Changing the culture in healthcare - part 1

In 1995 two independent surveys (Tito, Wilson) revealed that being admitted to a hospital in this country was the most dangerous event in the life of the average Australian.

Since then there have been media exposures of problems in Canberra Hospital, King Edward Memorial Hospital in Perth, the Macarthur Area Health Service (Camden and Campbelltown Hospitals), Illawarra Health’s pathology - and it is even alleged that a single doctor in Bundaberg Hospital has been the cause of 88 deaths and 14 serious injuries.

According to John Menadue AO, “Bundaberg Hospital is the tip of a very large iceberg. The risk from terrorism is miniscule by comparison [to medical error]."

Tip of a very large iceberg! The nurses at Macarthur AHS who blew the whistle used the same words. What is going on? What follows are three clues.

The accreditation farce

In the accreditation process, performance assessments are made by external surveyors. The approach indicates that there is a greater fear of treading on toes than there is concern for patient safety:

• the procedure is basically to make an observation and then put a tick in a box. Probing the culture of a health organisation is avoided. For example, there is no box which is labeled: “Clear of political intrigue which could render this department dysfunctional.”
• a service is given months of notice in advance that an inspection is coming. Inspection is, thus, confined to the image presented by the management on the day of inspection;
• if the service is found wanting by the assessors with proper management practices clearly beyond the understanding of its current managers, that same management is given a reprieve and allowed months to meet the set criteria.

Do you as a potential patient find the above hard to believe? Here is an extract from Quadrant magazine and which was quoted in the February 6, 2006 issue of the Medical Journal of Australia. This is a description of an accredited hospital:

It is virtually impossible to describe the ingrained evasiveness, the compulsive buck-passing, the deliberately obfuscatory language, the strategic amnesia, and the mechanical reciting of rules to excuse the inexcusable displayed by the Bundaberg Hospital administrative staff …

There have been so many external structures set up to look into quality and safety in health care over recent years that health care staff cynically refer to the “health standards industry”. The action has been mainly to create the delusion of productivity with a seemingly countless number of meetings and generating a seemingly inexhaustible stream of printed paper.

Out of this Ivory Tower, and apparently seeking ever more complexity to justify its own existence, the “health standards industry” devises processes which stressed staff have no time to implement.

In 2007, the system is promising reform, but refuses to acknowledge that external inspections can only ever be superficial and that only the staff-on-the-ground know exactly how their service is performing. And yet, nothing is done to guarantee witness protection from covert reprisals. It is dangerous to stick one’s hand up.

Staff grievances are unwelcome

Public health in this country is about 150-years-old. There are currently more than 300,000 employees in public hospitals and community health centres. The total number of individuals working in the system over the past 150 years would probably be well over two million.

There is one question we should be asking: Where are the hundreds of formal disclosures one would reasonably expect from such a great number of employees witnessing millions of serious adverse events?

The following is from the Sydney Morning Herald for the weekend March 31 to April 1, 2007.

Over the past 10 years the surgeon has written letter after letter detailing a litany of complaints and cover-ups at the hospital (Royal North Shore) which he says has failed to properly investigate any of the incidents. He says - “The system allows multiple problems to occur. There is no one person who takes ownership of the problem. Obsessed by process at the expense of health care, the hospital gave medical and surgical units untenable service goals and limited resources. We are exposed to a rotating door of middle managers who are servants to a paperwork process that hides the problem.”

That surgeon may have spoken up, but junior doctors, nurses and associated health care professionals who are on a much lower rung fear to speak up about what should be an unacceptable performance. To report entrenched incompetence or unethical behaviour is an indirect attack on senior management’s failed supervision.

As quickly as possible, the spotlight will likely move from the substance of the disclosure and onto the credibility of the disclosing employee. The “internal corrective mechanisms” which are supposed to improve the system are little more than policies on file. Recently (August 27, 2007) the Chief Executive Officer ACT Health announced another on the ABC’s Four Corners program:

… We have put in place a system that actually requires people [staff] to notify incidents that are serious …

Why were elementary structures such as this not put into place a century ago? Why now? These are questions a 14-year old child would ask. There can only be one explanation. The ministers and area executives feel that the media has the sniff of blood in its nostrils. They have to be seen to be doing something. In this respect, the media are writing the health care agenda.

Nevertheless, nothing is likely to change because there are unwritten policies inherent within big organisations which will ensure that assurances, such as those trumpeted on Four Corners, remain as ink on paper.

All health services have risk assessments regarding patient care. There is a more important risk assessment than that. It is who will pose the greatest litigation threat to the service? It’s certainly not the damaged patient who cannot gain access to the evidence (unless he or she dies - and then the coroner provides the evidence). The attention given to a grievance will depend on its perceived capacity to cause trouble.

Investigations into allegations and disclosures require hard evidence in the form of signed statements from insecure and even intimidated witnesses. As few people wish to stick their necks out, such documentation is almost impossible to obtain. There is no probing. Clues are ignored. There is no passion to rectify.

A gigantic system has evolved which lacks leadership at all levels

It would be a futile attempt to be a leader in an entrenched culture which does not support creativity, seeks out scapegoats, has an obsession with mechanisms, is oblivious to staff at the coal-face feeling devalued and which sanctifies the passive conforming to a poorly performing workplace by using the term “team-player”.

While doctors and nurses are making critical decisions on the run, in the same system there are bureaucrats who will make no decision until every backside-covering contingency is taken care of. In the absence of one person with real power at the top of the organisation, anomalies such as this get worse over time.

Good leaders win respect from subordinates. But instead, incompetents are sheltered and innovators are shafted. It is the dedication of the staff at the patient-service interface which holds back a system from the brink of collapse.

The health ministers believe that the core problem with public health is getting the right specialist at the right place at the right time. The doctors believe that the core problem is the misallocation of resources to patient need. As the standard at the top sets the standard for everything underneath, the public health workers want courageous executives who the minister will support.

In conclusion

The administrative culture is every bit as important to patient outcomes as is the relative lack of resources - and yet the latter gets almost all of the media attention. In Part 2, the author will propose a lateral solution.