STATEMENT OF S.A. SKILLICORN, M.D., DIRECTOR OF MEDICAL AFFAIRS, SAN JOSE HOSPITAL, SAN JOSE, CA

Dr. SKILLICORN. Thank you.

I appreciate the invitation to appear before the subcommittee. I have submitted a statement which is comprehensive. I would like to paraphrase some of my views for the sake of time.

I want to make it quite clear I appear as an individual. I do not represent any medical organization in my testimony. My remarks reflect my personal experience devoted over the past decade, or so, to quality assurance in hospitals.

I picked up the inference this morning in the discussion about health services in the military that at least implicitly all goes well in the civilian sector. I am here to testify that all does not go well in the civilian sector.

The quality of civilian medical care in the United States, in my opinion, is not nearly as good as it should be. Even the widely publicized clinical calamaties and horror stories that occasionally break through the heavy curtain of concealment surrounding the health care industry do not reflect the extent of the problem.

Something must be done to improve the situation. I have found that is not easily accomplished because most health professionals are reluctant to admit there are serious deficiencies in the health care delivery systems, particularly in hospitals, where our sickest patients are treated.

Hospital leaders prefer to dwell on the good things that happen in American medicine today. When they do face up to the problem of impaired quality, they tend to look for scapegoats.

There is a growing conviction that the solution for substandard medical care is simple, that all we need to do is to identify those physicians who are clinically, physically or mentally incompetent, and remove them from the health care system.

I wish it were that simple. There is no question that tougher licensing credentialling and peer review procedures for physicians need to be instituted in order to weed out the incompetents.

However, it is my opinion that incompetent physicians represent just the tip of the iceberg of inadequate quality controls. Bad doctors account for a very small percentage of the total spectrum of breakdowns in the quality of patient care. As a matter of fact, more often than not it is our very best physicians who are involved in patient care tragedies. So, why does substandard care exist?

Well, my experience has been that most medical mishaps occur because of inefficiencies in the internal systems of care, particularly in hospitals. With the growing complexities of medical and surgical treatments in the past two decades professionals have become increasingly dependent on those systems of care.

Unfortunately, many of those systems are obsolete and inadequate. They are in need of drastic revision. Let me describe one example.

Currently it is being recommended that mortality and morbidity rates, that is death and complication rates, be established as a

prime method for the measurement of performances of individual physicians and of hospitals. The belief is that the profiles will reflect the level of the quality of care.

There is even talk of installing a national data bank of physicians' mortality and morbidity profiles that can be evaluated.

Obviously, monitoring of deaths and complications is important, but it is after the fact. By the time incompetent physicians are identified, patients have suffered serious damage. I am personally very uncomfortable with the knowledge that as a patient I may involuntarily become a statistic in a mortality data bank that eventually demonstrates I got there because my physician and my hospital were incompetent.

Perhaps the retrospective information will be of benefit to future patients, but I would prefer to contribute to their well-being in some manner other than self-sacrifice. Seriously, that is the way the present review system works. It is always after the fact.

To my mind, there is an urgent need to establish concurrent reviews of health care professional activities. That is, we need methods to measure performances while they are happening. We must find ways to prevent bad outcomes through stricter surveillance of the processes of care, not just identify and evaluate adverse events after they have occurred.

Our traditional practice of "learning from our mistakes" is simply too hazardous for patients. We have got to find better ways to measure quality.

It is my conviction that the revision of our medical delivery systems can be accomplished more expeditiously in the armed services than in the civilian sector. The military has the organizational advantage of operating under a structure of authority that is lacking in civilian hospitals.

Resistances to change in the highly competitive civilian health care system are so intense that the modifications that will be necessary to favorably impact the quality of patient care are not likely to occur in the near future. It is going to take a significant change in economic incentives to turn the civilian system around.

The incentives presently do not encourage the provision of quality care. The military medical services have the unique opportunity to become a model for quality health care in our Nation. All they need is the commitment, the determination, and the support to do so. I sincerely hope that the armed services will accept the challenge.

Thank you.

[The prepared statement of Dr. Skillicorn follows:]

PREPARED STATEMENT BY S.A. SKILLICORN, M.D.

A career change more than a decade ago placed me in an opportune position to devote full time and energies to hospital quality assurance work, including evaluations of numerous American hospitals. The experience has allowed me to formulate some personal observations and opinions regarding the current status of quality controls of health care.

The care of patients in American hospitals in large part is good, but it is not nearly good enough. The mission of hospitals is to provide and facilitate quality health services. Unfortunately, they have forsaken much of that responsibility. Things happen to patients that should not happen. Sometimes they are terrible things that occur because operational budgets, building programs, external regulations, exciting new technology, and other activities of survival and expansion receive more attention than does the basic quality of care.

