Kathryn Schulz, author of Being Wrong, Adventures in the Margin of Error, sent along this link to a recent Slate interview with James Bagian, director of the VA's National Center for Patient Safety. Bagian, a former astronaut, had some great observations about improving quality and safety in the health care environment. Some excerpts that I like:
You can't change the culture by saying, ‘Let's change the culture.' It's not like we're telling people, "Oh, think in a systems way." That doesn't mean anything to them. You change the culture by giving people new tools that actually work. The old culture has tools, too, but they're foolish: "Be more careful," "Be more diligent," "Do a double-check," "Read all the medical literature." Those kinds of tools don't really work.
One thing we do that's unusual is we look at close calls. In the beginning, nobody did that in healthcare. Even today probably less than 10 percent of hospital facilities require that close calls be reported, and an even smaller percentage do root cause analyses on them. At the VA, 50 percent of all the root cause analyses we do are on close calls. We think that's hugely important. So does aviation. So does engineering. So does nuclear power. But you talk to most people in healthcare, they'll say, "Why bother? Nothing really happened. What's the big deal?"
In theory, punishment sounds like a good idea, but in practice, it's a terrible one. All it does is create a system where it's not in people's interest to report a problem.