Medical Errors Report #7
A Four-Year Solution Implementation Study
Hospital Management Needs Redesign to Face the Challenges of the Future
The power of fixing medical errors lies squarely on the shoulders of hospital executives who are presently not ready to step into this very important role. Cost containment remains the major priority to most of them. They are however, unaware that improving the quality of patient care may not only improve patient satisfaction, it will reduce cost by reducing waste. The issue of medical errors is not created in most cases by bad medicine so much as it is created by a defective system of delivering care. If physicians and other health-care workers are responsible for patient care, then the hospital establishment must be directly responsible for management of delivering the care. This is not to say health-care workers should wash their hands of the process because their cooperation with the administration is crucial and will guarantee the success of any intervention. The major problem today, is the lack of interest of health-care executives in being drum majors for quality improvement.
In his article, Invisible Injuries (Washington Post, Tuesday, July 29, 2003) Dr. Donald M. Berwick, the CEO of the Institute for Healthcare Improvement stresses that we need a better system for tracking and preventing medical errors. He explains that hospital executives misunderstand why errors occur. First, they believe errors are made by bad people. Second, that by analyzing errors, a single cause will be discovered. Third, that adding complexity improves reliability. Fourth, that human errors are inevitable and so are patient injuries. Dr. Berwick stresses that health-care executives clinging to these unscientific theories creates counterproductive responses to problems, consequently slowing progress to safer care. He says the present system could be improved by new training, improvement of teamwork among doctors and nurses, better computerization, job redesign, cultural improvements, and many other actions. He warns that this would initially cost money but will pay off in the long run since improving patient safety has to involve all departments within the health-care system.
There is an urgent need to redesign the present system of management in most health-care systems to influence solution implementation to fix medical errors or systemic failures. This is one of the major findings of this study and is also supported by other professionals working on medical errors and the improvement of patient care. We have been working on process redesign to fix medical errors, but the efforts have been frustrated due to barriers created by the administrative forces of the old system. The old and outdated health-care management system remains a giant barrier to improvement. The wave of employee-empowerment through worker-driven performance improvement, steering committees, and problem-solving groups is new in many health-care institutions. Process redesign through action committees and shared accountability to empower employees are new concepts to most health-care workers. But the old and archaic child-parent or master-servant relationship remains as some managers grab on to power regardless of how it is hurting the business. This type of management style does not create a conducive atmosphere to fixing medical errors. In the future, as the population of older people gets larger, the health-care industry will be pulling a much larger group of people through the health-care system, costing billions of dollars. The present management system needs urgent redesign to make the industry more efficient.
Process redesign will not work effectively with the frontline workers unless the current administrative system undergoes drastic process redesign to maximize employee potential instead of allowing ego-driven managers to kill the excellent initiative of hardworking employees. The book Managing Crises on the Job was initiated based on the series of barriers encountered along the way to fixing medical errors during this phase of our study. If health-care institutions want sustained motivation of employees to correct problems, the present administrative system needs immediate reorganization. Creative potential of all workers is needed for teamwork for the best results. Such excellent performance cannot be expected of employees working in dehumanizing conditions in which they are constantly berated by managers, administrators and medical staff. This is a major and constant complaint by health-care workers throughout this study.
Maureen Connor, RN. of the DanaFaber Cancer Institute in Boston, MA., discusses the importance of support from health-care executives to improving the quality of patient care in her August 2002 article; Nurses May be Your Best Tool For Improving Quality of Care. She stresses that quality improvement can only be initiated from the top by an administration using a non-punitive approach to making patient safety a top priority
One of the findings of this study is the break down of the checks and balances because every case deserves a special consideration. Take a case where surgical specimens were mislabeled and the physician forced the pathology department to accept the specimens. In another situation, the lab received unlabeled blood samples, according to set protocol the lab was supposed to have rejected such specimens to protect patients. The emergency room director forced the lab to accept the specimens. Safeguards will work only if the hospital executives are willing to enforce the checks and balances designed to prevent errors from impacting patients. As long as they are still sitting down in their comfortable offices and pushing their pens, nothing is going to happen, errors will continue to kill patients.
Creating an atmosphere in which employees are able to report concerns without being victimized by verbal abuse is essential for continuous quality improvement. When employees feel that the upper management is not responding to their concerns, they not only stop reporting, they start to ignore dangerous incidents leading to patient harm. Checks and balances can only work when process-line workers are ready to spot deficiencies before they adversely impact patients.