Friday, November 13, 2009

Welcome to Lake Wobegon!

Last Monday, over at the Wall Street Journal Health Blog, Jacob Goldstein was not kind to the residents of Lake Wobegon, calling out their leaders for believing that Only 1% of Hospitals are Below Average. Goldstein's piece shares findings from a study by Jha and Epstein published in Health Affairs this month, one that links knowledge and value ascribed to clinical quality on the part of not-for-profit board chairs to the quality measures their organizations post. [link]

Additional findings from Jha and Epstein's survey of 1,000 not-for-profit hospital boards chairs between November 2007 and January 2008 include:
  • less than 1/2 of respondents rated “quality” as one of their “top 2” priorities
  • 3/4 reported their hospitals had “moderate” or "substantial” expertise in quality of care
  • only about 1/3 had received formal training in clinical quality measures
  • when clinical quality training was included in education provided to the board, the mean amount of instruction time was 4 hours 
  • less than 1% rated their hospital's performance as worse or much worse than a typical hospital's performance on standard quality measures (like The Joint Commission's core measures or other publicly reported measures)
When you dive deeper to find the "take-away" lessons from data like these, resist the urge to see the chairs' overly optimistic assessments as nefarious or necessarily careless. Their estimates are, in point of fact, consistent with what people do when they are asked to evaluate their performance relative to others. Cognitive psychologists call this bias illusory superiority, and it describes the tendency of people to overestimate the degree to which they possess desirable qualities relative to others or underestimate their negative qualities relative to others. It fact, illusory superiority is referred to as the "Lake Wobegon Effect."

The real take-away lesson here is that the Lake Wobegon Effect is proportional to the specific knowledge and skill a person is asked to rate. If you ask someone who plays ball how well he plays compared to others, he will provide a more accurate assessment than if you ask someone who has no experience with ball at all. Wildly optimistic estimates of performance suggest profound lack of experience.

This means that board chairs often don't know enough about quality to know whether the organizations they oversee reliably deliver quality outcomes. I don't fault them for their "glass half full" outlook (which likely serves them and their organizations well on other fronts). But I do worry who is in a position to tell the emperor about the problem with his clothes.

Two places where you'll find this being done, albeit a bit more genteelly, is the Institute for Healthcare Improvement's Boards on Board and creative partnerships, like the one housed at, that help make the National Quality Forum's Safe Practices expectations come to life through free webinars and web-accessible transcripts.

Closer to home, though, finding a credible champion for quality and patient safety becomes more challenging. What powerful community leaders know and believe likely mirrors the opinion of powerful people in the organization and the community. I'm sympathetic to where board leaders find themselves these days because for most of my career, I've lived in the same "small towns" they govern.

Healthcare culture values processes that rely on knowledge contained in human memory and devalues those that rely on more mundane performance shaping measures. For a very recent example of how this thinking shapes culture, consider this tweet I picked up from a PSO insider yesterday:
"I had one surgeon tell me that checklists are for the lame and weak"
If the chair of your local hospital's board (or one of her close family members) hasn't been the beneficiary of physicians, nurses, and pharmacists who hold similar opinions, you may indeed be somewhere very good. But it's a very different place from where the average American gives, receives, and oversees care.

Healthcare is a place where "intention" still trumps "outcome." Jha and Epstein reinforce the need for senior decision makers to become familiar with how desirable quality outcomes are fostered, then measured in healthcare.

Everyone else in town needs these lessons, too. It's easy to become lost under the standard normal curve out here.

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