Find the Black Box: Prevent Needless Hospital Deaths

Find the Black Box: Prevent Needless Hospital Deaths

by Ira Williams


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Product Details

ISBN-13: 9781491702451
Publisher: iUniverse, Incorporated
Publication date: 08/09/2013
Pages: 302
Product dimensions: 6.00(w) x 9.00(h) x 0.68(d)

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iUniverse LLC

Copyright © 2013 Dr. Ira Williams
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ISBN: 978-1-4917-0245-1


Who is Responsible?

STATES are responsible for our nation's healthcare delivery system. It's that simple. Why? Because of two fundamental facts:

(1) States license doctors, and (2) all medical care is local.

I assume no one will attempt to deny that states license doctors, therefore I will focus on the second point for a moment with a quote from a New York Times OP-ED article, "10 Steps to Better Healthcare" by Atul Gawande, Donald Berwick, Elliott Fisher and Mark McClellan, all medical experts, in August 2009.

"But all medicine is local. And until a community confronts what goes on in its own population – to the point of actually seeking the data and engaging those who can solve the problem – nothing will change.

YES, I say!!! From the horses' mouths! I assume no one will wish to dispute those words from these impeccable medical sources.

However, I see two problems with any community trying to find what is needed to confront such matters.

First, these four experts fail to explain exactly how any community can CONFRONT, OBTAIN DATA, and ENGAGE THOSE WHO CAN SOLVE THE PROBLEM.

Second, since MORE PEOPLE ARE DYING NEEDLESSLY in our nation's hospitals now than were dying needlessly over two decades ago, where and how might community members engage those who can SOLVE the problem?

More importantly, can those four medical experts identify such a healthcare "problem solver" in any community in the nation? They couldn't then, and they still can't today.

There are too many "quality of healthcare experts" out there who are speaking out of both sides of their mouths—but that is just my opinion.

Chronological Review of Key Facts

1990: Healthcare experts estimated that 98,000 preventable hospital deaths occurred annually.

1999: Healthcare experts (in To Err is Human) claimed to have a comprehensive strategy to reduce preventable medical errors, and set a minimum goal of achieving a 50 percent reduction in errors over the next five years.

2008: National Quality Forum (NQF) reported that patient safety measures in our nation are improving only 1 percent each year.

2009: National Patient Safety Foundation presentation "Reflection on the Past 10 Years: Why Have We Not Gotten Further?" by Lucian L. Leape, MD (co-leader of the 1990 report) and Janet Corrigan, PhD, MBA (coeditor of To Err Is Human) is made to a select, non-public audience.

2009: Doctors Gawande, Berwick, Fisher, and McClellan assert that ALL medical care is local.

2010: Dr. Spence Taylor, Greenville Hospital System, says, "Even if you cured cancer, you couldn't get it to the people because the medical system is broken."

2012: Sully Sullenberger says, "There are 200,000 preventable deaths each year in the US healthcare system. It is like having 20 Boeing 747 airliners going down each week."

"Our" Problem

No one, and I do mean no one, within the entire army of quality of healthcare experts ever provided the slightest evidence of any recognition (since all medical care is local and state's license doctors) that each of the fifty states bears the major responsibility for the creation and maintenance of an effective healthcare delivery system. Thousands of patients continue to die needlessly in our nation's hospitals (and surgery centers), and no one appears to recognize those two fundamental truths about healthcare.

Back in 2010, when I asked one of the "premier" patient safety experts in the world, Dr. Robert M. Wachter, "How do you get your system of systems errors to all of the hospitals in the nation?," he acknowledged, "That's a problem."

Now my (our) "problem" is this: How do we get the army of quality of healthcare experts, and everyone else, to recognize that the healthcare delivery system is a state responsibility—so that states can actually then accept that responsibility? I have three reasonably simple steps to offer those who wish to better understand the state responsibility.

Finding the Black Box

The tragic loss of the Air France airplane that crashed in the South Atlantic (with no survivors), and their protracted and ultimately successful search for the two black boxes contained in that aircraft, planted the seed in my mind for the creation of this exceedingly informative, yet simple test of any state's healthcare regulatory system.

My first "brilliant idea" for how a state, any state, could better recognize the flaws in their current healthcare delivery system involves a comparison between two existing state regulatory agencies in South Carolina. I first presented this simple idea to my state representative, at that time the House assistant majority leader and a young (to me) attorney who I liked and respected very much. I assumed he would be able to see the logic in this simple idea.

Unfortunately such was not case. Within this book, I have the opportunity for a broad scope assessment of what I feel this simple test offers to any state's leadership strong enough to consider it.

First Step toward a State Regulatory Agency

Consider the tactics of Mothers Against Drunk Driving (MADD)—a well-recognized force in most state legislatures. Over the years they have found awaytocompelstatelegislatorstohearthemandreactfavorablytotheirwishes. Such was the case in South Carolina several years ago that led to legislative changes regarding the DUI regulatory mechanism that eventually resulted in positive improvement in that state's drunk driving statistics. This positive step was so desperately needed (though much more needs to be done).

