Mr. Ness, everybody knows where the booze is.

A quality-driven MD colleague writes with frustration about two problems in his academic medical center.  I often hear similar comments from nurses and doctors, and so I present the examples for your consideration.

This hospital has a poor record with regard to hand hygiene (in the 30% range), and my colleague suggested at an infection control meeting suggested that the rates be publicly posted in the hospital to provide an impetus for improvement.  "I suggested that instead of being embarrassed, maybe we should OWN the data." This, of course, is a standard and accepted approach in quality improvement.  S/he was told that the "the lawyers will not let us do this."  S/he wonders, "Who, exactly, is our primary concern?"

At another meeting, the chief nursing officer asked why there had not been more progress made with regard to central line infections in the ICUs.  It turned out that there had been meetings with  the bedside staff which identified a number of problematic workarounds they had created. However, the team was limited in what they could do because decisions about equipment and kits are made based on cost, away from the bedside. The CNO was upset because the local folks had not shared with her what they had already done and wanted to know why they hadn't told her about these problems – while acknowledging she couldn't do anything about them.

My friend summarized: 

I explained that if she wanted to find out what was going on – she need only walk onto the unit and ask.

This all reminds me of the scene in The Untouchables. Elliot Ness talks about busting Al Capone if only he knew where he was making his booze. Sean Connery's character (Jimmy Malone) takes him to a post office across from the police station.  Ness can't believe the booze is there. Malone says, "Mr. Ness, everybody knows where the booze is. The problem isn't finding it, the problem is who wants to cross Capone."

The problem isn't knowing HOW to fix this problem. It's doing what it takes to accomplish that -- over-ruling the lawyers and accountants and doing the hard-work to change the culture. This can't happen if the C-suite leads from meeting rooms.

These stories exemplify the huge cultural schism in the country between the minority, those institutions that have taken on the quality and safety agenda and internalized it into their decision-making and process improvement efforts, and the majority, the ones that have not.  Each year at the IHI Annual Forum, I hear from nurse managers and young doctors asking, "What can I do to get my CEO/CFO/CNO/Board of Trustees to support us in what we know must be done?"

I want to state this as clearly as possible:  The leaders of academic medical centers and medical schools are failing to be the leaders the country needs at this time. In their failure, they sow the seeds of burdensome governmental and regulatory requirements, for those in policy positions will see the vacuum and will fill it. In their failure, they persist in accepting the view that "these things happen," and are personally -- yes, personally -- responsible for thousands of preventable deaths and injuries each year.  This is the most significant ethical issue facing the profession, and they simply fail to accept responsibility.