Doing it right
No one goes to work intending to do a poor job. With the possible exception of work slowdowns and similar temporary political strategies, no one tries to provide inferior goods or services. But that is sometime the result. Why?
Last week, I read a book, Fatal Care, which is a compilation of events you don’t want to happen in your hospital. Looking past the human drama, there are a few recurring themes that resonate with cases we have reviewed in my system.
Busy. Not only that, but one consequence of being busy is that we skip steps that are designed to protect us from making errors that harm patients. Routine checks that every nurse does before administering a medication--except when she’s busy.
Carelessness. Picking up the closest syringe rather than the one intended for your patient--a syringe someone else had put down rather than dispose of properly across the room.
Procedures. No one follows the rules, because there aren’t any. The antithesis is rules that are so ancient and arcane that no one follows them anyway.
Protocols. An ER doc once told me, “If you complain to me of the worst headache in your life, you get a CAT scan. Period.” That’s a protocol. Then you follow the procedure for ordering the CAT scan.
Management. Some smart person said, “The job of management is not to make people work but to make it possible for people to work.” I came across a very old NEJM article yesterday that concluded that interns make fewer mistakes if they don’t work 24 hour shifts. Well, gee whiz.
History. We must learn from the experiences of others. The airline industry has certainly demonstrated the benefit of sharing our mistakes and near misses so that everyone doesn’t have to make every mistake. Some preventive actions are mostly unnecessary but cheap insurance. (The time out before surgery comes to mind.)
You can probably add to this list, from your experience, from the literature, from Root Cause Analysis of problems in your institution. The point here is that there is a finite list, and we should have a strategy for each category. Checklists help. Pilots do this. So do anesthesiologists. The busier you are, the more necessary the checklist becomes.
Human beings make mistakes. We all do. We must design our systems to prevent the inevitable human errors from reaching the patient. FMEA. Another example of the migration of quality control principles from industry to healthcare.
But, does it pay? There is some question about the financial return for quality initiatives. The current Pay for Performance initiatives are not shining examples of the value of improvement. They tend to pay for trivia that doesn’t improve anyone’s bottom line. On the other hand, PRHI and others have demonstrated dramatic savings from preventing central line infections. Doing it right does pay, depending on the definition of “right.” Compliance with someone else’s idea of what good healthcare should be may not add value.
I recall a Baldrige Award winner (manufacturing) showing a sign they used to have in their shop, “We make it nice, ‘cause we make it twice.” Essentially everything they did came back for re-work. Imagine thier bottom line when they finally got it right, and rework went from 100% to less than 1%. We don't often get a chance to do it over in heatlhcare.
Elizabeth Teisberg is quoted as saying, “better health is less expensive than poor health.” She is a strong advocate of competition in healthcare as a means to force improved value and lower cost. Our present system does not provide meaningful competition, and this is one of the reasons costs keep escalating but care hasn’t noticeably improved.