This poor order of priorities is causing hospitals and physicians to lose control of their own destinies. Various external forces are starting to move into their territories to accomplish what they have failed to do. The growing malpractice crisis has upset them. They have deluded themselves into believing that a lawsuit-hungry public and overzealous attorneys are primarily responsible for their plights. They are wrong. Lack of adequate quality controls is why troublesome events occur in hospitals. There are far more episodes of malpractice occurring without the attendant filing of a liability claim than there are occurrences where claims are filed. The public is beginning to recognize that fact. So long as hospitals, their medical staffs, and their governing boards continue to treat the quality of patient care casually and so long as the public becomes more knowledgeable and plaintiff attorneys become smarter, things are going to get worse. The malpractice crisis will be turned around only when malpractice is curtailed. It is for physicians and hospitals to accomplish this task by significantly improving the quality of care that they render. Mishaps in hospitals do not occur under complicated or sophisticated circumstances. They usually result from simple oversights, absentmindedness, or neglect. Most of the breakdowns occur because of patient care performance deficiencies, not because of a lack of knowledge or training. Busy professionals become involved with other duties, they are interrupted or easily distracted, or they become nonchalant in their work. They begin to believe that mistakes are inevitible, and they treat them as expected risks of being hospitalized. When such an attitude takes over, people begin to make even more errors.

Although the majority of patient care mistakes are due to errors in the performances of individuals, the professionals making the errors usually do so because of inadequacies in the hospital systems. Some of the systems even appear to have been designed to allow or to encourage breakdowns. There is a paucity of check and double check practices. The situation will not improve until those systems are revised. But comfortable traditions and long-standing occupational behavior habits are so dominant in hospitals, that proposed changes often meet with much skepticism and resistance.

Physicians play a major role in the management of patients. Yet the system used to determine the competency of physicians in the hospital setting has some serious deficiencies. The focus is predominantly crisis oriented and punitive directed rather than problem oriented and preventive directed. Almost all peer reviews of physicians' performances are retrospective rather than concurrent evaluations. Some adversity has to happen before review takes place.

Because physicians are in authoritative positions, most of the mandated patient care evaluation regulations have been directed toward them. However, it is important to recognize that they have minimal personal involvement in the 24-hour care of hospitalized patients. The majority of care is provided by other professionals who are under the supervision of hospital management. Evaluation of performances logically should be applied to all other professionals as comprehensively as it is to physicians. But evaluation systems under hospital management are frequently inadequate, and the evaluations that do take place tend to be highly subjective and lacking in uniformity.

Management attitudes are influenced significantly by external pressures. Numerous governmental regulations and detailed standards developed by the Joint Commission on Accreditation of Hospitals have been imposed upon hospitals to keep them functioning at least at a basic level. Unfortunately, hospitals become smug once they have met those mandated standards, and a minimum-requirement mentality pervades the institutions. Some hospitals even resent the enforcement of the minimum standards. Improvement of quality controls will not occur until hospitals increase their commitments to quality assurance programs and until minimum-requirement attitudes are overcome.

The Joint Commission on Accreditation of Hospitals in 1980 published new standards for quality assurance, and over the past few years there has been considerable pressure exerted to ensure hospital compliance. The standards represent a good start, but much more needs to be done. The foundation has been laid for taking a really important step in quality assurance beyond the passive, ritualistic, retrospective methods of today's patient care evaluations. Death chart reviews, a traditional form of peer review, are of some benefit in helping us learn from our mistakes, but they have virtually no

value to the patients who have died as a result of medical error. A more dynamic, system-oriented and problem-oriented approach is needed with concurrent and prospective reviews that evaluate situations while they are happening, if not before they happen.

Earlier this year I had the opportunity to make a rather thorough evaluation of the quality assurance program of a large military hospital. It is an excellent program that compares favorably with most civilian hospitals that I have visited. Recently I participated in a Department of Defense Health Council Conference in which I became familiar with the quality assurance policy directives which the DoD Health Affairs has promulgated over the past three years as well as future quality assurance activities planned by DoD Health Affairs. I am impressed by the obvious commitment of William Mayer, M.D. to improve the quality of health care in military medicine. I believe he has made an excellent start in the right direction. The task that lies ahead is formidable.

Although my knowledge about the present status of the quality of medical care in the military is limited, I am convinced from what

I have learned recently that health care problems in the Armed Services are probably not significantly different from those that exist in the civilian system. Unfortunately, the shortcomings in the military sector have been receiving considerably more publicity than have those that occur regularly in civilian hospitals.

In my opinion, the Armed Services are in a far better position to improve the quality of American health services than are their civilian counterparts.

Improving the quality of care in hospitals, whether they are civilian or military, will not be easily accomplished. Lifelong patterns of professional behavior will have to be changed. Coveted inner sanctums of patient care will have to be invaded and the mystique of their functions erased. Peer review, especially physician peer review, will have to become more comprehensive and much more aggressive. There are serious matters about the preservation of confidentiality that have to be worked out. There are also important financial considerations that will have to be addressed--quality is never cheap. Indeed, it is going to be very difficult. Nevertheless, it has to happen. It is no longer a matter of choice; it is a matter of necessity. Quality controls must remain as the "conscience" of all health care systems.

October 1, 1985

flakey. Skillica

Stanley A. Skillicorn, M.D.
Director of Medical Affairs
San Jose Hospital

San Jose, California