About those clinic rankings

I know many of the local health care providers well enough to have a good idea of how they must have felt at seeing their favorable performance in a statewide ranking of medical practice quality, published this week by Consumer Reports. It must have been a really good moment for them.

My own reaction? A rush of smugness (or pride, perhaps) for being a patient at a medical practice that did so well.

But on second thought, this may not have been the best response, because it’s not really the purpose of rankings like these to enable people or organizations to feel superior – or, in the case of lower-performing clinics, to be singled out as sub-par. The purpose is to provide one of the many pieces of information that go into health care decisions – which clinic patients should choose and which doctor to see, what type of care an organization should provide and which internal systems should be created for delivering good care.

In an introduction to the special report, Dr. John Santa, director of the Consumer Reports Health Center Ratings, explains why it’s important to collect and share the data:

First, it generates conversations among doctors about changes they can make in their practices to lift the quality of care they provide to patients. And making this information available to patients leads to one of the most powerful forces driving improvement – educated health-care consumers.

The report points out that many factors can influence the performance of a given medical practice. Some of it depends on the patient population that’s served – whether the clinic sees a large number of people who are uninsured, for instance, or has a concentration of frail elderly individuals for whom aggressive disease management might not be appropriate.

A well-known name or suburban location doesn’t necessarily equate to the best care. Many of the top-performing clinics did not have a high public profile, and many were in rural Minnesota.

So how can consumers use the rankings in a meaningful way? What they should not do is flee from a medical practice that didn’t do so well in the rankings – at least, not without careful thought. The advice from Consumer Reports:

Instead, use our Ratings as an opportunity to talk with your doctor about how you can work together more effectively to manage your health. Ask what the practice is doing to improve its performance, and whether its scores are moving in the right direction. And remember that your participation is key, too. Your doctor can only make recommendations; you have to follow through on them.

There’s also the larger picture to consider. Minnesota Community Measurement, the main source of the data for the Consumer Reports rankings, tracks many other measures besides diabetes and cardiovascular care. Medical practices that are mediocre at managing diabetes might perform much better at managing asthma or depression or encouraging patients to follow through with recommended cancer screenings. A medical practice that earns an average ranking one year might improve significantly the next.

Finally, there are the intangibles. Are patients able to have a good relationship with the doctor? Is the staff competent and professional? Is the practice welcoming, and does it take patients’ special needs into account? These things are very difficult to measure but they can matter a great deal.

Perhaps the most important thing about the rankings isn’t the singling-out of who’s the best and who’s the worst. It’s the fact that there’s a useful rating system at all. Not that long ago, information like this simply wasn’t available – or, if clinics were tracking some of these measures internally, it wasn’t shared with the public. Now it’s out there for everyone to see, to talk about and to use the data as a spur for continued improvement.

What’s really remarkable – and something I’m not sure is recognized enough – is what it takes to achieve quality care. Because so much of the effort happens behind the scenes, patients generally don’t see it. Over the years, though, I’ve had glimpses of what’s involved and have come to realize the tremendous amount of work that’s required to earn a good rating. Sustaining this effort week after week, year after year, is even harder.

So, yup, we ought to feel good (and maybe indulge in a few moments of pride) when our clinic does well. Good performances don’t happen by accident.

Fire all the fat patients

Ida Davidson, of Shrewsbury, Mass., started seeing a new primary care doctor but on the second visit, she was told by Dr. Helen Carter that she needed to find another doctor. The reason? Davidson weighs 246 pounds, give or take the occasional fluctuation, and Dr. Carter’s policy is to turn away any new patient who weighs 200 pounds or more.

Discriminatory? Davidson certainly isn’t happy about it. “I have never heard anything so ridiculous in my life,” she told WCVB-TV of Boston last week.

Policies such as Dr. Carter’s might not be common but they’re not unheard of. When the Miami Sun Sentinel conducted a survey earlier this year among obstetrics-gynecology practices in South Florida, 15 of the 105 clinics that responded said they refuse to take new patients who weigh too much.

