To improve safety, hospitals should make ‘radical transparency’ a reality


VSovid-19 may be backing down, but it’s leaving a quiet threat lurking in hospitals in its wake.

In a Perspective essay in the New England Journal of Medicine, four senior doctors from the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention warned of a “serious” decline in patient safety after Covid. The Association of Professionals in Infection Control and Epidemiology came to a similar conclusion, warning of an increase in “common, often fatal” infections.

To help reverse this troubling trend, federal medical leaders have called for “promoting radical transparency.” Although they did not detail what it should entail, our years of work in the area of ​​safety and quality strongly suggest that “radical transparency” must be radically different from current efforts, both in form and in content, in order to successfully catalyze real change.


Medical care is intensely personal; buying cancer care is not like buying a car. That’s why we believe that adapting the psychological principles of Maslow’s Hierarchy of Needs as an organizing framework, coupled with information design principles, can dramatically boost both the use and impact of safety and quality information.

Psychologist Abraham Maslow postulated in a landmark 1943 paper that human behavior is driven by an increasing set of needs. Its main categories can be roughly mapped to categories used to measure quality of care. The most basic physiological need is survival (mortality), followed by protection from harm (complications). There is also esteem or respect for others (patient experience) and, finally, self-realization (functional status).


Marketers have long known that Maslow’s hierarchy can be exploited to drive desired consumer behaviors. Using the framework, one marketer noted, can get customers thinking about a problem causing “stress and anxiety” and “how your product or service can fix it.”

Is there a problem that causes more “stress and anxiety” than illness?

As the Covid-19 pandemic has shown all too clearly, how information is presented is crucial. Numbers alone can be numbing. In contrast, intelligent information design focuses on organizing and simplifying complex information so that users can grasp it quickly.

A famous example in health care is the “coxcombs” chart designed by Florence Nightingale in 1855, which The Economist ranked among the “three of the best charts in history”. He converted statistics on the deaths of British soldiers during the Crimean War into a graph showing that more soldiers died from infections than from wounds. The impact on military hospitals was immediate.

Compare that with the US government’s Care Compare site on hospital quality. It uses long lists of comparative numerical data on technical indicators that are both complex and confusing; for example, two hospitals close to one of us (MM) were “no different from the national benchmark” for the rate of abdominal hysterectomy surgical site infections, even though one had one rate of 2.786 and the other of 0.313. The site is topped with a “star” rating system, the reliability of which remains controversial. Most online health reports are built in the same vein.

“Radical transparency” requires something radically different.

Applying Maslow to Maternity Care

To illustrate what a more powerful representation of information might look like, we compared maternity care at three Baltimore-area hospitals based on quality data from the Maryland Health Care Commission website.

A visual approach based on Maslow’s Hierarchy of Needs could help consumers better understand hospital safety ratings. STAT

To start, we mapped Maslow’s categories to the categories used by the site: “Am I going to be safe?” mortality and complications; “Will I be heard? » the patient’s experience of care; and “Will I be able to live my best life?” in functional state. The graph is intended to show a hierarchy, while the shape and color of each metric indicates above average, average, or below average performance.

In a dynamic web-based version, a user could mouse over various elements to get detailed information such as the actual quality score and its statistical significance. For example, the category “Will I be safe?” can use patient videos and a hospital’s Leapfrog note to tell an easily understandable and emotionally resonant story. “Will I be heard? could incorporate patient reviews from Yelp. (Yes, those can be valid.) “Will I be able to live my best life?” could include measures of patient-reported outcomes regarding their quality of life after discharge from hospital.

As we are neither information design professionals nor psychologists, we are sure that there are other possible improvements.

Jhe opportunity to use radical transparency to bring about radical improvement in patient safety is a valuable opportunity that the nation cannot fail to seize. Before the pandemic, a quarter of hospitalized Medicare patients experienced some kind of harm, according to a new report from the Department of Health and Human Services. HHS separately estimated that even before the pandemic, preventable medical errors killed some 200,000 men, women and children in the United States each year. With a “severe” decline in patient safety, how much higher is that death toll today?

Playwright Oscar Wilde once observed that a cynic is “a man who knows the price of everything and the value of nothing”. Without quality and safety information to supplement health care price tags, the effort to move to a value-based system will fail, and the cynicism of “more is better” and “more is expensive, best quality” will continue to reign.

The hospital industry has been shy about transparency since the first large-scale quality survey was conducted by the American College of Surgeons in 1919. While only 89 of 692 hospitals met minimum standards, college regents went down to the basement of the hotel where they were gathered and threw the pages into the furnace. A similar recalcitrance has resurfaced regularly since then, if not in such dramatic fashion.

Radical transparency involves rocking the boat. Are professionals now sounding the alarm about patient harm, ready to force change urgently even if it upsets some powerful groups?

That I am safe, that I am heard and that my care allows me to live my best life are emotional, even existential questions that have become more urgent since the emergence of Covid-19. Applying information design principles to Maslow’s Hierarchy of Needs framework is a deliberately radical effort to provide information that resonates emotionally and intellectually, thereby empowering and motivating each individual to choose the best and most sure.

Michael L. Millenson is president of Health Quality Advisors LLC and adjunct associate professor of medicine at the Feinberg School of Medicine at Northwestern University. J. Matthew Austin is Associate Professor of Anesthesiology and Critical Care Medicine at the Johns Hopkins Armstrong Institute for Patient Safety and Quality.


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