Revisiting Taxis, Medical Errors, and Systemic Problems
You might have read my blog post from last week about an unsafe taxi driver and medical errors – Said the Unsafe Taxi Driver, “Well, Did I Hit Anybody?”
In a colossal coincidence, the New York Times columnist Maureen Dowd wrote a piece called “Giving Doctors Orders” that was published the exact same day. No, I'm not part of a “vast left-wing conspiracy” here. My post had YouTube videos of a bad driver, while Dowd name dropped the actor Alec Baldwin and cited him on how to confront unsafe cabbies. Data would probably show that systemically unsafe healthcare practices harm and kill more people each year and probably deserve more of our attention.
In Dowd's column, she wrote of how her brother died after coming down with FOUR hospital-acquired infections.
She asked the doctor what might have caused it:
Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother's hospital gown.
“It could be anything,” he said. “It could be my tie spreading germs.”
I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds
As Dowd points out, best estimates show that hospital-acquired infections lead to 100,000 deaths annually in the U.S. As she points out the UK National Health Service banned long ties, long sleeves, lab coats, long fingernails and other known germ havens that can lead to passing on germs to patients. For a profession that talks about being “evidence-based” (or aspiring to that, as Dr. Brent James points out), why haven't we followed that practice in the U.S.? Is this the new patient protection norm in your country?
It's easier to identify my taxi driver's dispatch distractions or Alec Baldwin's newspaper-reading drivers as patently unsafe practices. It's very usual. We all drive and we all know the risks of distracted driving. But we're not all doctors. It's not obvious that a neck tie that's hardly ever cleaned can spread germs. It's visual and obvious that a long neck tie can kill the wearer in the factory, but it's less visual that the long necktie can harm OTHERS in healthcare.
There are also societal norms of different sorts in play, where Dowd and I struggle with speaking up to a cab driver, it's even harder to speak up when it's a highly educated physician. We're taught to respect physicians while cab drivers are more often the butt of jokes from stand up comedians. We should respect all people regardless of their job, as there is honor in work of any kind.
Dowd repeatedly found it difficult to speak up when she saw ICU clinicians not following proper hand hygiene. She cites Dr. Peter Pronvost, a leading patient safety advocate:
“There's no doubt that it's really difficult to question physicians,” Dr. Pronovost says. “It's hard even for me when my wife or my kids are ill. Many clinicians aren't the most welcoming. They give verbal or nonverbal clues to say, ‘Hey, I have the answer.' We just need to change the culture. The patient really is the North Star.”
That's why I question the efficacy of campaigns that urge patients and families to “speak up.” That unduly puts the burden on the customer to maintain quality. Does a car dealer ask the customer to “speak up” to ask if the steering wheel was put on properly? Maybe if you drive a Chevy Cruze you should. The auto industry generally takes care of its quality without asking the customer to play final inspector. I think healthcare owes patients as much.
Healthcare quality is arguably WAY worse than your run of the mill automaker, as recent studies point out the lack of adherence to even the most basic of infection control measures:
The study of intensive care units released Wednesday, for instance, found that health care workers wore gloves only 82 percent of the time when such precautions were specified, donned gowns only 77 percent of the time and washed their hands after only 69 percent of patient contacts. The lead author, Dr. W. Charles Huskins of the Mayo Clinic in Rochester, Minn., noted that those numbers were “not woefully bad,” as previous studies had found hand-washing compliance to be as low as 50 percent.
Not woefully bad? Wow, that sets the bar VERY low, don't you think? It's better, but nothing to brag about, as an industry.
You can also argue that transparency leads to better quality. Studies like JD Power and the book The Machine That Changed the World made it painfully clear to GM, Ford, and Chrysler (and the Europeans) that they had a big quality gap to close with Toyota and Honda.That data and comparison led to great improvements in auto industry quality.
Those who push for quality transparency data in healthcare make the same argument that transparency will force the whole industry to improve. Paul Levy's recent blog post called “Second thoughts on transparency in Ontario and Denmark” suggest that there might be a backlash against the transparency movement from at least some providers. Paul reports how some medical leaders thinks transparency will get in the way of proper quality improvement and one person suggested that the general public can't be trusted to handle such quality and patient harm data responsibly. Hogwash.
One comment on Paul's post passed along a second hand quote:
“I presented the Kumar and Nash article to our hospital's CME committee and one ‘long-time' psychiatrist reacted quite passionately – ‘we can never let the public know about this bad medicine…it is embarrassing' “
It's “embarrassing”? The cat is already out of the bag with studies from the Institute of Medicine that estimated almost 100,000 deaths from preventable medical error each year (in addition to the infections) and a Health Affairs study that suggests 1 in 3 hospital patients will suffer an error or an adverse event.
What's embarrassing is the healthcare industry and medical professions moving more slowly after more than a decade of awareness. I guess the long sleeves and long ties are visible evidence of some of that denial and inaction? Bow ties are a great alternative as one of the letters about Dowd's column points out.
The good news is that Lean, checklists, six sigma, and other quality improvement methods show such benefits and such promise. We have hospitals that are pretty much eliminating central line associated bloodstream infections, ventilator associated pneumonia, MRSA infections, falls, bedsores, and other preventable harm. As the science fiction author William Gibson wrote, “The future is already here â€” it's just not very evenly distributed.” Will efforts and spending like this from CMS actually help reduce errors and spread better care more quickly?
My friend Naida Grunden shared a Lean-based good news story: “Study Finds Drop in Deadly V.A. Hospital Infections.” Maybe Lean implementors everywhere should call for a moratorium on 5S-ing the nurses' station until everybody has solved these important patient harm and safety challenges?