to people about creating a safety culture, those are the things I focus on.
Kelly: Those are some great points. Thanks. And what are the costs, seen and unseen, that most impact patient care?
Dr. Feldman: Well, the obvious ones are somebody has a complication, drug reaction, something untoward that goes on during surgery, then they require more care, and more care is more cost. We know that. So that’s the sort of the most obvious thing. Some of these things now in the last number of years won’t be reimbursed, even though we still mostly work in a fee-for-service system. There are some events that neither CMS, which pays Medicare and Medicaid costs, nor commercial payers will cover, if they are considered to be preventable, like acquired pressure sores, retained surgical items, and so forth. So, there’s not only the additional cost, but the lost income that goes along with when things go wrong. But then there’s all the unseen costs. And unfortunately, we’ve seen a lot of that in the last couple of years during this pandemic, the human costs. Healthcare providers are human and watching your patient have a problem can be pretty devastating for a physician, a nurse, others. There’s burnout from that. There’s burnout from all the things that have gone on with this pandemic the last couple of years, and there’s a cost to that also. We have data to show that clinicians that have burnout are much more likely to make mistakes. It becomes this vicious cycle. Many of them may experience a lawsuit. That’s the world that I come from here. And we know lawsuits are pretty devastating. They’re distressing, and many of them are not– they’re really not based on much, unfortunately. But we like to think of the fact that we can help people through some of these times. But there is a human cost to all of this that we often don’t see when there’s patient harm.
Kelly: Thank you for that. Where is our current system for patient care falling short? And who stands to lose the most and why?
Dr. Feldman: Well, I think we’ve talked about some of the things that we still don’t do very well. And of course, it’s the people who stand lose the most, the patients, which interestingly enough is all of us, including healthcare providers. I’d like to say I really can’t wait– many folks talk about the issues in healthcare, some of them being generational, and my response to that is, “Well, I can’t wait a generation because I’m a patient as well.” I don’t want to wait around for this. None of us do. So, we need more of a sense of urgency to try and get people to move things faster than they can. And it’s very difficult to do for all the reasons that I mentioned before. So, I think that’s something that all of us have to keep in mind as we move forward. How do we create a sense of urgency amongst healthcare providers so that we don’t have to wait a generation to see changes happen? And a lot of this costs money, money for people, money for equipment, for technology. And there always seems to be a shortage of funding when it comes to healthcare for all the reasons we’ve sort of reviewed.
Kelly: Thank you so much for all of that, and we’re so appreciative of all this fantastic information, Dr. Feldman. If someone wants to get in touch with you, what’s the best way to do that?
Dr. Feldman: Well, I’m happy to respond to emails. My email address is dfeldman – that’s my first initial, last name – at tdchra.com (firstname.lastname@example.org). Delighted to communicate with any of our listeners today who have additional questions, concerns, or just want to share some thoughts, ideas. I’m always looking for new avenues to improve patient safety.
Kelly: Wonderful. Well, thank you so much for joining us today, Dr. Feldman. We look forward to your return to continue this discussion around patient safety.
Dr. Feldman: Thank you.
Kelly: We appreciate you all joining us for this episode of The Hospital Finance Podcast. Until next time.
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