A Primer for Health Care Executives, Prepared by David Marx, JD, for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute
There’s an interesting discussion underway at e-paients.net, about a recent case in Minnesota, which I was asked to (and did) comment on.
(e-patient) Dave brought up an important point, which concerns holding people accountable. Is it for the error, or knowing that the potential for error exists, or both?
I remembered this excellent paper from my files about this, and fortunately it is public domain, since it has been funded by our tax dollars. It’s useful to review the principles contained in it, which include supporting accountability and learning at the same time. Interesting that a lot of smart people have already done the thinking. Now we need to operationalize it.
With regard to the discussion on e-patients, I also remembered something about me. Whenever I walk into one of my organization’s medical centers, I assume that I am 100 % accountable for everything that is happening there. As I walk by the pharmacy, the lab, and head up to primary care, I imagine that my role is to protect every patient receiving care in all of those areas, whether or not I am directly involved in providing that care.
Now, imagine that every physician, staff member, patient, patient’s family, community member, carried themselves that way in every hospital and medical center. What would health care be like?
This cannot happen unless we support the idea that everyone on the care team, patient included, deserves access to all of the information about their care.
Apology to visitors – due to some technical glitch, at this moment Ted's comment isn't available on e-patients.net. But you can see a second, follow-up post at http://www.e-patients.net/archives/2008/03/minnes… pending release of Ted's.
Better to light a candle than curse the blogware… Here's the comment Ted submitted on that second post:
I think it might be useful for us to abstract ourselves from the details of this case and think about the situation in general terms.
In any system as carefully choreographed as health care, and in my work, a health information system, it only makes sense that every actor has a role in making it safer. This is what the Toyota Motor Company has done throughout its history, and what we implemented in our care institution.
We found that it was important that the Medical Director of Informatics be aware of all potential safety threats. But that is not enough. Every patient, nurse, and physician must also be aware. And when they believe there is a problem, it is taken seriously. By taking seriously, we mean a scripted answer to every query that is something along the lines of, "Patient safety is very important. How can I help?" A staff member or patient should never feel uncomfortable in bringing problems forward.
What Toyota did is apply a democratic process to discovering errors, and I have found this works very well in health care, when we step back and think about it from our patients' perspective.
We wrote about this in our blog on LEAN in Health Care about a year ago:
Unfortunately, the first time something happens in a health care situation can often be one time too many, so even the potential of it happening must be seen as discovered gold, not something to be buried.
Our patients want to be our partners in supporting a safe health care system. Being a partner means that they have all of the information that we do.
Thank you for bringing up this important issue.
Ted Eytan, MD