Culture of Safety in Healthcare

This search for the why of the situation is a search for transparency, a call for an investigation and clarity about the care that was received. This request is incompatible with the closed, controlled culture within many health care organizations.

Healthcare is a high-stakes industry.  For everyone involved, from the CEO to the physicians to the nurses and even down to the housekeeping staff, has come together for one purpose: to heal those who are ailing from all manner of medical conditions. At times the care is routine; an antibiotic for an ear infection in a toddler for example.  But at other times, the stakes are life and death.  When the stakes are that high, any mistakes can tip the scales.

This is one of the reasons that the culture within many health care organizations tends to be very closed, very controlled and very top-heavy.  When a patient suffers an adverse health event, or dies, patients and their families often seek to answer why this happened, and what, if anything, could have been done to prevent it.  This search for the why of the situation is a search for transparency, a call for an investigation and clarity about the care that was received.  This request is incompatible with the closed, controlled culture within many health care organizations.

A recent article posted in Modern Healthcare titled Hospitals slow to adopt patient apology policies takes on this issue, and what is being done to combat it.  The reason this kind of culture exists within many organizations is a simple one: defensiveness.  Even if a physician realizes that a mistake was made and wants to apologize to patients, they are often barred from doing so by lawyers and legal counsel, who advise them to say absolutely nothing about the incident as anything they say could be used against them if the patient or their family files a lawsuit.

GavelThis fear of lawsuits and the large payouts that can be ordered for cases of medical malpractice are an ever-present fear for physicians and their administrative staff.  It’s also been shown to add the costs of healthcare, with the cost of malpractice insurance rising ever higher.  And it’s not just the cost of malpractice insurance.  As the article points out, according to a 2010 study in Health Affairs, the cost of liability and the resulting practice of defensive medicine in the healthcare sector amounted to $56 Billion.  This means that 2.4% of healthcare spending in 2010 was spent on liability claims and defensive medicine to try to avoid liability.

Some hospitals have taken the approach of promoting apologies and transparent investigations of deaths and adverse health events in their facilities in an effort to bring these costs down.  Findings show that hospitals who do exactly the opposite of what lawyers advise (apologize promptly and conduct a transparent investigation, and being willing to pay for those mistakes if found) has two main benefits: It actually reduces the costs of liability and helps improve the healthcare system.  By making patients feel that the facility cares about them and that they are involved in the process and will address any systemic errors that will found, patients or their families are often more comfortable with the situation and less likely to file lawsuits.

The toughest part about implementing this, as the article states, is that it requires a culture shift within the institution.  It cannot investigate the issue on the patient’s behalf if the nurses or aids are afraid to point out mistakes in the system which might have contributed.  This is what is referred to as a Culture of Safety, and it’s a hard thing to implement within healthcare.  Charles Duhigg gives one powerful example of why this changes is needed in his book The Power of Habit, which I read and reviewed.

As important as these kind of changes to the healthcare system are, the change cannot be squarely laid at its doorstop. Patients and their families need to remember that healthcare also involves humans, who are biological beings.  No matter how skilled the physician or how much state-of-the-art equipment the hospital has access to, the rules of biology win out. The simple truth is that not every patient who enters a hospital is going to leave it alive.

Hair wreathOur culture has become very uncomfortable with death, mainly as a result of its relative infrequency and segregation within society.  Historians remind us that there was a time when death was inescapable, and was simply a part of life.  Death occurred much more frequently, and that meant that humans were forced to accept its existence and deal with it in any number of ways.  In some cultures, this meant building shrines to loved ones who had passed.  In others, it meant creating mementos to remember the person by.  In the early 19th century, it wasn’t unusual for relatives to cut hair from the person who had passed and weave them into elaborate wreathes that they framed and displayed, or to pose for post-mortem photos with the bodies of the deceased.

With the advance of medicine and improvements in diet and sanitation, death now only seems to occur to those who have reached advanced age.  This has had the effect of making us very uncomfortable with death, and in some cases unwilling to accept it even when it is inevitable.  If the communication lines between clinical staff and patients were more open, it would improve matters in this area significantly.  A Culture of Safety can help foster this kind of communication and transparency.  As Martin H. Fischer once said…

In the sick room, ten cents’ worth of human understanding equals ten dollars’ worth of medical science.

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