A “plethora of policies” won’t fix hospital safety

Today’s newspaper reports that changes to hospital safety are too slow. As we’ve noted here before, it’s a $1.8bn annual problem.

The Health and Disability Commissioner requested each DHB to review the case of death at Wellington Hospital in 2004 and “report to him on the safeguards that they have in place to prevent a similar case in their DHB”.

The responses were analysed and the report prepared by Dr. Mary Seddon (PDF 80kB) makes fascinating reading as she identifies three categories of approach to safety by DHBs (District Health Boards):

  • those that really understood what a safety culture was and demonstrated systems thinking
  • those that superficially used the language of safe & quality care but their action plans did not give confidence
  • those that have not really moved on from the individual blaming culture — they continue to believe that if doctors just concentrated harder, worked harder and were more careful, then medical errors would not occur

Apart from a difference of approach, a common factor was “the plethora of policies that almost all DHBs have produced.” The report concludes, “Many DHBs could stop writing policies tomorrow and not see a drop in the quality of care that they deliver.” Policy writing in our view is a classic example of treating the symptoms and not attacking the root cause.

The problem with “fixing the symptoms” is that the cure doesn’t really work and the side-effects become even more problematic. The classic effect is to make systems and processes even more complex and to provide ever more checks and balances to pick up failure - rather than preventing failure in the first place. The staff don’t use the policies? Then the policies or their implementation are flawed - and typically they become ever more prescriptive turning smart people into dummies (so the smart people just ignore them). Here’s our favourite quote again:

“Simple, clear purpose and principles give rise to complex, intelligent behaviour. Complex rules and regulations give rise to simple, stupid behaviour.”
- Dee Hock, former CEO of Visa International

Regular readers of this blog will know that we strongly advocate Root Cause Analysis as a powerful tool to deal with repetitive failure and we practice our version of this, the “Corrective Action Team System” (CATS).

“Some DHBs now have Sentinel Events Review panels (eg, Auckland DHB), and some mention Root Cause Analysis (RCA), though it is not clear how many staff in these DHBs have been trained in RCA, and how much is being done. Two DHBs (Capital & Coast DHB and Canterbury DHB) are now reviewing all deaths.”

Root cause analysis only works in a climate of “open disclosure” (also identified in the report). You will never get to the root cause in a blaming culture because a blaming culture rewards reticence, obfuscation, and passing of the buck. In such a culture truth, facts and information never see the light of day.

Congratulations to Dr. Mary Seddon for her forthright approach in preparing her report. Paradoxically, in our view, if you want to look for and find areas of improvement then don’t look for areas of improvement - look for areas of failure.

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