How Could This Happen?
By Cary D. Gutbezahl, MD, President, Compass Clinical Consulting:
This week, the administration of Broward General Medical Center announced that a nurse had been reusing single-use IV tubing and saline bags. This problem had gone on for years, putting patients at risk for infectious diseases. Upon learning of the problem through the compliance hotline, the hospital acted responsibly. But one can’t help but ask, “How could this happen?” More importantly, we must ask, “How could this have gone on so long?”
As we all know, sometimes things happen in hospital operations that result in patient harm. Not infrequently, the proximate cause is that one or more people are not doing what they are expected to do. Although many factors may contribute to an avoidable injury, investigations often reveal that the policy and procedures were in place, the staff was trained on and understood the policy and procedures, staffing was adequate to do the work, but people didn’t follow the policy. Upon further investigation, it is often found that this one negative event was not a unique occurrence. Rather, lots of people fail to follow the policy, this just happened to be one time when the problem was detected. So, you have to ask, “How could this happen?”
The common managerial response to such adverse events is to punish those who were caught. Executives believe that this shows leadership and sends a message to others. But does it have any lasting effect? And does it convey the right leadership message? Punishing the guilty is appropriate, but it conveys the message that bad apples are the source of problems and that getting rid of them solves those problems. In other words, it’s not the system; it’s the people. Not only is this not a humanistic management message, but it ignores the observation that many people weren’t following the policy. Furthermore, a one-time event is not likely to have a more sustained impact on behavior than the original training on the policy.
To fix the problem, executives and managers must do two things. First, you have to investigate why people aren’t doing what they know they should be doing. You have to involve people who haven’t been doing their jobs to understand their reasoning. While it may be a challenge to do this in a non-threatening way, gaining the trust of the participants is critical to developing a systematic solution to the problem. You can’t assume that the problem was due to “bad people.” People act in response to their environments, whether that means workflow interruption or cultural norms. You can’t fix the behavior if you don’t understand the source.
The second step is to fix the problem. A highly attractive, but rarely available method is to develop mechanisms that force the desired behavior to occur. These types of solutions are usually technology-driven, e.g., an alert that is only turned off after blood pressure is checked. Of course, people may find ways to circumvent such technology. People can falsify documentation so modifying documentation requirements is not foolproof.
One critical component for management, especially when implementing a corrective action, is to design and implement a management information system that monitors the desired behaviors. You can’t assume that one-time corrective actions will continue to have the desired effects. Behaviors can drift over time. You need information, and you need to be creative in thinking about how to get that information. For example, if one-time use material is being reused, one should observe unexpectedly low supply costs.
In healthcare we also have an obligation to assure the competence of our staff. People have to be evaluated not just on knowledge, but on practice. Supervisors need to work side by side with staff to observe behaviors and make sure that the staff is following the policies and procedures. If this isn’t happening, management needs to find out why.
Finally, in our work investigating adverse events, we have found episodes of mass non-compliant behavior. Undetected errors lead to patterns of errors. At one hospital, “everyone” took wheelchairs across the entrance into the MRI suite, but “this was the first time that the metal wheelchair was (violently) pulled into the magnet.” These are particularly hard issues to monitor, unless you get out and see what’s going on. MBW (or Management By Wandering around) is still a good idea – old ideas should not be discarded just because they are old. But you have to look for problems, not just socialize.
The absence of a detected problem is not evidence that policies and procedures are implemented as designed. As hospital executives and managers, you don’t want to ask, “How could this happen?” because you’ll be reading your answer in the newspaper. Instead ask yourself, “How do I know what really is happening?”
To learn more about hospital policies and patient safety, visit Executive Leadership.
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