In our January 2011 What’s New in the Patient Safety World column “No Improvement in Patient Safety: Why Not?” we lamented the relative lack of progress we have made in reducing the number of harmful patient events. In that article we did discuss some of the reasons, including implementation of some “evidence-based” interventions that turned out to be not-so-evidence-based, unintended consequences of other interventions, etc. However, we ascribed much of the problem to our failure to significantly change the culture of safety.
When we do root cause analyses (RCA’s) three themes always make their way to the top of almost every one we do: (1) communication issues (2) failure to heed alarms and (3) failure to buck the authority gradient. Of course, all three have their roots in the culture of safety or, rather, the lack of a culture of safety.
Last week a very valuable contribution to patient safety came from the AORN (Association of perioperative Registered Nurses) and the AACN (American Association of Critical-Care Nurses) working together with the leadership and corporate training company VitalSmarts. Their study “The Silent Treatment. Why Safety Tools and Checklists Aren’t Enough to Save Lives” is a revealing look at the current state of the culture of patient safety.
Based on a previous study done by these groups (Silence Kills. The Seven Crucial Conversations for Healthcare. 2005), the new study utilized two types of survey sent to members of AORN and AACN. One was a traditional survey, the other a “story collector”.
They honed in on three “undiscussable” issues: dangerous shortcuts, incompetence, and disrespect. They found that 4 out of 5 nurses participating in the study admitted they had concerns that one or more of these three “undiscussables” were potentially causing patient harm and that very often they did not discuss the issues with the party doing the undiscussable (who could be another nurse or a physician or other healthcare worker). In some cases they were more likely to bring the undiscussable to the attention of a supervisor. But even the nursing supervisors participating in the study admitted that they often did not confront the offending party or take appropriate action.
They did go a step further, however. Those nurses who did confront the offending parties provided examples of how they handled those difficult discussions. Those that did so successfully often used techniques that were “face saving” for the other party, yet effectively addressed the “undiscussable” issue.
Also, though the “silence” remains problematic, the authors do note that there has been progress since they did their previous survey in 2005. Compared to that study (“Silence Kills: The Seven Crucial Conversations for Heatlh Care”) participants were about 3 times more likely to speak directly to the person doing the offending activity in the current survey.
Both are studies that provide incredible insight and provide further evidence that our difficulties in “moving the patient safety needle” lie in our failure to change the culture of healthcare. You can download the "Silent Treatment" study and associated materials at the site below for free.
And, of course, physicians are little better in dealing with the same issues amongst their colleagues. A study last year (DesRoches 2010) showed many physicians fail to report or confront their colleagues who are either impaired or incompetent. A third of physicians who knew that a colleague was incompetent or impaired failed to report that physician. The most common reasons cited were belief that someone else would take care of reporting, belief that nothing would happen as a result of reporting, and fear of retribution.
The 2007 American College of Physician Executives (ACPE) Quality of Care Survey (Steiger 2007) revealed numerous issues considered by physician executives to be obstacles to quality of care or patient safety. But in many of the cases the perceived obstacles were failure of the system as a whole to deal with incompetent, impaired or disruptive physicians. Below are some of the quotes from respondents to that survey:
· “An interventional cardiologist with questionable skills (is) being allowed to continue with endovascular procedures because he’s part of the dominant cardiology group.”
· “One of our highest volume cardiac catheterization physicians routinely exercises questionable judgement. All in administration acknowledge this but do not ‘rock the boat.’”
· “Orthopedic surgeons are tolerated in their unprofessional behavior and erratic delivery of care, as long as they keep booking their spines and total joints.”
· “An orthopedist who is terribly out of date and refuses ED call, but is intimidating and generates big bucks for the hospital.”
And, of course, the Joint Commission’s Sentinel Event Alert #40 “Behaviors That Undermine a Culture of Safety”, issued in 2008, discusses the impact that disruptive behavior has on developing a culture of safety and makes numerous recommendations for each organization to identify such behaviors and deal with them appropriately.
Turning a blind eye or deaf ear to such problems just continues to make the working environment worse for all parties involved. We’ve seen numerous occasions where staff had previously stepped forward to report such behaviors, only to be ignored or, worse yet, suffer retribution for their actions. So the organization as a whole needs to ensure a supportive environment is present so that staff do not feel uncomfortable in confronting such individuals or in addressing such threats to patient safety. You can have all the policies and procedures in the world but if your culture is not conducive to eliminating these hazards we will never move patient safety to that next level.
AACN/AORN/VitalSmarts. The Silent Treatment. Why Safety Tools and Checklists Aren’t Enough to Save Lives. 2011
American Association of Critical-Care Nurses (AACN) and VitalSmarts. Silence Kills. The Seven Crucial Conversations for Healthcare. 2005
DesRoches CM, Rao SR, Fromson JA, et al. Physicians' Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues. JAMA 2010; 304(2): 187-193
Steiger B. Doctors Say Many Obstacles Block Paths to Patient Safety. The Physician Executive 2007; 6-14 May • June 2007
ACPE. 2007 Quality of Care Survey
The Joint Commission. Sentinel Event Alert, Issue 40: Behaviors that undermine a culture of safety. July 9, 2008