Tuesday, January 26, 2016

Fostering a non-negotiable safety mindset

Apparently, my recent blog post about preventable medical errors at a Victoria community hospital was widely circulated among the local health care community.  Maybe it's helpful to have an outside observer say things about such a circumstance, but there are also local observers who fully understand the underlying issues and have been working on them for some time.

One is Cathy Balding, who wrote this article on the same situation back in November.  Here are some excerpts that go to the heart of the matter, not just in Djerriwarrh, but more generally through the state of Victoria:

Creating and maintaining consistently safe, high quality care requires an understanding of complexity, and the mix of interconnected organisational factors required: great people supported by great systems, led from the top, based on a relentless pursuit of excellence. But--we haven't yet achieved universal acceptance that this is what it takes. The belief that point of care is fundamentally clinicians' business is buried in our healthcare DNA; an unconscious attitude that drives a hands off approach to clinical governance in still too many health, community and aged care services.

So--There's a step before all the action. And that's the step that many health services miss: fostering a non-negotiable safety mindset that addresses this deeply held belief head on. I see ‘excellence’ everywhere in mission statements and strategic plans. But it doesn't take much to scratch the surface and realise that in too many cases, these words are about image, not substance. The way we'd like to be perceived, rather than the way we really are. As if saying it will somehow make it a reality. But saying it is just the beginning. 

I've addressed a common pyschological reaction of clinicians: everybody likes to think they are doing better than others.  It turns out that boards also fall into this trap.

Marie Bismark summarized this phenomenon in a paper delivered in May 2014: "Almost every respondent believed the overall quality of care their service delivered was as good as, or better than, the typical Victorian health service."  Here's the pertinent graphic from her talk:

I addressed this issue once with regard to US hospitals, noting:

We know that most medical harm does not derive from the individual actions of doctors. It derives from the work patterns and systems that are in place in hospitals. These are not organizational aspects in which most doctors and nurses have been trained. They are trainable with some time, effort, and resources—but those in a position of authority must encourage and demand that it happen. The “those” in this case must be the boards of trustees, the governing bodies of the hospitals. 

But it is in this arena that we have a public policy lacuna. While trustees often have a statutory responsibility for the quality of care given in their hospitals, they are never held accountable for that care. The history of involvement by lay governing bodies is heavily centered on the social and community aspects of governance. Clinical decisions are left to the clinical staff, as they should be, but oversight of clinical activities by the governing body is often rudimentary at best.

In another article, I offered a suggestion as to how transparency of clinical outcomes could help a board do its job better.

I think the issue is not the unavailability of reliable information on peer performance.  I think the issue is a failure, in the first instance, to even measure one's own performance and to share that with one's own team. After all, the issue is not so much benchmarking.  That only goes so far.  As I've often said, there is no virture in benchmarking to a substandard norm. 

So, the first step is to accurately collect one's own data and make it transparent to your own team. It is that transparency--more than benchmarking--that will establish the creative tension in an organization that will drive people to meet their own stated standard of clinical excellence.  A smart board does not have to apply pressure on its staff by drawing comparisons with others. Rather, they take governance steps to demand transparency, so that the deep sense of purpose that is inherent in the clinical staff is employed to stimulate the team to do better on their own.

In short, the conclusions reached by Dr. Balding, Dr. Bismark, and many other observers must be revisited by the broader community. Victoria, in contrast to, say, New South Wales, has determined that a highly devolved structure of health services best suits it population. That may indeed be the case for a number of reasons, but a necessary condition for such a devolved structure is that the CEOs of local hospitals are given the clear mandate from their boards that quality and safety are the first and highest measures in their performance reviews--and that the boards are given the identical clear mandate from Government.  Yes, access and cost are important factors as well, but if the underlying care delivered by health services is not safe and effective, the public service mission of these organizations has not been achieved.

1 comment:

nonlocal MD said...

My comment really only applies to the U.S., as I have zero experience of health care in other countries, but I think that governance of health care organizations, as well as the public's (patients') perception of them, is severely distorted by their historical origin as a community resource, often in small communities where local lay people served on the boards and everyone was a patient at the hospital or of the community doctors. It was recognized that in general everyone involved was trying hard and had the patient's best interests at heart, so much slack was cut.

The current health care system is far, far different - but the old governance and public perception remains. Maybe this is why the industry has been allowed to get away with outcomes and practices which would have resulted in severe regulatory penalties, if not receivership or forced bankruptcy, in any other industry. We need to seriously re-think how health care should be organized - be it a branch of government or a more corporate model - and apply standards and expectations of expertise and regulation which follow from that model. So far, the industry is literally getting away with murder.