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…
I 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.
“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.
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