Regular readers will recall that my posts about a botched kidney transplant at UPMC were harsh with regard to the center's decision to punish a nurse and doctor when it was evident from the start, and now confirmed, that the problems there were systemic in nature. Perhaps the folks at UPMC should take a leaf out of the book of Dr. Mary Seddon and CEO Geraint Martin of the Counties Manukau District Health Board in New Zealand.
In a post entitled "CMDHB's Attitude to Errors," the authors note:
[I]t’s vital to be clear about our organisation’s standpoint on this so that we can work towards a culture which supports staff to do their best.
Errors aren’t intentional, they don’t improve through punishment and they’re hard to predict. Usually they come about through a fault of the system. If somebody else could make the same mistake, it’s a systems error.
How we respond to errors is vitally important. The tendency can often be to place blame on the staff member involved. However the danger in this approach is that it discourages staff from reporting errors or communicating openly for fear they will be blamed and punished. Even if individuals are identified and removed, the cause of the error usually remains unidentified and the risk that the error will happen again remains.
What we need to do if something goes wrong is pull back from the instinct to place blame and instead think more deeply about the contributing factors. We need to think about how the system got us to where we are and where the faults in it lie.
I was pleasantly surprised to learn that the experience at my own hospital helped contribute to this understanding:
At CMDHB, we have a ‘Just Culture’. This means an expectation of high quality individual performance but open disclosure should an error occur. In this case, we will acknowledge the error, apologise to the patient and their family, and commit to investigating the error and sharing learnings from it. All of this requires a culture in which people feel empowered to report errors and make suggestions on how to fix them. One of the motivations for doing this post was reading about a situation at Beth Israel Deaconess Medical Centre in Boston where, after a case of wrong site surgery, the chief surgeon went straight to the CEO to openly communicate about it. That ability to be open and to communicate well is critical to the kind of culture we need to foster at CMDHB.
Congratulations to the folks at CMDHB!
Dear colleagues at UPMC:
The flight from Pittsburgh to Auckland takes about 20 hours. Well worth the trip, I'd say.