Why do Physicians and Nurses make Mistakes?

When will Paul O’Neill receive the recognition he deserves?

Many years ago I left my office to meet the Vice President of Medical Affairs down the hall and in his office. As my door swung open, I noticed the Risk Manager talking with one of our more prominent orthopedic surgeons. I had no idea what they were talking about, but whatever it was, they both seemed very concerned.

Later that day I found out. The Risk Manager requested that he see me on an urgent basis. He informed me that the orthopedic surgeon had reported to him that he had operated on a patient’s knee . . . the wrong knee. How could this possibly have happened? The orthopedic surgeon in relating the mistake told the Risk Manager that, “He just could not understand how it happened; he could not remember what he was thinking about?”

Somewhere in his confusion is the answer. He should have been thinking about one thing . . . operating on the correct knee.

We live in a world that celebrates “multi-tasking.” We can drive a car, talk on the phone, listen to music, comb our hair and play a harmonica all at the same time. Physicians and nurses are human beings, with busy lives and lots of things to think about. They care about their patients and are mortified when they make a mistake. When you accidentally spill a cup of coffee on your host’s carpeting, an apology is usually good enough. When a patient accidentally dies due to a medical error, an apology is normally not enough to satisfy the grieving family. A national consensus within healthcare has developed that we can do a better job . . . a lot better. To see the American Hospital Association touting a program to save 100,000 lives would surprise many people in the general public.

At the root of the extraordinary increase in medical errors is the reality that the number of things we can do to patients has expanded much more rapidly than our safety systems. When one considers the history of aviation, there was a time when airplanes would get thrown together by “barnstormers,” and they would race in a primitive form of “Nascar in the sky.” Accidents were routine. A friend of mine who is a private pilot has opined that if automobiles were regulated as closely as airplanes there would never be an automobile accident due to mechanical error. The Federal Aviation Agency keeps a file on every airplane ever licensed and a record on every part that fails. If a pattern of failure is observed, a plan of correction is developed and mandatorily deployed in the aviation community. Still, we have airplane accidents. They are almost always attributed to “pilot error.”

Medical mistakes are almost always “pilot error.” The consequences in aviation are almost always fatal to the pilot. The consequences of medical errors on physicians and nurses will haunt them for the rest of their lives. Insult to injury is the grief that loved ones feel in the aftermath of a medical error discharged against a member of their family and the associated injury or death.

I am not unfamiliar with commercial aviation. Today is July 1. Since January 1, I have flown 67 commercial flights. I know the routine well. What if it were modified in the following manner? When approaching the gate agent, you are taken aside and asked to sign a multi-paged “consent form” moments before boarding the aircraft. You ask the gate agent what this is about; and he says, “Well, everyone signs these consent forms. By flying on our airplane there is a chance you will be killed or injured. If you are killed or injured, this consent form will absolve the airline from any liability, and you will waive all of your rights and the rights of your family to seek any legal redress. Everyone signs these, and you cannot fly until you sign this form.” You think about this for a moment and then ask, “How risky is this flight?” The gate agent says, “Well, since 1999, there is a consensus in the airline industry that we kill 98,000 passengers annually. We have no idea how many we injure.” You think for a moment and ask, “How many passengers did you kill or injure last year?” He says, “Well, that data is hard to get, and by the time we get the data, it will be about eighteen months old. But, I have some good news! The Association that represents all airline carriers has a campaign to reduce the number of accidental deaths by 90,000 this year. See, I’m wearing one of the buttons as a part of the campaign.” This scenario is so absurd it is hard to take seriously. It is an accurate reflection of where the hospital industry finds itself today.

There are two sides of this issue. One is not so nice. The fact is that the American hospital and the healthcare delivery system, in general, are danger zones. Trying to sugar coat this reality is misguided and unwise. Just as exquisitely engineered multi-million dollar airplanes fall out of the sky as a consequence of "pilot error,” hapless citizens will enter the healthcare delivery system and will be injured or die. The problem as described by knowledgeable observers of the healthcare industry is that it happens too often. We don’t have to save 100,000 people annually from flying in airplanes. Far more people fly each year than are admitted to U.S. hospitals, but we are trying to save 100,000 patient lives from the consequences of interacting with U.S. hospitals.