It seems to be completely legal. After all, there’s nothing that obligates physicians in private practice to see any and all patients who come through the door.

But as stories like these pop up from time to time, medical ethicists have expressed uneasiness over such policies. At the very least, it violates the spirit of the medical profession, some ob-gyns told the Sun Sentinel.

“No doctor should be unable to treat patients just because they are heavy” was the assessment of Dr. Bruce Zafran of Coral Springs, Fla.

Medical ethicist Dr. Arthur Caplan said doctors have a duty to provide care regardless of the patient’s health issues. “Simply saying ‘I’m not gonna take someone who’s obese,’ is, I think, not the way to approach the whole challenge of obesity, either for that person or for any American,” he told WCVB-TV.

Doctors who set weight limits for the patients whom they’ll accept into their practice say they have reasons for their policies. Some of the Florida ob-gyns told the Sun Sentinel that heavy female patients are more likely to have complications and are too much of a liability. According to news accounts, Dr. Carter decided to stop seeing patients like Davidson because three of her staff were injured while caring for obese patients. She also felt other facilities were better able to meet the needs of these patients.

Fair enough, but it makes one wonder where the line should be drawn. People who are aging or have higher-risk medical conditions also can be more prone to complications; should physicians stop seeing them? If it’s too much trouble for a medical practice to accommodate the special needs of overweight patients, should they also stop accommodating patients who are frail, who use crutches or wheelchairs, who don’t see well, who have low literacy or don’t speak English as their first language?

Although back injuries are a very real occupational risk for those who work in health care, proper training and equipment can go a long way toward making it safer to handle overweight or obese patients. And to simply dismiss overweight patients without first attempting to assess their willingness or ability to lose weight seems unfair (as well as an inaccurate generalization that these people couldn’t possibly have health issues or health-related goals other than their weight).

Sadly, numerous studies have documented that anti-fat bias is as prevalent among health care professionals as among the rest of the public. The typical medical school training also tends to be woefully short on education about nutrition and physical activity, with the result that many doctors are ill-equipped to effectively help their overweight patients.

So what – if any – should be the physician’s role in working with this population? A consensus report issued in May by the Institute of Medicine tackles this question and concludes that although policy and environment are significant areas that need to be addressed, doctors also play a key part in reducing and preventing obesity.

The report calls on doctors to be more systematic in assessing body mass index in their patients and talking to them about nutrition and physical activity. It recommends focusing on the patient’s overall health goals, not just weight loss, and providing advice and support to help patients meet their goals.

It doesn’t say anything about refusing to see these patients or delegating them to someone else’s responsibility.

Ethics aside, if doctors profess to be serious about reducing the incidence of American obesity, it’s hard to see how the “it’s not my problem” approach would meet this goal. An opportunity to forge a doctor-patient relationship with Ida Davidson and help her take care of her health was squandered here, and nothing positive was accomplished.

Show me my test results

Many people are perfectly satisfied with having their doctor communicate the results of medical tests and explain what they mean. Others want the results, like, right now instead of waiting for the information to first be channeled through the doctor.

Which way is best?

Once upon a time, there wasn’t much choice. The way the system worked was that the doctor reviewed the test results first, then shared them with the patient. Now all of this is changing, propelled by a growing desire by many people for direct access to their medical information. It’s being further fueled by a U.S. Department of Health and Human Services proposal to expand direct consumer access to laboratory test results, an option that’s currently only allowed in a handful of states, to all U.S. health consumers.

There’s considerable debate, however, over whether this is good or bad, and how the disclosure of test results should best be handled.

By all means, give patients access – but there should be guidance by a physician in order to understand what the test results mean, is the position of uberblogger Dr. Kevin Pho, who recently wrote on the subject for USA Today.

