Patient Safety: September 2008 Archives

As many of you know, I've been a professional speaker for well over two and half decades and, for the last 18 of those years, my primary audience has been healthcare - ranging from individual physician groups through hospitals to most major medical associations. That experience, coupled with my long-time advocacy of patient safety and service quality (as well as governance and improvement of intra-staff relations) meant that it was no surprise on release of Why Hospitals Should Fly that an increasing number of hospitals would want these concepts presented in person by the author.  Each such request presents a wonderful opportunity, since a dynamic verbal presentation provides not only a clear picture of the solutions and recommendations in the book, but goes beyond the text by bringing some of the book's major stories to life (such as the accident at Tenerife in 1977). It this case, a major keynote based on Why Hospitals Should Fly is a chance to breathe form and, quite frankly, excitement into the realization that a St. Michaels environment can be created in almost any medical facility by changing the culture and the focus of the people who are that facility.

Speaking, of course, is a performance art, no matter how important and useful and serious the information presented. But whether a major keynote speech or a seminar, it can deliver depth and understanding that even a dynamic manuscript can't achieve.

Yet, the structure of this message - the keel beam - is vital, which is what this post is all about.

Just this last week I was asked to prepare a summary of one such upcoming keynote presentation centered around the Lessons from St. Michael's, and in writing it, I decided that perhaps it might also be a useful addendum to this blog.  I know, I know, this is anything but the traditional blog, whether the stream-of-consciousnes version or the mini-essay type. But since the birthright of this version is to support the ideas brought together in the book, you might just find this amalgam interesting:

This talk will dive headlong into a set of disturbing realities that block the path between where we are and where we must go in terms of the safety and quality of American healthcare delivery.

For instance:

For at least the last ten years, leaders in all facets of American healthcare have grappled with the terrifying reality that somewhere between 48-thousand to perhaps several hundred thousand patients lose their lives each year unnecessarily to medical practice mistakes in the hospital setting alone. (The death figures do not even touch the staggering assumed number of patients who are injured but survive - patients such as the two women in the past six years who underwent double mastectomies only to find that their records had been mixed up and neither had cancer.) That journey of recognition and initial reaction has led to - among other seminal realizations - acceptance of the heretofore unspoken reality that safety and quality in medical practice are NOT the same thing. Though safety and quality are inextricably intertwined (i.e. You can''t have safety without quality and vice versa), healthcare leaders had to begin looking for entirely new ways of reducing the carnage. That search has led to the following recognitions:

1. The traditional methods of performance improvement (more training, more rules, more effort) seem strangely unable to significantly improve overall system safety.

2. The CULTURE of medicine in America supports the current rate of deaths, survivable mistakes, and near-misses, and the inertia of that CULTURE resists change (recall Dr. Don Berwick's quote that "Every system is perfectly designed to get the results it consistently achieves").

3. Almost all, if not virtually all, medical tragedies and near-misses involve failures in one or more of three basic areas: Communication, Assumption, and Perception.

4. Improving patient safety and service quality requires significant improvements in (1) The rate of successful Communications in medical practice, (2) Decreasing the number of dangerously flawed Assumptions (IE "I thought someone had added the warning in his chart about that allergy"); and, (3) Decreasing the number of dangerous mis-Perceptions (IE "I read that as a 1.0, not a point one!").

5. The functional ability of any medical unit or department to decrease failures potentially leading to adverse patient impact rises in direct proportion to the level of collegiality, human caring, and human interaction among the medical staff.

6. The traditional Physician-Nurse communication relationship is, by definition, dysfunctional and dangerous and must be radically improved.

7. As the Joint Commission has now agreed, disruptive conduct by medical professionals toward each other cannot be tolerated a day longer because it has a direct negative impact on quality of care and medical outcomes, as well as increasing the possibility of medical mistakes reaching patients.

8. Safe and quality patient care, especially in hospital and clinical setting, directly depends on the quality and engagement and attitude of the nurses, yet the state of the nursing profession is one of abject crisis. (Too few nurses, an aging population, massive downward pressure on resources and upward demands for productivity along with an institutionalized rejection of nursing as having a legitimate voice in the governance of hospitals has fueled a cultural epidemic of horizontal hostility directly linked to low quality care and patient injuries and deaths).

The aerospace industry and nuclear power industries have blazed the path to massive cultural change by showing us how to take high-risk enterprises and make them high-reliability and low-risk.  Now medicine must understand and incorporate, on an emergency basis, the same basic human lessons. As for the book, Why Hospitals Should Fly is a compilation of most of the remedies we now know are needed to address these (and other) dysfunctionalities placed in one fictional hospital. If we can't envision such a place, we can't build it.

 John J. Nance