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Discipline and Blame in Healthcare Oversight


State's long disciplinary process doesn't protect patients, critics say

Here is a story about complaints with Florida's disciplinary system for physicians. The system seems to be based very much on individual blame and punishment for things gone wrong. If an error occurs, let's investigate the doctor. Maybe the doctor needs to be punished? Medicine is a complex system. If something goes wrong, you can't necessarily just point at the doctor or any one individual.

“A death does not automatically mean the doctor did something wrong,” said Lucy Gee, director of the Health Department's medical quality assurance division.

True. Nor does it mean that only one person messed up. What if it was a systemic problem? Maybe the oversight system needs to ask “Why?” more often than asking “Who?” Can medical oversight boards learn to do more than just punish people?

“We are not out to get doctors; we are out to see what the real genuine situation is,” said Mari “Miki” Presley, deputy general counsel at the Health Department.

The medical board believes punishing doctors is not the cure-all to preventing future mistakes, said Larry McPherson, the board's executive director.

That's why this summer it lowered the minimum $10,000 fine for doctors who make wrong-site surgery mistakes — operating on the wrong person, or on the right person but the wrong body part — to $1,000. Fines and public awareness of the problem had not reduced the number of incidents, McPherson said.

The board is launching an education campaign to have each surgical team take a timeout to make sure it is doing the right operation on the right body part on the right patient.”

Ah, good. So, they realize that the threat of punishment wasn't working, it wasn't reducing the number of wrong-site surgical mistakes. Telling people to “be careful” or using fear are never the most effective methods. Does your factory use these methods to “ensure” quality? Does your hospital? This seems to be “human nature” or at least “management nature” to want to blame individuals when something goes wrong, whether it is a factory defect, a medical mistake, or an airplane crash.

I don't understand how, in the above example, lowering the minimum fine helped. But, an educational campaign is a better action — teaching people to work as a team to make sure surgical errors aren't happening. However, I've read earlier articles that talk about how nurses are sometimes afraid to speak up when they know a physician is making a mistake — this is a complicated situation with a hospital's culture and medical culture in general.

Another thing that comes up in the article — when there is a review situation with a physician, it often takes 18 months to review their case. Sounds like an opportunity for lean, to reduce that cycle time!

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Mark Graban is an internationally-recognized consultant, author, and speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus. He is currently writing his next book, tentatively titled Measures of Success.

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