Safety in a recession?

That hospitals are under financial stress in 2009 is not a secret to anyone who has been reading the newspapers, trade journals or your own organization’s financial statements. Investment income (on which too many institutions had become dependent) has dropped off the map, and philanthropic giving is now following suit. Patient volumes have plummeted, as financially strapped patients postpone or forego elective procedures. The rating agencies have issued “negative” outlooks on hospitals, and credit downgrades far exceed upgrades. Many hospitals are tripping the triggers for “days cash on hand” on their bond covenants. Hospital leaders’ response has been exactly what one would expect. In many settings, capital spending has come to a halt. More than half of all U.S. hospitals have cut staffing expenses. More than one-fourth of hospitals have eliminated or reduced services. Most of these steps are painful, but some of them might also be unsafe. Many hospitals have made substantial improvements in safety during the last 5 to 7 years--times that in retrospect will likely come to be viewed as the “good years,” financially speaking. We are aware of dozens of hospitals where hospital-acquired infections have been reduced dramatically, medication safety has improved by an order of magnitude, and risk-adjusted mortality rates have dropped by 20 percent or more, during this time. These results are no accident. They have occurred because hospital leaders chose to pay a new level of attention to safety and to make additional investments in infrastructure and technology. The resulting improvements are gratifying--and fragile. In many cases, these improvements have not been permanently “baked into” the hospital’s operations and culture but continue to depend on special attention from leaders and managers, new levels of measurement and support from the quality staff, and other add-ons to care processes that leaders chose to make during the good years.