Dr. Pho writes:

Patients should have access to their lab tests. But it is crucial that a medical professional explains the results. Raw numbers without the benefit of context can also cause patient anxiety. Some abnormal results are due to chance or lab errors. Other results can be a normal variation for that individual patient. Many lab results are misleading and not indicative of any disease. Patients often assume the worst, so viewing results alone might cause unnecessary alarm.

He has a point. It’s often difficult for the layperson to sort through the numbers and try to figure out which, if any, are significant. People can become upset by what they see, and it isn’t always easy to allay their fears over something that has been misunderstood or misinterpreted.

On the other hand, why not give patients some credit for being able to comprehend their test results and deal with whatever the emotional fallout might be?

Barbara Bronson Gray, a registered nurse who blogs at BodBoss, holds the latter view. In a recent blog entry, she demolishes all the reasons physicians often give in favor of maintaining the status quo.

Patients might become unduly anxious by their test results. “We’re grown ups. We deal with good and not-so-good information all the time. No one holds my hand when I see what happened to the stock market on a given day.”

Patients won’t understand the results. “Try me. If I don’t understand, I won’t freak out. I’ll just do some research or ask you.”

Patients will take up too much of the doctor’s time asking questions about their lab results. “It doesn’t really take very long to explain what these things mean.”

The debate over direct and immediate access to lab results is an echo of an even larger conversation about access to the complete medical record. It’s a power struggle over information – who has it, who controls it, who decides.

Health care practitioners are being forced to rethink how they’ve traditionally regarded the patient’s medical information. Simply communicating to someone that their test results are “normal” doesn’t (and shouldn’t) really cut it anymore. And given the amount of health information available online these days and people’s willingness to pursue it, the assertion that patients don’t have what it takes to understand their test results is beginning to ring rather hollow.

From the clinician’s point of view, there may be problems and nuances about giving people direct access to their test results – logistics, for instance, or timing – that make this somewhat more complicated than a straightforward case of “gimme my results.” There’s a fine line, however, between honest concern over whether the public is ready for this and plain old-fashioned paternalism. The real question seems to be where that line should be drawn.

What do readers think? Do you want direct, immediate access to your test results or would you rather receive them from the doctor?

The value of doing nothing

For one glorious day this summer, I did nothing.

Well, not literally nothing. The cat was fed, a couple of reasonably nutritious meals were prepared and the dishes were stacked in the dishwasher.

But I didn’t do anything that could remotely be defined as constructive. And it felt so, so good. So good, in fact, that I want to do it again.

Most of us, truth be told, don’t have days like this very often. Why not? Guilt, I suppose. Busyness. A sense of responsibility. Sheer necessity.

Like just about everyone else I know, my life has all these elements, and in spades. But for one day I managed to (mostly) suppress the feeling of I-know-I-really-should-be-doing-something-worthwhile and concentrate instead on the research: namely, that science tells us it’s good to switch off the circuits every so often and let our brains lapse into the calm, quiet space of nothing.

There’s biology behind this. The human brain is an incredibly complex organ, containing billions of nerve cells that process millions of information bits per second. A certain amount of stimulation is good. It’s well known, for example, that infants need physical, mental and emotional stimulation early in life for optimal brain development.

But if inadequate stimulation is bad, so is too much. And let’s face it, the American environment is overripe these days with stimulation, from background noise to occupational workloads to the perpetual presence of laptops and Twitter.

When the American Psychological Association conducted a survey of 1,200 adults last year, 39 percent said they were more stressed than the year before. Work-related stress was the major culprit, with relationships and health problems not far behind.

More tellingly, however, many people seemed to perceive this as normal. “Previously it was seen as something to be fought against,” Marie Dacey, of the Massachusetts College of Pharmacy and Health Sciences in Boston, told USA Today earlier this year. “People are not identifying stress as stress but as part of the norm. Our culture really applauds and rewards that.”

No wonder we often feel guilty for slacking off; it makes us look, well, like slackers.

