For your health, officials prescribe a culture change at hospitals

TimesLeader.com (Wilkes-Barre, Pennsylvania)
Monday, July 11, 2005

By JD MALONE, Knight Ridder/Tribune News Service

WASHINGTON – (KRT) – Setting foot into a hospital ought to be a safe
thing for anyone requiring medical treatment, but the truth is that the
best-trained medical personnel surrounding a patient, from top-flight
surgeons to highly recruited nurses, may end up doing more harm than
good, according to comments made Monday at a health-care leadership
conference at Georgetown University.

The Institute of Medicine, an independent health and science institute,
reported in 1999 that deaths in the United States caused by preventable
adverse effects from care given to patients outnumber deaths caused by
motor vehicle accidents, breast cancer or AIDS.

Dr. James P. Bagian, a former NASA astronaut and currently the director
of the Veterans Administration National Center for Patient Safety, said,
“The problems stem from a combination of ignorance and arrogance. Either
you don’t know (what you are doing) or you think that you know best.”

Bagian added that health care has a cottage industry mentality – with
many different units working as individuals inside the same
organization. This has bred a culture of total reliance on individual
responsibility, individual perfection and has perpetuated a cycle of
“train and blame” philosophies that put patients at risk, he said.

“People do not typically understand the goal in health care,” Bagian
said. “What you should care about is prevention of harm instead of
prevention of errors.”

Bagian said that the aviation industry – unlike the medical industry –
seeks to fix a system so that when an individual isn’t perfect, there is
still a positive outcome. For instance, commercial airliners have one
more engine than they need to operate safely in case of a catastrophic
failure, but in surgery there is no backup or well-developed plan to
avert errors or to correct them. If something bad happens, it is likely
that something much worse will result, he said.

The costs of the errors that are made in hospitals do far more than
raise individual premiums. Complicated surgery (often a result of a
critical error) is far less profitable (3 percent on the average) than
noncomplicated surgery (34 percent), and as a result, hurts the bottom
line, Bagian said.

He added that one of the fundamental problems with health-care systems
is a “normalization of deviance, or people saying, `That’s the way the
world is.'”

Instead, Bagian called for sweeping changes in the way the health-care
industry organizes its internal systems. He wants to see hospitals move
to a learning system instead of one based on accountability or blame. He
said that the systems need to mirror that of the aviation industry –
non-punitive and de-identifying, so that individuals will not fear
reporting errors and close calls.

Hospital administrators agreed that the culture of their organizations
needs to change, but they said change also needs to occur at medical and
nursing schools so that medical professionals are ready to work as a
team to discuss and prevent mistakes and share the results so that
others learn through detailed reporting.

The American Medical Student Association agreed. AMSA’s president, Dr.
Brian Palmer, said in a news release that malpractice litigation reform
“should include a system to share the potentially life-saving
information learned through medical error reporting, and fostering
better communication between physicians and patients.”

Bernard Horak, a professor and director of Health Systems Administration
Programs at Georgetown University, said that health-care institutions
should have an immediate response to a crisis and a system in place to
report information so that others can learn from it.

He said that health care systems should get away from the mentality of
“first as an individual, do no harm” to a system of “first as a health
system, do no harm.”

“Successful change means looking below the waterline,” Horak said. “We
need to look at the underlying structure that allows for mistakes to occur.”

Horak said that coordinated communication is the most important factor
in quality patient care and that the traditional practice of separating
medical teams (nurses on one team, doctors on another) has created a
communication system that is fundamentally impaired.

To help fix the problem, Horak recommended that doctors, nurses and
others talk every day about “what did we do right? What do we need to do
differently? And what did we learn?” so that the systems change from an
individual- to a team-oriented approach that views every member as a
critical link – including the patients.