The Blame and Shame(ful) Culture of Healthcare

Mark’s Note: This is another guest post by Drew Locher (check out past posts and my podcast with him). There’s been a lot in the news about “medical error” arguably being the 3rd leading cause of death in the United States. But what about the errors that don’t cause death, but cause harm and/or annoyance? Drew writes about one such case today and it hits close to home for him…

5451746855_e659be36c7_zI was part of a group heading by bus to a company visit in central Ohio when I received the call. My wife was on her way to an Emergency Room in southern New Jersey. The preliminary diagnosis was a burst appendix. The host company, with whom I had worked in the recent past, made arrangements for me to immediately return to Columbus to get a flight back home. The rupture had become encapsulated, and the infection that resulted meant approximately five inches of her colon had to be removed. A seven-day hospital stay followed the operation as the infection was brought under control. And that was just the beginning.

We met with the surgeon in his office two weeks later. “This isn’t going well,” he said and he opened up about four inches of her five-inch abdominal incision. He proceeded to dress it and turned to me and said, “Did you get that?” I said, “Get what?” “You’ll need to do this several times a day over the next few weeks until the wound heals. Just pack it with gauze, she can rinse it when she showers every day.”

And that was the full amount of training and education that we received on wound care when we returned home. The next several weeks were interesting, to say the least.

We did the best we could, questioning all the time the effectiveness of this course of action. After another four weeks, we met again with the surgeon. “We are going to have to re-admit her,” he said, as he inserted a swab stick about three inches up her abdomen. We learned about “tunneling and undermining,” a sign that the tissue was clearly not healing properly. I felt responsible for not taking better care of my partner in life. Perhaps if we had better dressed the wound, it would have healed more effectively. Did I pack it properly? Could the tunneling and undermining had been prevented? What if we had received proper instruction? Could the readmission have been avoided?

In the time before returning for a second surgical procedure, I found myself teaching a workshop on A3s, a problem solving and process improvement methodology, to a group of healthcare professionals as part of a public workshop for the ThedaCare Center for Healthcare Value. I described the events of the past two months to the group that included clinicians. I described the instruction that we had received on wound care.

Their collective response was best described as outrage.

“Disgraceful!”

“Shocking!”

“The surgeon should have immediately directed you to a wound care center.”

Then came important advice including, “You are not to leave that hospital without seeing a certified wound care nurse.” It was advice I intended to take.

In post-op, I asked the surgeon about seeing a wound care nurse. He ignored the request and left. I asked several nurses who told me that, while they agree, only the doctor can order such care. When I insisted, they said, “There’s nothing we can do. You don’t know how he gets. He’ll start yelling.” Undeterred, I asked the surgeon again when he returned. This time he said, “Your wife will be put on a wound vacuum, and I’ll order a wound care nurse who will come to your house.” Finally… satisfaction.

A few days later, we visited a wound care center for preparation and instruction on the wound vacuum system and process. In private, I described the events leading up to this point to the doctor overseeing the center. He visibly winced when I described the instruction that the surgeon gave us and told him that the surgeon directed us to simply rinse the wound in the shower every day. He all but acknowledged that my wife should have been put on a wound vacuum after the first surgery, given the nature of the procedure.

My point was that this surgeon’s cavalier attitude to wound care was harmful to patients and was the probable cause for the re-admittance of my wife. I suggested that he speak to the surgeon and perhaps future patients will benefit. His response was, “I can’t say anything to him. You don’t know how he gets.” Again, there was greater concern about the reaction of the surgeon than the welfare of patients!

The inability to have critical but respectful conversations seems to be the single biggest obstacle facing the healthcare industry as it works to improve quality and lower cost. You can be sure that this surgeon doesn’t hesitate to point out shortcomings in others. He has instilled enough fear in others, including peers, that they are unwilling to point out a significant opportunity for improvement to him. Without objective reflection there can be no improvement. The concept of “humble inquiry” is completely foreign to him and many others in the industry. In a Lean Enterprise, leaders do not assume that they know all of the answers. They seek input from others, regardless of title. It is a culture of “together we learn, and improve.”

For decades, the expression “blame and shame” has been used to describe the culture in healthcare. Unfortunately, the result of this culture is sometimes shameful care.

Photo used under Creative Commons license, from Flickr user frankieleon.


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Drew Locher

Drew is currently Managing Director for Change Management Associates. CMA provides various Business Improvement Consulting and Organizational Development services to industrial and service organizations. In 2004, Drew Locher co-authored book titled, “The Complete Lean Enterprise – Value Stream Mapping for Office and Administrative Processes”. In April 2005, the book won the prestigious Shingo Prize for Excellence in Manufacturing. He published “Value Stream Mapping for Lean Development – a How-to Guide to Streamline Time to Market” in 2008. His book “Lean Office & Service Simplified: the Definitive How-to Guide” was a 2012 Shingo Prize recipient. His latest book is titled “Unleashing the Power of 3P”.

5 Comments on "The Blame and Shame(ful) Culture of Healthcare"

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  1. Dean Bliss Dean Bliss says:

    Drew, thanks for sharing a powerful story. We all have much to learn about how bringing a Lean approach to a situation can be difficult as we encounter strong personalities. All the best to you and your wife.

  2. Debra Thompson says:

    Drew,
    Thank you for sharing such a difficult and painful postoperative experience for all of us to learn. Your experience identifies the significant challenge in effectively speaking up when a care giver is concerned about the quality of patient care. The American Association of Critical Care Nurses provides excellent insight in this issue with two studies: The Silent Treatment and Silence Kills . These are powerful adjuncts in helping staff speak up in the course of work to identify problems. Continued good health for you and your wife.

  3. Drew Locher Drew Locher says:

    Thank you Dean and Debra for the kind wishes. And that you Debra for the link to the study. I look forward to reading about it.

  4. Pam White says:

    Drew, Patient stories such as yours are a powerful way to reinforce why we, (those of us in healthcare), chose our professions – to do what is right for the patient. Healthcare organizations that do not embrace collaborative just culture, where leaders empower all members of the healthcare team to hold each other accountable, (even the surgeon), in a safe and respectful work environment, will have a difficult time trying to be a lean enterprise. Thank you for sharing your patient story. As a member of the global healthcare community, I am sorry this happened to your wife and hope she is doing well.

    • Drew Locher Drew Locher says:

      Thank you Pam for the kind wishes. I believe that such experiences are important learning opportunities for all of us. Hopefully it helps in some small way. Thanks again.

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