There are bigger things to worry about than the guilt factor, though. Researchers have found that chronic stress, even the everyday kind, can have a negative effect on portions of the brain that govern impulse control, emotions and physiological functions such as insulin and glucose regulation. Over time, the cumulative impact can literally shrink the brain and leave it more vulnerable when a major stressor or adverse life event occurs.

Doing nothing allows us to step back from the constant stimulation and just let the brain relax. Thoughts, memories, impressions swim up aimlessly without the pressure to do something about them. The racing mind finally has a chance to slow down, and with this slowing down comes more clarity, more attentiveness to the here and now.

As a writer, I’m especially intrigued by some of the research suggesting that creativity and innovation are born out of those quiet times when the brain is meandering and then — eureka! — there’s a flash of insight.

Some fascinating long-term study by the Harvard Business School has found that people are usually most creative in the workplace when they have fewer distractions and interruptions, have deadlines but not intense time pressures, and can allow their ideas to “incubate” while working on other tasks.

Doing nothing may look superficial on its surface, but underneath this tranquil surface a whole lot of beneficial things are happening — and that’s not nothing.

Negative moments of truth

Regardless of what industry you’re in, customer service matters. But if a recent new study is any indication, it especially matters in health care.

The findings by the PwC Health Research Institute are pretty interesting:

- 42 percent of the 6,000 survey participants said personal experience, rather than price, was their most important consideration when choosing a health care provider.

- Personal experience was 2.6 times more important in choosing a doctor or hospital than for other industries, and peer recommendations were twice as important. (Banking, airlines and the retail and hospitality industries were among the industries used for comparison.)

- Six out of 10 health care experiences were defined by the attitude of the staff, making this twice as important in health care than in any other industry.

There are two conclusions to be drawn: Patients value having a good health care experience above all else, and they value it more than a good customer experience at, say, a movie theater or retail store. The report calls it “moments of truth” – the experiences that can cause customers to either love the organization or loathe it.

If I worked in health care, I would sit up and take notice of this survey. For organizations that already place a priority on patient-centered care and the patient experience, it validates that they’re on the right track. And for organizations that aren’t quite there yet, it’s a warning that they’d better start giving more consideration to what matters to their customers.

For what it’s worth, many health care organizations do get it right when it comes to the patient experience. It shows in details such as the receptionist who brings a form to the patient in the waiting room rather than summoning him or her back to the desk. It shows in the hospital housekeeping staff who ask, “Is there anything else I can do for you?” before exiting the room. It shows in the attention being paid nowadays to privacy and dignity, to explaining things to patients before sticking needles into them or subjecting them to a procedure. It shows in more courtesy, more respect and even more interest in what patients think via surveys and feedback.

Although plenty of health care organizations already did this to some extent, it was often hit-or-miss, and it tended to be seen as an added-on nicety rather than essential. This approach doesn’t seem to cut it anymore. The PwC survey found that people were not very forgiving of bad health care experiences – so-called negative moments of truth -  and one-third said they would switch providers if they thought they would have a better experience elsewhere. For those in health care who wonder why public sentiment is sometimes so angry and hostile toward them, this finding helps partially explain why. And as reimbursement increasingly becomes tied to patient satisfaction, the patient’s experience is going to matter whether providers are ready for it or not.

There’s in fact a fair amount of ambivalence in health care about how far the patient satisfaction thing can be carried. Does it mean that the patient’s every whim should be catered to, regardless of whether it’s medically appropriate?

Give health care workers a break, grumbled a registered nurse on the Hospital Impact blog: “It is difficult enough to deal with the increased acuity of illness of the patients but the demands the families are putting on the staff, wanting extra blankets for family, water, food, etc. are taking time away from their loved one. Where does it end?”

Yet is this really what’s meant by “the patient experience”? Or does the patient experience encompass something more?