I offer a simple diagram of the point I am seeking to make.

Next Step

In 1947, at the request of the South Carolina sheriffs, Governor Strom Thurman established by executive order the State Law Enforcement Department (SLED). This department was created to provide assistance to all law enforcement agencies and allowed to delegate authority, through a regulatory mechanism, to the city police, county sheriffs, and the state highway patrol (the three recognized local agencies also mandated to regulate drunk-driving violations).

South Carolina's highest level of AUTHORITY created a state agency with authority sufficient to further delegate authority to local agencies—each of which had been created to provide ACCOUNTABILITY within their designated areas. However, that process of DELEGATING AUTHORITY to the local level required the presence of an intermediary regulatory mechanism, which I have euphemistically placed in a BLACK BOX. South Carolina legislators were later able to assess the benefit of their legislative improvements in their state's DUI regulations by revealing the results obtained from those three local law enforcement agencies throughout the state.


Who would have believed? Those prone to negativism will instantly jump to the fact that, "It's not perfect!" Well, no regulatory process run by humans will ever run perfectly; but it's better than what anyone might find in most parts of the world, and at least as good as other countries who try to do the same.

Let's now compare the regulatory mechanism that made a difference with DUI regulation to that assumed regulatory mechanism within the South Carolina healthcare delivery system.

South Carolina's highest level of authority created a State Board of Medical Examiners, as did every other state, more than 100 years ago. Some states (Alaska, Arizona, Hawaii, and New Mexico) had medical examiner boards even before they became states. The South Carolina State Board of Medical Examiners, like every other state board of medical examiners, was mandated to regulate the practice of medicine as provided by physicians within that state's borders.

A similar process (that was noted for the regulatory efforts involving drunk driving) is necessary for similar regulatory efforts regarding the practice of medicine. Figure 2 depicts the South Carolina regulatory mechanism for the practice of medicine. The State Board of Medical Examiners is assumed to have been provided with sufficient authority to delegate authority through a regulatory mechanism to the LOCAL LEVEL of medical patient care.

Remember: All medical care is local. If you license them, you are obligated to regulate them!

FIND the Black Box Containing the Medical Regulatory Mechanism

The primary component of each state's board of medical examiners is to "regulate the practice of medicine." Therefore one can presume that each state's board is where one should look for that state's medical regulatory mechanism. But don't be surprised if each state's board of medical examiners has difficulty producing such a mechanism.

In fact, hospitals (and surgery centers) are the ONLY places in America where an accidental death receives NO immediate review by a STATE SOURCE OF AUTHORITY.

Stop and think about that. An estimated twenty Boeing 747 airliners going down each week in our nation's hospitals—and no one in any state can FIND their state's medical regulatory mechanism? And none of the army of quality of healthcare experts has seemed to notice. The exercise of any state's efforts to find their Black Box might prove comical except for the fact that so many people are needlessly dying in their hospitals.

How to Demand this First Step

Those who have lost a loved one to a needless hospital death can take a page from the MADD playbook, and come together under one umbrella, and with one purpose. Collectively confront your state legislature and demand that they replicate their efforts in the past for MADD, and now find (identify) their state's medical regulatory mechanism. Any effort to find the medical regulatory black box should bring them to the next demand.

Second Step

The best and quickest way to find out "Why Have We Not Gotten Further?," and why "Even if you cured cancer you couldn't get it to the people, because the medical system is broken," is to demand that some source of state authority begin to immediately track who responds, and how they respond, to the next needless hospital death in their state's healthcare delivery system.

People may be surprised, but shouldn't be, that no one in any state healthcare agency even hears about such tragic events until well after the fact, if at all. To find out how bad each state's healthcare delivery system truly is, try to track the response to a needless hospital death within your healthcare delivery system. Good luck!

The first and second steps go hand in hand to demonstrate how each and every state's healthcare delivery system is truly broken and how every governor and state legislator, past and present, have always been clueless regarding one of the most important components of their state's efforts to provide for their citizens.

Take special note of the sources that choose to speak against these tests and their potential for providing need-to-know information of a critical nature. Theoretically, every state governor and legislator should want to know, in detail, how their current healthcare delivery system functions. In reality, most governors and legislators would actually prefer not knowing, and just continue kicking that can down the road. (If you license them, you are obligated to regulate them!)

Third Step

This third step is offered to demonstrate how the army of quality of healthcare experts has completely failed in recognizing each state's responsibility regarding the healthcare delivery system.

There are reported to be forty-seven accredited schools of public health and seven associate schools. I assert that not one school of public health can be found to have a department head, or faculty member, who has written and taught on those two fundamentals of healthcare: that all medical care is local and states license doctors, therefore, states are responsible for the creation and maintenance of an effective healthcare delivery system. If my assertion were even only marginally true, this still illustrates the failure to recognize each state's responsibility in healthcare.