The second reality, and a lot more optimistic, is we can do a better job and there is a lot we can learn from the aviation community. To avert “pilot error” there are many checks and balances before an airplane leaves the ground. There are checklists that go over hundreds of mundane issues seeking to assure that all aircraft systems are operating properly. None of these tasks are intellectually challenging, but each one must be checked each time an aircraft flies. In contrast, there are fewer such systems in the American hospital. They exist, but it is often considered unnecessary, an insult to healthcare professionals and frequently ignored. One only has to remember the girl who died at Duke University Medical Center because someone failed to follow the “checklist” with respect to checking if her blood type was the same as the donated heart offered for transplant. As a consequence, a sequence of adverse events went into a tail spin, and the young girl died several weeks later. This was an accident that could have been averted.

Like pilots, physicians and nurses have busy lives that involve a lot more than flying airplanes or taking care of patients. The whole system has to be slowed down to make sure that the mundane details are checked and double-checked. It is annoying and time consuming. It has to be done, and it can be done. The work of Paul O’Neill and the Pittsburgh Regional Healthcare Initiative has demonstrated that when physicians and nurses accept this reality they can make an enormous difference.

A related, but equally important, reality is that the American hospital does not enjoy two realities we find in the aviation community; i.e., training and well engineered systems.
As I crisscross the country flying from client to client, I often overhear pilots talking about the need to get their mandatory re-training completed. It is a cost of doing business that is embedded in the aviation business, if you will. The re-education and training of physicians is woefully underfunded and poorly regulated. Hospitals, under cost pressures, have gutted education and in-service education programs to their nurses, other caregivers and employees, in general.

Is it any wonder that patients are frequently the “grist on the mill” of hospitals in which shortcuts are taken, physicians do not receive appropriate continuing education, nurses and others do not receive ongoing education and training and the hospital systems are thrown together by dilettantes?

While it is true that “bad things happen to good people,” it is equally true that “good people do bad things to good people” in the American healthcare delivery system.

Our firm does not have the expertise to make a difference in this area. We do not try. We are not qualified. We refer such business to others. One of the leading firms in this area frequently turns us away because they are simply too busy to take on another hospital client. They have another reason for turning business away. Believe it or not, they still find many hospitals leaders who “just don’t get it.” Not shared from a religious or spiritual point of view, Jesus said at the Sermon on the Mount, “. . . cast not your pearls before swine.” The unnamed consulting firm would rather “gargle with ground glass” than spend their time working with hospital leaders, physicians and other caregivers who are still in denial about the opportunities for patient safety. Worse, some healthcare leaders do "get it" but are not prepared to invest the will, energy, drive and "stick out their neck qualities" necessary to get their organizations on a new and improved pathway to success.

In time, ignorance will be exposed to light, and we will remember this as the “transition era in patient safety.” One hundred years ago, Dr. Abraham Flexner exposed the healthcare education industry to the “light” that medical education could be performed better . . . much better. At the time he was despised for stirring the pot. One hundred years from now, Paul O’Neill will be remembered for speaking “truth to power” and exposing the healthcare industry for performing well below its capabilities. We can only hope his dream for an error-free healthcare delivery system will occur during his lifetime.

Jan Jennings

Republished with permission from the Hospital News Group

Faith Based Healthcare and Persons of Faith in Healthcare

Why are we so skeptical?

People of faith and organizations proclaiming faith always end up categorized by one of the religious congregations or societies. For those of us who have served in faith-based organizations or worked for people who wear their faith on their shirtsleeves, there is often disappointment and skepticism. Why? In Christian circles, is it not good enough that Catholic, Baptist, Methodist, Presbyterian, Lutheran and Episcopal organizations that operate hospitals and other healthcare institutions are living out the story of the Good Samaritan? After all, how good was the Good Samaritan? We only know one story of the way he conducted his life. At home, he may have been abusive to his wife. Who knows? We do know this. If he was a real human being, he had his own set of strengths and weaknesses.