An article appearing earlier this month in American Medical News tackles this issue by talking to Dr. Mark Friedberg, an internist and researcher at RAND Corp., who says clinicians can deliver good care while also providing a good patient experience. “I don’t think it’s unreasonable to ask clinicians to meet multiple goals,” Dr. Friedberg told American Medical News. “It is possible for highly trained professionals to be excellent in all respects.”

Of many nuggets of information contained in the PwC report, one stands out: Individual attitude is everything. Providing a good patient experience is partly about organizational culture but it also comes down to individual interactions between patient and staff. A handful of people who are caring and competent in their dealings with the patient can help redeem an organization that’s mediocre when it comes to the patient experience. Likewise, one staff person’s abruptness or missteps can undo everything else the organization is doing to improve the patient experience.

It’s not clear how well this lesson has sunk in. Recent new research by HealthLeaders Media suggests that although most hospital executives see the patient experience as a priority, more than half have yet to make a specific investment in bettering the patient experience in their hospital or health care system.

That health care is even talking about the patient experience, let alone making it a priority, is a measure of the progress being made. As recently as 10 years ago, it was only beginning to register on the radar screen in a meaningful way. But expect many more negative moments of truth along the way as health care struggles to change longstanding attitudes and practices in the business of providing patient care.

New flu, old lessons

It feels as if we’ve been here before: New type of influenza is identified, virus begins to spread, public health officials sound the alarm.

This time it’s influenza A (H3N2), which apparently is being transmitted from pigs to humans. As of Thursday, more than 120 cases had been confirmed in the United States since July. The new form of swine flu has been found in four states and is overwhelmingly occurring among young people. A common denominator seems to be state and county fairs where teens are handling or in contact with hogs. Some farmers and veterinarians also have fallen sick.

Should we be worried? By all accounts, at least so far, this new type of influenza virus doesn’t appear to cause severe illness. It seems to have been around for awhile; the first human cases actually were identified a year ago.

Naysayers might write it off as a big deal over nothing, the same way some felt the H1N1 pandemic of 2009 was vastly overblown. Perhaps we shouldn’t be too quick to dismiss it, though – if for no other reason than the reminder it provides of the wily nature of the influenza virus and microbes in general.

Some years ago I attended a crash course on pandemic influenza that included an overview of how readily the flu virus mutates, circulating among various species, swapping bits of genetic material and shuffling the deck in a perpetual evolutionary process. It’s the main reason why flu vaccines need to constantly be updated and why the flu shot you received five years ago might not be very effective anymore against the flu viruses currently in circulation.

For an illustration of just how crafty the virus can be, here’s CNN’s explanation of how the H3N2 swine flu variant arose:

What makes this new version of the H3N2 flu virus different is that it has picked up a gene from the novel H1N1 flu virus that became a pandemic three years ago. This can happen when a person or an animal is exposed to two different viruses at the same time.

Somewhere along the line, H3N2 and H1N1 viruses were present in a mammal at the same time, and the “matrix-gene” (or m-gene) from the H1N1 pandemic virus was picked up by the H3N2 swine flu, creating a new variant version of H3N2.

It is this m-gene that has experts on the lookout, because the presence of the m-gene can make it more easily transmissible to humans.

See what the virus did there?

Even if it’s not an especially severe form of influenza, H3N2 nevertheless has the potential to make many people sick. A vaccine that would offer protection is in development but hasn’t hit the market yet. Widespread flu can lead to absenteeism at work and school and overflowing doctor’s offices. Inevitably, some of the people who get the virus will be particularly vulnerable and could end up becoming extremely sick.

We have only to look around us to see that the battle against infectious diseases is still going strong: Whooping cough. HIV. Ebola. Tuberculosis. Methicillin-resistant staphylococcus aureus. Although people don’t die of infectious diseases in anywhere near the numbers seen 100 years ago, microbes remain very much a global presence to be reckoned with.

