Changing the culture in healthcare - part 1

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.