For people of faith serving in the healthcare industry, there can be a personal sense of ministry in exercising medical, nursing, or even executive skill in serving God. When they choose to openly talk about their faith or religious life, we tend to hold them to a higher standard. This is probably not a good idea. Many are jaded by personal experience. The truth is we expect something more of religious organizations and people. Why? Well, we just do.

I work with an individual who claims to be an atheist. His life is bereft of any pretense that there is a higher power. The way he lives his life is consistent with his belief system. He is ruthless, self-absorbed and a moral reprobate. Most people really like him. There is no pretense . . . and he can be very charming while he drops that knife between someone’s shoulder blades. One thing is clear at all times, you know that his philosophy of life and faith (or lack thereof) is consistent with the way he lives his life.

I have been guilty of talking too much about my religious affiliation (Eastern Orthodoxy). I have noticed that it puts me in a position in which people expect more from me than others. The truth is that I am a flawed creature like everyone else. I carry a bag of personal and professional strengths to work everyday. Most days, I carry a heavier bag of personal and professional weaknesses.

I have become close friends with an Eastern Orthodox priest. I serve on the Board of Directors of a ministry he started forty years ago devoted to housing and healing. He refers to himself as the “country priest.” When I have discussed these concerns with him, he quips, “We all have a story and pretend that we don't .” It is an honest representation that these religious organizations and religious people have their strengths and weaknesses just like everyone else. Somewhere in our childhood development, most of us were encouraged to show deference, if not reverence, to people of faith. When we find out they are flawed in some way we are frequently surprised and disappointed.

Once I served a religiously sponsored hospital and was shocked to observe that there was behavior at work that was frequently petty, ruthless, ethically challenged and frequently wrong. Where was God when we needed Him or Her?

There was a time when I reported to an individual who wore his religious affiliation from head to toe. Every morning, even at work, he would read from a religious book, meditating on the Word of God. He was generous to a fault and was devoted to his religious organization as much as he was involved in his healthcare organization.

At a point during our relationship, I developed a cardiac illness with potentially life altering consequences. I did not hear from him for eight weeks. The hurt feelings were amplified by the visual recollection of him reading aloud from his meditation manual. His concern was that I would potentially become a financial liability to the organization. There was no concern demonstrated for me or my family. When his name comes up in healthcare circles, the typical reflection on him is this, “. . . that fellow can really hold a good grudge.” It is too bad. In many ways, this is the most generous person I know and was good to me in so many ways.

The essence of how we evaluate people is the way they conduct themselves in their personal and professional dealings. We really do not care very much about what their religious affiliation is or is purported to be. The cultural expectation that religious organizations and people of faith are going to be better than expected is unfortunate and unfair. Remember what the good “country priest” said, “We all have a story and pretend that we don’t.”

Jan Jennings

Republished with permission from the Hospital News Group

What is worse, “poor” management or “under-management?”

Our firm normally gets called two or three years after the client hospital or health system needs help. These hospitals are normally “in the financial ditch” and require admission into our consulting intensive care unit. Explicit poor management is not difficult to detect. These hospitals have been losing money month after month and/or the leadership of the hospital has no vision for the future of the institution and/or the administration, board of directors, medical staff or some combination of these relationships are throwing sand on each other. Worse, we see patient and employee safety problems that would make you lose your appetite. It is this kind of client that does not even challenge our skills and abilities. It is often so patently obvious what needs to be done . . . we frequently discount our fees because it is not heavy lifting.

The potential clients we hate to work with have the following kind of attitudes and opinions. “We are breaking even, everybody seems pretty happy and we are not sure we need any help.” Pleeeeease deliver me from this cup and cross! These are the hospitals and health systems that are under-managed. They do not know what they do not know. They rarely monitor productivity against reliable benchmarks, the agenda for the board meeting is thrown together at the last possible moment, the input of the medical staff is studiously avoided and no one seems to really care about whether the employees work in a safe environment and if the patients are treated safely.