Now back to Dr. Elizabeth McGlynn, from the Rand Corporation, who said in 2004, "Only a fundamental redesign of the health system will improve the situation."

The major premise of Find the Black Box mirrors Dr. McGlynn's judgment of the situation except for one point: "redesign" assumes there is sufficient organizational structure in the current system to start with to allow for rearranging of the parts. The only way to save the healthcare delivery system at this point is to finally, and FOR THE FIRST TIME, begin to create a healthcare delivery system that recognizes the state's responsibility to create and maintain such a system.

Despite Machiavelli's view that there is nothing more difficult than attempting to create a new system, healthcare is important enough to attempt the almost impossible. Surely the nation that allowed men to walk on the moon and return them safely can assemble the expertise to create a healthcare delivery system based upon each state's responsibility. I offer a plan that goes far beyond anything ever imagined in this regard, but more on that later.

First Obstacle

Find the Black Box is predicated on the seemingly undeniable fact that states bear the major responsibility for the creation and maintenance of their state's healthcare delivery system—and—chaos will continue to reign in that aspect of healthcare until and unless that fact is recognized and dealt with in a meaningful manner.

The initial obstacle in redirecting all considerations for healthcare delivery system change is how to clarify and overcome the overwhelming focus on controlling the cost and access of healthcare—as if that would eliminate many, if not most, of our current healthcare problems. Sadly, nothing could be further from the truth. It is time to confront this first obstacle.

Two Aspects of Healthcare

In every discussion or conversation I've engaged in regarding healthcare during the years since writing two books about our healthcare delivery system, it took only moments for the other person to turn the subject to how to pay for healthcare after the fact.

Cost and access issues are vitally important and clearly in great need of increased understanding that would hopefully lead to beneficial change in each. However, even a perfect solution there, if possible, would still leave our nation with a broken healthcare delivery system. The "decision makers" don't get that.

I am convinced that I cannot repeat that point often enough to make people realize that the healthcare delivery system is just as important, and just as messed up, as how to pay for healthcare after the fact. They are each different aspects of the system as a whole, and each much be dealt with separately. These two vital aspects of our current healthcare system must be dealt with in complete isolation, one from the other.

Regina Herzlinger, in her book Who Killed Healthcare?, wrote that due to her three decades as a researcher and teacher, "I know the current system from top to bottom." She knows the cost and access aspects of healthcare and is fully qualified to participate and contribute in efforts to improve those issues. But Professor Herzlinger, I say with the utmost courtesy and respect, doesn't know beans about the healthcare delivery system issues.

Find the Black Box offers my expertise regarding the healthcare delivery system itself—that is what I know how to correct. I am as unqualified to contribute to efforts regarding cost and access issues as Professor Herzlinger is in dealing with delivery system issues.

I have attempted to articulate my point that the healthcare delivery system is a state responsibility (and is how and where patients enter the healthcare system) in every way I can think of to drive home this point. The Wall Street Journal printed two letters to the editors, offering my comments regarding RomneyCare:

"States Must Lead Health Reform," Wall Street Journal. November 14, 2011

Regarding your editorial "Romney's Fiscal Awakening" (Nov. 8): You should examine in detail "RomneyCare Original," prior to its being legislatively compromised into "RomneyCare Modified." Next, ponder Newt Gingrich's sage advice contained in his 2010 Foreword for Governor Rick Perry's book Fed Up: "States have been called laboratories in democracy precisely because every problem potentially has fifty different approaches to solving it. Some solutions work in some states and not in others."

Finally, consider which offered our nation the more beneficial attempt to address the cost and access aspects of healthcare: RomneyCare Original in one state, ObamaCare poured over the entire nation by a democratically controlled Congress, or the far more usual response of doing nothing?

There are two basic fundamentals of healthcare that are constantly ignored: All medical care is local, and states license doctors to practice medicine. It is in the states where the reorganization of our highly dysfunctional healthcare system must begin. The federal government, with the best of intentions, is focusing on how to pay for care after the fact, and prevents the states from considering radical changes in the design of the healthcare system itself.

Excerpted from FIND THE BLACK BOX by IRA WILLIAMS. Copyright © 2013 Dr. Ira Williams. Excerpted by permission of iUniverse LLC.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents


Dedication....................     v     

Foreword by Robert H Maguire, Jr....................     ix     

Foreword by Ronald Critser....................     xi     

Introduction....................     xiii     

Chapter 1 Who is Responsible?....................     1     

Chapter 2 What's Missing?....................     22     

Chapter 3 Quality of Healthcare Army of Experts....................     33     

Chapter 4 Quality of Healthcare Improvement Eff orts....................     75     

Chapter 5 Behind the AMA Curtain....................     134     

Chapter 6 What a Collage of Book Reviews Tells Us....................     174     

Chapter 7 Timeline Checklist....................     222     

Chapter 8 The Solution....................     229     

Chapter 9 Conclusion....................     251     

Notes....................     261     

About the Author....................     267     

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