Mea culpa

We are really, really trying to get better at this quality and safety stuff, but there are so many aspects to it that sometimes things slip by. Here's an example. Today our Medical Executive Committee was preparing to vote on a universal protocol policy related to taking "time-outs" before invasive procedures. We already had done this for surgical time-outs; but we recognized that a slightly different approach would be more suitable for procedures outside of the ORs (e.g., in endoscopy or interventional radiology suites).

Part of the policy includes some unambiguous guidelines, like this: The team will stop, pause, and verbally verify their agreement on the identity of the patient, the procedure to be performed, all patient allergies, the site of the procedure, including laterality, the correct position of the patient and radiological exams, if applicable. There was unanimous support among the MEC members about the need for this policy, and it started to move quickly to adoption.

But then I noticed two problematic items in the document that was about to be approved. Here's the first: It is the responsibility of the physician initiating the procedure to initiate the time-out. On its face, there is nothing wrong with this, as it is, indeed, the physician who has final responsibility for what happens to the patient. But, I said, don't we want to expand on this and make it clear that each staff person in the room is encouraged and empowered to question whether the time-out has taken place and/or to remind the physician that it should be. After all, when we had our recent wrong-side surgery case, only part of the problem was that the surgeon was distracted and forget to initiate the time-out. An equal contributing factor was that no one else in the OR thought to remind the doctor or question whether the time-out had occurred.

The second problematic sentence was this: It is not necessary to include the patient's participation in the time-out process as this may not be applicable. Hold on, I said, don't we want to reverse the emphasis and establish a presumption that the patient should be invited to participate, unless it is somehow inappropriate or not possible. Why not involve the person with the most direct interest in the procedure to help out?

In both cases, the doctors and nurses on the MEC immediately agreed and even suggested helpful language that would accomplish these objectives. But I was left thinking, "Why did I have to suggest these modifications? Why wouldn't they be self-evident to the subcommittee that had written the policy? And if not, why wouldn't any other member of the MEC have thought to raise them." In fact, later I was a bit critical of our SVP for Health Care Quality on these points in a private conversation with him.

One of our trustees was observing the meeting, and I also raised these questions with him. "Too much to do, too busy to read," was his commentary about the medical staff members of the MEC. While that is true, it is not a satisfactory answer. After all, it has just been a few weeks since the wrong-side surgery case, and everyone is attuned to this type of error.

My friends in the patient advocacy world will probably say, at this point, that's why you need patients on every committee and working group in the hospital. Patients will see things that the medical staff overlook and bring in a useful perspective. This can be true, but it actually takes a lot of thoughtful planning and time to create a productive environment for that kind of patient advisory input -- and, even then, there will always be some decisions made without patient consultation.

I have a different answer. After the Blue Cross Blue Shield conference yesterday, I asked a question of Sweden's Göran Henriks, who has worked for two decades on improving safety and quality to make Jönköping County's health system one of the best in the world. "Knowing what you now know," I said, "how long would it take your doctors, nurses, administrators and staff to get to your current level of performance if you were starting afresh?" His reply: "Five years."

Old habits and viewpoints, in other words, are deeply embedded. While every sentinel event presents an opportunity for learning and improvement, it is in the everyday tasks that the possibility for continuous and lasting improvement exists. I happened to be the one to call out two examples today. But, it is the marvelous diversity of experience and perspectives of the people in an organization that provides a reservoir of such possibilities. Our goal is to create an environment in which everyone in the hospital will feel empowered and excited to do the same, whenever they see opportunities for improvement. Training people to do that is what takes time, as we each have a unique way of learning.

And so I realized that I was wrong to have criticized the SVP. It's my job to help people to engage in this learning adventure by setting the appropriate example of humility and encouragement, and I blew the chance today with one very well intentioned individual. But tomorrow will certainly provide other chances to do better.