Controls AND Communication AND a Patient-Centered Healthcare Vision: Why ALL are Key for Preventing Disasters Like Hepatitis C Outbreak at Exeter Hospital

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This topic really should be a book not a blog post, but hey, maybe someday it will be.  In the meantime, here are some thoughts about our response to disasters, like the Hep C outbreak in Exeter NH and what we consistently seem to overlook.  I’m not talking about the emergency response or the ongoing CDC investigation, but I am talking about what I perceive as our overreaction about controls that failed or were not in place and our underreaction about the lack of communication/collaboration  and the presence of fragmented systems that must have contributed!  These are more systems-related symptoms of bigger problems in healthcare and society.  Taking note of these in addition to controls is crucial for long-term meaningful change.

Fox News Headline this morning (7/27/12:  “Suspect in Hepatitis C Outbreak Fired in Arizona”)

If you are following this story, a Medical Technician, David Kwiatkowski, 33, is accused of stealing anesthetic drugs from Exeter Hospital in New Hampshire and contaminating syringes used on patients with Hepatitis C.  As the nightmare for this small community hospital in Exeter, NH and the 30 people testing positive for the virus unfolds, so too does an alarming and unchecked trail of employment by a drug-using, traveling medical technician.  (Kwiatkowski’s employment history involves hospitals in Arizona,  Georgia, Kansas, Maryland, Michigan, New York and Pennsylvania before being hired in New Hampshire in April 2011.)

The Patient-Centered Healthcare Vision Part

We are competing to fill beds rather than provide care for all.  This is the vision part.  Patient feedback can surely be helpful for addressing hospital issues such as time, flow and noise, but when it is done to fix THAT hospital in competition with other hospitals we are missing the boat.  If hospitals in the USA were really collaborating for best care for all, wouldn’t we have processes in place to send out warning messages?   There is a good chance that the legal proceedings in the prosecution of Mr. Kwiatkowski, will lead us to legislation that mandates some sort of reporting and/or licensing regulations that will limit or prevent this from happening again.  Please know, I am all for this, but my point is that if we were working together effectively for the right reasons the system would naturally move in this direction.  These new controls will take years.

The Communication Part

Maybe not everything is STAT in healthcare, but we do seem to be reacting to crisis much of the time!  As long as there is always something urgent to do and in my >25 yrs as an RN, there always is something urgent to do, we have trouble making effective and respectful communication the priority that it needs to be.   I know in my per diem role as a staff RN on a dementia unit, I seldom have time to have engage with my colleagues in private and unhurried conversations.   Even to the extent that we use a tape recorder or dictation machine to report about our shift to the next nurse on duty.  Rush, rush, rush seems to be the name of the game.

  • We don’t have time to give and receive constructive feedback.
  • We don’t have the skills or expectation to give and receive constructive feedback.
  • We don’t have private and quiet space appropriate for giving and receiving feedback.

And we need all of these if we are going to be collaborating optimally.  And further, these are the skills and this is the kind of culture that will help to ensure that staff notice a colleague’s unusual behavior, offer feedback to her/him, and when necessary share with leaders.

There is a wonderful Ted Talk by James Stavridis: A Navy Admiral’s thoughts on global security that illustrates the importance of building trusting relationships in addition to controls.  His point about building bridges along with more typical military efforts is right on!



beth improvOD Consultant and Author, Beth Boynton has been trained in the Professor Watson Medical Improv Curriculum at the Feinberg School of Medicine Northwestern University.  Please contact or 603-319-8293 to learn more about how a program can be adapted to your healthcare team, students, or organization.

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