Tuesday, June 18, 2013

Not like too many hospitals

#TPSER9 I write this after leaving the residents' and students' education programs in Telluride as I await the delayed departure of my Southwestern Airlines flight out of Denver airport.  It is delayed because there is a malfunctioning windshield wiper, and the mechanic (above) has been making repairs. We need to understand that this windshield wiper, on the co-pilot's side, is not likely to be needed while the plane is in flight as the airspeed cleans the windshield, or even on the ground taxiing, as it might not be raining. Nonetheless, quite appropriately, the flight will not commence--and passengers will not be loaded--until or unless it is fixed.

Let's contrast this with the procedures, or lack of procedures, followed in many hospitals.  How many times have surgeries begun without a proper time-out to ensure that all necessary supplies and equipment are at hand and in working order?  The lack of compliance with pre-surgical checklists is rampant throughout the world.  Sometimes this is from a lack of training.  Sometimes it is because an impatient surgeon starts a case in violation of the protocol, and his/her OR team is too intimidated to mention the issue.  (Remember this episode from the TV show ER? An associated story here.)

As I have said before:

Sometimes, I remind myself to be patient.  It is hard to change the medical system quickly.  But, more often,  I find myself agreeing with the words of Captain Sullenberger:

"I wish we were less patient. We are choosing every day we go to work how many lives should be lost in this country. We have islands of excellence in a sea of systemic failures. We need to teach all practitioners the science of safety."

I hope and trust that our attendees these last few days in Telluride will have the commitment and courage to make a difference during their careers.


Anonymous said...

I agree despite having checklists it's not being properly done the whole OR must be focused on this , chit chat stops , music off , etc

Paul Levy said...


Anonymous said...

The difference is that the aviation industry understands and embraces that these things are necessary; while medicine still regards them as bothersome administrative edicts interfering with the 'important work.' Woeful (and willful) ignorance.

nonlocal MD

Mustafa Hamadah said...

Great post

Mike Manning said...


I can’t seem to find your email and have a quick question about your blog. Could you email me?


Anonymous said...

I work in a military hospital that was not ready to go on its first day---the call bell system was not in place, for one thing, and there were several other things that needed to be fixed before it was truly safe. BUT, pressures from leaders make it very hard to pull that andon and the hospital opened anyway. Once it's opened, it's very difficult to put pressures on the contractors to complete things or fix things.

Richard said...

Paul - great post.

From where I sit these are leadership choices. It's a choice to skip, bypass and "not do".

It's a leadership decision to know that this happening and either do or not do anything about it. We are rewarding behavior.

Thanks for the post

Paul Levy said...

Mike, please post yours as a comment, and I will respond (but not publish it.)

Paul Levy said...

Mike, please post yours as a comment, and I will respond (but not publish it.)

Unknown said...

Great post. As a patient who went into surgery a couple of months ago who went under and woke up on the table I agree. My surgery didn't even start yet cause one of the machines was not working and all the other rooms were in use. Anyways a 45 min surgery took 3 hours and I had to get put back under when we switched rooms. They should of checked everything before putting me under.

EKG MachineMan said...

Good Post. I was in for surgery two months ago and the doctor put me under and then I woke up in the surgery room on the table and they were all trying to fix a machine not me. They told me that machine didn't work so they haven't started surgery and a s soon as another room is available they are going to put me back under and move me and start the surgery. This all could of been avoided if they went through their checklist!

Barry Carol said...

I think the hospital CEO, the senior leadership team and the Board of Directors need to build a culture that puts patient safety ahead of short term revenue and profit maximization goals. Nurses need to feel empowered to speak up if they see a doctor making a mistake. Doctors who flagrantly violate the rules due to impatience and/or arrogance need to be fired if they are employees or have their admitting privileges revoked even if they are business rainmakers. This is hard stuff for a hospital’s management and Board to push especially if the institution is in precarious financial condition.

Payment strategies like paying for value instead of volume and financial penalties for excessive preventable readmissions and too many hospital acquired infections would push this in the right direction. Price and quality transparency could help to reward hospitals that do a good job in the areas of process, risk adjusted outcomes and patient safety. If this were easy, we presumably would have accomplished it by now.