In Part 1, I pointed out that judging “success” and “failure” in business and war is hard to do. Both are entangled with one another containing contradictions and complicated enough to provide neither easy nor swift judgment. In this post, I look at providing health care in hospitals and schooling the young as further instances of a difficulty in determining “success” and “failure” even when relying on measures of performance.
The U.S. health care system is a model of inefficiency. It is by far the most expensive system in the world, consuming 18% of our gross domestic product. The results in terms of almost all quality measures, from life expectancy to childhood mortality, are in the lower half of the industrialized nations of the world.
Robert Pearl, M.D. 2015
This grim view of U.S. health care delivered by hospitals and physicians costs a lot yet delivers well below what most other nations give their citizens in health care. This framing of the problem leans decidedly toward picturing the nation’s hospitals and medical practices as failing to deliver what other nations do at lower cost. “Success” is not the first word that comes to mind in how the problem of health care is defined by those who agree with Dr. Pearl.
Yet when looking at success and failure with patients in hospitals it should be easy to figure out. As in business and the military, performance in meeting health care goals and objectives is everything.
Ranking systems using metrics that capture percentages of readmission and deaths, timely and effective care, complications that develop, use of imaging, patient satisfaction surveys, and other measures lead to judgments about high and low quality of hospital care.
Apart from ranking systems, there are the personal encounters that patients and their families have. Surgeons, for example, cut out cancers and oncologists administer chemotherapy to kill remaining cancer cells to achieve remission. Many patients return to better health than they had when the disease ravaged their body. Ditto for other medical clinicians who work in hospitals. Those are the successes.
But there are the failures. The operation was a success, but the patient died is an oft-told joke dating back to mid-19th century physicians. While old it does suggest difficulties of defining success and failure in hospitals.
For example, some diseases have no reliable treatments. For those children and aged who have such diseases, the prognosis is grim. And for many elderly patients who have multiple chronic conditions, surgery, chemotherapy, new treatments and drugs still fall short and patients die.
Then there are medical errors in diagnosis and treatment that kill patients in and out of hospitals. And do not forget that some hospital patients contract infections while there leading to longer stays and even death.
So success and failure are uneasy concepts when it comes to doctors treating patients in hospitals.
Who runs hospitals has further complicated providing health care to Americans as Pearl’s opening quote suggests. With just over 6,000 hospitals in the U.S.—a number that has been decreasing over the past few decades—decisions about health care are increasingly made by non-doctors, mostly corporate leaders.
Where a generation ago, medical staff made hospital decisions balancing quality health care and efficient operations, now more non-profit community hospitals are led by non-medically trained CEOs deeply committed to breaking even and having revenues that come from patients, private insurers, federal, state, and local governments exceed expenditures (about 20 percent of U.S. hospitals are for-profit and seek a positive return to their investors). The tension between reducing costs, increasing efficiencies, and hitting the quality measures of successful health care continue to be fraught with conflict. Thus, judgments of success and failure are seldom clear-cut.
SCHOOLING THE YOUNG
For the past half-century, the multiple goals that American schools are expected to achieve (e.g., engaged citizens, graduates prepared for the workplace, strong character, move up the social escalator) has been compressed into one salient measure: high scores on U.S. and international standardized tests. Schools that score high and have high percentages of high school graduates who move on to college are crowned “successes” and drape their schools with award banners. Schools with low scores, percentages of students graduating high school and even fewer attending college are deemed failures, subject to criticism, imposed changes, and even closure.
Yet schools tagged as “successes” have groups of children and youth (e.g., ethnic and racial minorities, low-income) who fail year after year to keep pace with their classmates. Failure within success?
Or consider the high test-scoring elementary school that is closed nonetheless because the school board decides it is costing too much to keep the low-enrollment school open. Enrollment trumped high academic performance. The “successful” school gets mothballed; children go to a neighboring school. Successful yet closed?*
Moreover, there are schools in the “failure” category that plug along year after year with declining test scores, high dropout rates, and few graduates attending college. These schools persist in their failure to perform even with severe criticism and reform piled upon reform. In spite of persistent failure, they continue to open their doors every September. Successful failures?
Furthermore, from time to time, schools once labeled “failure” turnaround and score high on standardized tests and receive awards. Failures then become successes?
These examples are puzzling to those who believe “success” and “failure” based on performance are easy both to identify in sustaining businesses, the military waging war, providing hospital-based health care, and schooling the young. Such puzzles arise when it comes to defining and capturing both “success” and “failure in institutions that serve the American public.
- In Arlington (VA), where I served as superintendent (1974-1981), I recommended to the School Board in 1975-1976 the closing of very small elementary schools (200 or less students) even though they scored well on state tests. The Board approved the recommendations.