More than a century ago, pioneering Boston surgeon Dr. Ernest Codman came up with what was then a revolutionary idea. He argued that clinicians should follow patients long enough to evaluate whether the care they received had the desired impact. And, crucially, he argued that health care should share the results of these evaluations with the public.
Codman called this the “end result idea” and his thinking became the basis for the American College of Surgeons’ hospital standardization movement. It cemented “transparency” as an essential lever in every effort to improve the quality of health care.
So, why does an idea first developed over a hundred years ago still make health care leaders nervous?
A Powerful Catalyst for Change
Although we’re decades removed from the old mindset that transparency is a bad risk – that all it does is invite litigation – full and open transparency is still hampered by fear, from both individual and organizational perspectives. There is fear of competition, fear of judgment, fear of harm to reputation, and yes, fear of litigation. But fear should never get in the way of doing the right thing. And I’d be surprised if many disagreed with me that being fully transparent is the right thing to do.
Fear of transparency often comes from how certain shared data are used. It’s important to use data to publicly report and monitor information vital to an accurate assessment of performance. But using data only in this way can range from being ineffective to genuinely counterproductive. IHI has always urged improvers to “use data for improvement, not for judgment.” This approach to, and understanding of, data needs to be embedded in organizational culture.
It’s a leader’s job to create, if absent, and nurture, if present, a culture that celebrates the recording, analyzing, sharing, and use of data to drive and refine improvement. Transparency is a crucial characteristic for effective leadership in health care — especially leadership for improvement. It’s one of the five “high-impact leadership behaviors” in IHI’s High-Impact Leadership Framework. As IHI’s White Paper on this topic asserts, “Transparency is a powerful catalyst for organizational change and learning. It entails sharing data that demonstrates both positive results and defects, and helps reveal opportunities for improvement. Leaders need to be open and firm about the organization’s commitment to — and expectation for — transparency and a path to action for eliminating defects.”
Without full transparency on outcomes, quality, safety, and costs, we’ll never be able to accelerate the pace of improvement. Just as important, I think, are the ways in which full transparency opens up conversations with patients about their outcomes; their wants and needs; and their invaluable ideas about how to improve care.
Transparency from the Patient’s Perspective
Effective dialog with patients requires both full and frank transparency on our part, and transparency from the patient’s point of view. In other words, we as leaders need to ensure that the transparent information we’re sharing with patients, both in individual interactions and publicly, has meaning for them. We should create sets of measures that give patients what they need to engage in this dialog. And once the dialog has occurred, we need to follow up on patients’ ideas and recommendations.
When I was a health system CEO, we used something called Patient Opinion – an independently moderated website where patients could record their feedback, good and bad. And they did, good and bad. But the important thing is that the staff member or team can respond online, and create a dialog. Often the staff member would respond and include their phone number with an invitation to “Give me a call to discuss this further.”
Then the changes made by staff are also recorded on the website. You get the feedback from the patient about their experience. You get the response of the team who were caring for that patient. And you get a record of the changes that were made. I looked at the website just the other day, and there are over 200 changes recorded that have been made directly as a result of transparency around patient experience.
Transparency Builds Trust
The final point I want to make is one that’s obvious, but can nevertheless get lost among arguments over measures and ratings: Transparency builds trust.
Trust is essential to the healing relationship between patient and provider. Here in the US, we know that mistrust of health care is a key driver for persistent health inequities among people of color. Health care without trust is a waste of time and money. Trust can also go a long way to mitigating one of the fears I discussed above — the fear of litigation.
Despite decades of progress in making care safer, errors still occur. And with the stakes so high in health care, litigation will also sometimes occur. Studies on this issue reveal a fundamental truth: Transparency doesn’t invite litigation; on the contrary, transparency and the trust it builds can prevent litigation (see "When Things Go Wrong: Responding to Adverse Events").
We’ve repeatedly heard from patients who have experienced harm that what they truly want from the providers that harmed them is an apology. But an apology in the absence of transparency, humility, and trust is not likely to suffice. There is a direct line of sight from transparency to humility to trust, and finally to forgiveness. The evidence shows that one of the things that leads to patients taking the step of suing the health care system is when they sense that someone is hiding something from them, that there’s dishonesty. Transparency is the antidote to that.
Thankfully, we’ve come a long way since Dr. Codman. And it’s a good reminder that one era’s “radical” idea becomes a subsequent era’s foundation for improvement. Yet the temptation to be less than fully transparent in health care persists — driven by both systemic and human factors. With new payment structures based on value and outcomes, transparency is more important than ever. Even if these environmental changes weren’t taking place, being transparent with patients is necessary to truly engage them in improving care and health for them, and for all.
Editor’s note: Look for more from IHI President and CEO Derek Feeley (@derekfeeleyIHI) on leadership, innovation, and improvement in health care in the “Line of Sight” series on the IHI blog.