They’re incredibly tenacious and adaptable. In a weird sort of way, you almost have to admire the influenza virus for being so ingenious, so mutable. In spite of all the tools constantly being developed to fight them, flu viruses and their companions in the germ world have figured out how to outwit humans over and over.

The early lesson from the new H3N2 swine flu variant? Where microbes are concerned, it’s not a good idea to get too complacent.

Will the mental health stigma ever end?

My calendar today says it’s Aug. 8, 2012. That’s more than a decade into the 21st century. So why does it still often feel we’re back in the Dark Ages when it comes to mental health?

The latest evidence that the stigma surrounding depression and substance use remains alive and well was demonstrated this week in the petty politicking of Sen. Mike Parry of Waseca, Minn., who portrayed Minnesota Gov. Mark Dayton as a pill popper and “scary.”

You can say this for the critics: They were immediately all over Parry like glue on a cheap campaign bumper sticker. Maybe there’s more enlightenment out there than I think.

But would that this were about politics alone.

I don’t know Sen. Parry, I wasn’t at the Brown County Republican fundraiser where the remarks were made, and I wouldn’t presume to guess what he was thinking. But given that Gov. Dayton has been open about his depression and alcoholism, both of which have been treated, it’s hard to see this as anything other than a barb aimed squarely at the “weakness” implied by taking medication for a mental health issue.

And it’s shameful, because the last thing we need is to perpetuate the negative attitudes and judgments that often make it so hard for people to get help.

I had the opportunity last week to visit with some folks at Chippewa County Montevideo Hospital and Medical Clinics, here in west central Minnesota, about a community survey they’re launching this month to learn more about local attitudes regarding mental health and substance use.

The health providers in Montevideo have been working hard in the past few years to get better at identifying people who may have issues with depression and unhealthy substance use and connecting them with sources of help. What they’ve discovered, however, is that it’s often difficult to even begin the conversation. Patients are uncomfortable talking about it; sometimes doctors are uncomfortable too.

It’s hoped that the survey will give Montevideo health providers a better understanding of how their community feels about depression and substance abuse and lead to some strategies that will help.

People don’t get better when these issues stay in the closet. But to admit to being depressed, or to having a problem with alcohol, is to risk opening up oneself to negative judgments by the misinformed. The fact that a public figure would even go there – and on the record, no less – makes it painfully clear that the fear of being stigmatized is well founded.

Consider a poll conducted in 2004 in Tarrant County and Fort Worth, Texas, that found two out of five of those surveyed believed anyone with a history of mental illness should be barred from public office, more than 40 percent believed major depression was the result of a lack of willpower, and fully 60 percent thought “pulling yourself together” was an effective treatment for depression. Or a 2009 study in the Medical Care journal that concluded fear of stigma and how their parents would react was a major reason why adolescents didn’t seek treatment for depression. Or recent research suggesting that one in three U.S. soldiers with post-traumatic stress syndrome doesn’t seek treatment because of the stigma.

Really, the Parry incident shouldn’t be worth the ink being spent on it, except for one thing: the message that is sent by looking the other way.

Untreated depression and substance abuse take a toll on people’s lives, on their quality of life and their human potential. They take a toll on society. The consequences are serious indeed: Of the thousands of Americans who die by suicide each year, the vast majority have an untreated or ineffectively treated mental illness, most commonly depression.

Can we afford to allow the misinformation and stigma to continue? I don’t think so. Please get the facts and get educated. If you can’t or won’t, then at least have the grace to just keep quiet.

Getting a handle on patient harm

The worst harms that befall patients – removing the wrong limb, receiving a lethal overdose of medication, being accidentally set on fire during a surgical procedure – are always horrifying to hear about, yet there’s growing evidence that these are only a tiny subset of all the things that go wrong in patient care.

A raft of studies suggests that in spite of an unprecedented national focus on patient safety, errors and harm to patients remain vastly underreported.

One of the largest of these studies was issued this past month by the Office of the Inspector General of the U.S. Department of Health and Human Services. (A summary can be found here; the full report is here.)