Our friends and partner consulting firms that work in the industrial sector rarely run into this kind of client. Let me use an example or two. The publicly traded company has no confusion about who they serve. It is the shareholder. Management has incentives to improve revenue and drive out poor quality, sub-standard service and squeeze out every nickel of unnecessary cost. A friend of mine is a project manager by training and experience. The management to whom he is accountable held him in high regard, gave him the highest ratings for his services and praised him in every reasonable way. Last week he lost his job. Management was able to find similar talent on the Pacific Rim willing to provide the same services at 45 percent of the cost. He is now out of work. The unnecessary costs were not tolerated.

We see hospital management and boards of directors willing to accept unnecessary costs within their hospitals . . . well, because we are breaking even. The fact that breaking even will never be sufficient to refresh the physical plant or field new and improved technology is lost on these executives and the board of directors. This kind of thinking is Neanderthal, at best. It is the kind of thinking that thoughtful board members observe and shake their head when they get put in their place when trying to provoke reform and alternative thinking.

Let’s look at the customer service at a major industrial giant WalMart. If you buy something that you get home and you suffer “buyer’s regret” or it does not perform as you had hoped, you simply take it back for a refund. No questions asked . . . they want you back for future purchases.

How about when a patient receives poor care or lousy service? Do they get a refund, or is the health insurer informed that they should not pay the hospital or physician for slipshod service or outcomes? A friend of mine recently had a cataract removed, and his vision worsened. When he questioned the eye surgeon, the surgeon was only too willing to admit that his hand slipped and he accidentally cut the eye in a manner that was not appropriate. The physician bills arrived right on time just as if the surgery had been performed perfectly. From a conceptual point of view it is almost too hard to take in. If you have your auto dealer replace a defective new fender on your car and it falls off on the way out of the dealership parking lot . . . should you have to pay for the fender repair? Of course not! In hospital and medical care you get the bill regardless of the outcome. Why?

The answer normally comes back as follow, “. . . that’s the way we have always done it; I think everyone does it that way; why fix what is not broken.” Organizational reality is this: you are moving forward or you are moving backward. There is no such thing as standing still.

If your institution is under-managed it is only a matter of time before you end up out of work and your former hospital is admitted to intensive care for a retrofit. If you feel a little queasy after reading this . . . the best thing you can do is re-examine how things are done and get some help. It is not necessary to call our firm, but call someone before your board chairman starts calling around for you after you are gone.

Jan Jennings

Republished with permission from the Hospital News Group

"Baby Boomer" makes a life altering change . . .

Born in 1946, and without any input into the decision to join planet earth, and without my knowledge, I joined the ranks of the first year of baby boomers. Not to bore you with my biography, I have spent most of my working years as a CEO of U.S. hospitals . . . four to be exact.

In 2003 I simply had enough of that routine. The typical Hospital CEO gets up between 5-6 AM and gets his brains and emotions scrambled for 12 to 14 hours per day. Much of this work is very gratifying, and a lot is a "bucket full of busy." So, without a business plan, I plunged into a crowded pool of healthcare consulting firms. What a swim it has been. I have learned more in the past three years than the previous thirteen. There is a lot of flying, long days away from home and the associated concerns of starting something (new business) you know precious little about.

On the other hand, the joy of waking up in the morning and being responsible only to your family and employees is a real kick. There is no medical staff and there is no board of directors. I have advisors, and they speak frankly about what they like and don't like. But, in the final analysis, I make the key decisions on behalf of the firm American Healthcare Solutions and live with the consequences. I have my list of mistakes. But the successes are sweet and satisfying. Helping a little hospital get back on its feet and find its way in the market place is fun enough. The psychic rewards of a Board of Directors, Medical Staff and employees saying "thank you" is almost too hard to believe. This is the happiest and most liberated time in my life.

My friends and partners in the firm have been enormously patient and supportive. There have been good times and not so good times. However, if I want to know who is responsible, it does not take long to find a mirror.

So my fellow "baby boomers" on a road of despair I would only suggest that there are options. Take one. Life is short. There is little time to waste. Do not suffer fools. Nurture the young. Honor the elderly. Share your love everyday. Appreciate the little things in life. And first among equals, be honest with yourself.

Jan Jennings

Republished with permission from the Hospital News Group