Tuesday, September 06, 2011

Never events. Well, hardly ever.

Many thanks to Ishani Ganguli for inviting me to write an op-ed in Virtual Mentor, the journal she guest-edited for the American Medical Association.  In it, I discuss the persistent rate of wrong-site surgeries and argue that financial penalties for such "never events" are ineffective:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

I argue, instead, for the power of training in crew resource management and transparency. 

Transparency, combined with a commitment to and training in crew resource management, enables doctors to hold themselves accountable to the standard of care they would wish for their own family members. This combination of ingredients offers far more potential than financial penalties or other regulatory actions for sustained process improvement in the operating rooms of America.

The entire article is here.   I welcome your comments.


Jasmine said...

As a non-doctor in the health/medical field, I am always interested to learn more about how a hospital can change the attitudes of staff and encourage better coordination of care and teamwork for good public health outcomes (e.g. hand-washing, elimination of never-events, cost reduction). Quoting from the article, I think this is key:

“a checklist is not sufficient. What makes it effective are the attitude, behavior, and teamwork that go along with the use of it” [9]. It is important to confirm that the listed actions have actually taken place. This confirmation will only occur if there is sufficient trust and mutual respect among the OR staff that any member of the team can say to the surgeon, “Excuse me, have we properly carried out that step?”

Thank you for sharing!

Allison said...

Great article. Transparency and a no-blame environment is needed to remedy this.

Anonymous said...

Very interesting piece - one of the many things that stood out for me was "wrong-site occurrences were related to ... the lack of performing a ‘time-out’ [before surgery] (72.0 percent)” -- what impact would tweeting (or otherwise engaging) the patient's family in the Time Out process produce; having them "participate" in real-time as the OR team runs through the checklist? I think this sort of transparency could address the hierarchy issue that Capt. Sullenberger refers to -- your thoughts?