Why King-Harbor must die

We must admit that the patient can't be saved -- and move on.
FOR FOUR YEARS, Los Angeles County officials have been dithering and bickering over what to do about Martin Luther King Jr.-Harbor Hospital.

Those who believe it must be closed argue that patients are dying because of substandard care and that there is little indication that anything — including downsizing by 80%, firing hundreds of staff members and changing the hospital's ownership and leadership — has worked to overcome its staggering problems. Opponents counter that King-Harbor served 47,000 emergency room patients in South Los Angeles last year and that, even with all its flaws, a bad hospital is better than no hospital at all.

So how are we to know whether the benefits of closure outweigh the risks of keeping the hospital open? As the state Department of Health Services, the federal government and the Los Angeles County Board of Supervisors all contemplate the possible demise of King-Harbor, how are we to determine whether the time has indeed come?

This much we know: There are no perfect hospitals. A seminal study by the Institute of Medicine conducted in 1999 found that 44,000 to 98,000 patients die from medical mistakes in the United States each year — the equivalent of a commercial jet crash every day. The average hospitalized patient suffers one medication error daily, according to another report from the institute, and patients in intensive care units experience nearly two mistakes in their care each day.

Until recently, we approached problems of poor quality and safety by admonishing doctors, nurses and hospitals to try harder, underscoring these exhortations with threats of malpractice lawsuits. But eventually it became clear that that was not enough. As Albert Einstein observed, we cannot solve our problems with the same thinking we used when we created them.

What we've learned in recent years is that most errors are not committed by incompetent doctors or slacker nurses but by well-trained, committed caregivers working in environments that are simply too complex for any human to get it right every time. This epiphany has led us to embrace what is known as "systems thinking" — in which we aim to create systems and structures that anticipate errors on the part of fallible workers and catch those errors before they cause harm.

By implementing relatively simple system fixes — such as double-checking before administering dangerous medications, marking surgical sites on patients' skin with indelible ink to ensure that we don't operate on the wrong body part, implementing computerized prescribing systems and limiting resident work hours (to less than 80 a week) and the number of patients assigned to each nurse (to no more than five) — we have begun to move the safety needle in the right direction.

Evidence is emerging that medical errors are decreasing and that hospital death rates in the last five years have fallen. Certain problems once felt to be inevitable, such as hospital-acquired infections, can be all but eliminated by widespread implementation of a series of safe practices, including religious attention to hand-washing and the use of other sterile techniques.

But even as we chalk up some safety victories, there remain problems so stubborn that they can't be solved by changing procedures and implementing new systems. The question is — because even the best hospitals will commit terrible, even lethal, errors every year — how do we know when a hospital is so bad that it should be deemed unfit for patients?

This question has been brought into sharp focus by the extraordinary saga of King-Harbor. What is so shocking about the story is not that the initial reports in 2003 showed scores of safety problems, although the breadth and depth of the problems far exceeded the usual litany. Nor is it the tale of a resource-poor hospital serving indigent patients struggling to make ends meet; those problems exist everywhere. Nor is it that the organizational chart of King-Harbor needed reshuffling — reorganizations of failing enterprises, guided by consultants, are a dime a dozen (not counting the price of the consultants, of course).

No, King-Harbor's problems are distinguished by their intractability. Other hospitals have had highly public errors or sustained withering press coverage but used these traumas to create a platform for improvement. Boston's Dana-Farber Cancer Institute, for instance, was transformed after a chemotherapy overdose there killed a Boston Globe healthcare columnist. Johns Hopkins Hospital in Baltimore, often rated as the nation's finest, was nearly brought to its knees by the error-related death of a young girl, but it used the tragedy as a springboard to develop a world-class safety program.

And other resource-poor county hospitals — such as San Francisco General and Harbor-UCLA — manage to provide high-quality care even in the face of budget woes and enormous caseloads.

But at King-Harbor, highly public disasters involving quality and safety have not managed to upend the status quo. Regulators have issued stern threats to yank funding or certification — but have then lowered the bar again and again. Leaders have been fired, organizational charts have been reshuffled and consultants have come and gone, and yet the shocking revelations — including numerous deaths from medication errors and lapses in monitoring — keep on coming.

When a patient can literally lie dying on the ER waiting room floor — a janitor mopping up around her — at a hospital whose every move is being scrutinized by the media and legislators, we know that the problems cannot be fixed by a better computer system, a few new bylaws or more intensive personnel training. The troubles run far deeper than that.

We physicians are socialized to believe in the possibility of redemption and healing — that the tumor can be excised, the obese patient will finally stick with that diet, the baby will emerge from the womb hale and hearty. This is mostly a good thing, but it can take us down dark alleys. For example, our "never say die" attitude sometimes leads us to over-treat patients with terminal illnesses, flogging them with another course of chemotherapy long after realistic hope is gone.

We now teach young doctors to recognize when cure is impossible and, at those times, to help guide patients and families toward what we have come to call a "good death." When offering this "palliative care," we focus on keeping the patient comfortable while encouraging loved ones to honor the past, come to terms with the present and make appropriate plans for the future.

With that in mind, we can never forget what King-Harbor represented at its christening: a shining light emerging from the dark shadows of the '60s riots. We must recognize the service of those committed, competent caregivers (and there were and are some) who struggled to provide high-quality care in a dysfunctional environment. We have to empathize with the patients who may be inconvenienced, or even harmed, when their local hospital — bad as it was — is no longer down the street.

But how can we stay silent in the face of overwhelming evidence that this hospital cannot ensure a decent level of safety, knowing that no patient with a choice would dare cross its threshold? How can we continue to focus on cure when hope has long since vanished? Surely, the resources being poured into that one last change in the organization chart, one more consultant engagement or one more staffing surge could better be used to ramp up the capacity of other hospitals' ERs and clinics to absorb King-Harbor patients.

King-Harbor is on life-support, and has been for years. The disease is a cancerous culture, and one more course of chemo won't help. It is time to orchestrate a "good death" — to focus on healing the community and making plans to care for the patients of South L.A. once this hospital is gone.
By Robert M. Wachter, ROBERT M. WACHTER is a professor of medicine at UC San Francisco and the author of "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes" and the forthcoming "Understanding Patient Safety."