A few take-home points from the report: Nearly one in three Medicare patients experienced an adverse event in the hospital, yet the internal systems created by hospitals for reporting adverse events captured only a fraction of them. Statewide reporting systems didn’t necessarily help either. Overall, 60 percent of adverse events occurred at hospitals in states with mandatory reporting systems – but only 1 percent of events actually were reported, and most of the harms that went unreported to the state system also were undetected by the hospital’s own reporting system.

Several of the events were serious. In one case, a patient died when poor insulin management led to hypoglycemic coma. In another, a patient died of acute kidney failure after the hospital failed to recognize and treat a serious systematic inflammation.

The report notes that even though many of the adverse events required life-saving intervention and undoubtedly would have been noticed by hospital staff, they went unreported.

This was just one analysis of many that have been done in recent years on the ability of the reporting process to accurately identify patient harm. For instance, a 2005 study of a month’s worth of patient visits to an urban, academic emergency room found that only about half of errors were voluntarily reported – and most of the reports came from nurses, not physicians. Other studies have found that voluntary reporting, complaints from patients and even malpractice allegations tend to uncover only a fraction of the things that go wrong.

Although it would be easy to conclude that health care providers are deliberately covering up their mistakes, the real picture is more complicated than this.

One key point made by the OIG report is this: When adverse events weren’t reported, often it was because the hospital staff didn’t recognize that an adverse event had taken place. Indeed, in many cases they seem to have assumed that what happened to the patient was a complication rather than an adverse event.

Cumbersome reporting systems can be a disincentive for reporting all but the most obvious or significant incidents. Many studies also have documented that health care workers frequently remain silent about mistakes because they fear being punished.

For more than a decade, there has been considerable debate in the U.S. over reporting patient safety incidents. Many institutions and health care professionals are adamantly opposed to mandatory reporting, and this is reflected in the fact that only half of states require reporting of patient safety incidents (Minnesota was the first to adopt such a system). Nor is there a national mandatory patient safety reporting system.

By all accounts, adverse event reporting here in Minnesota is fairly robust and seems to capture most of the incidents that meet the criteria for reporting.

But even when states have their own reporting systems, there’s a weakness: They still rely mostly on the honor system in collecting reports, so it’s possible for some incidents to slip under the radar. They tend to be very specific about what must be reported – wrong-site surgery, for example, or serious pressure ulcers that develop or progress during a hospital stay. They also focus on more severe cases of patient harm, hence may miss numerous harms that are smaller and more common yet have the potential to add significantly to the burden on patients, the health care system and health care costs. Moreover, reporting systems focus mainly on the hospital setting, when most encounters for the majority of patients are in medical clinics.

Why report at all? Because it’s only by collecting and analyzing the data that health care organizations can truly see where the vulnerabilities lie. Often the problem areas aren’t what you’d think. When Rice Memorial Hospital here in Willmar did a study on which older patients were more likely to be readmitted to the hospital, they expected it would be those who were still living independently at home and perhaps didn’t have someone checking on them 24 hours a day. But when they actually looked at the data, most of the readmissions were among patients living in nursing homes.

There’s also this to be said for voluntary reporting: It keeps everyone accountable.

Exactly how to define “patient harm” seems to still be evolving. One person’s adverse event might be, to someone else, a known (and therefore unsurprising) complication. Nor is there universal agreement about the extent to which adverse events can be prevented, or mitigated once they happen.

There’s a certain tension here. Should some level of patient harm simply be accepted as an unavoidable consequence of receiving medical care? Or should health care do more to recognize that just because bad things can happen, they don’t have to be inevitable? Those who work deep in the trenches of patient safety would say that even when complications are known and somewhat expected, health care should do its best to keep them from happening – and should be honest about reporting them when they do take place.

Until these tensions can be better resolved, health care likely will continue to struggle with recognizing and reporting adverse events and getting a better handle on the how and why of patient harm.