Dear Senator Sanders and Members of the Subcommittee on Primary Health and Aging,
I am writing to you and the esteemed panel of experts who testified on July 17th, 2014 at the hearing: More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety as a nurse with over 25 years of experience in home health, occupational health, long-term care and as an organizational development consultant with almost 10 years experience specializing in communication and collaboration in healthcare. It may also help to know that I am an author with a self-published a book in 2009 Confident Voices: The Nurses’ Guide to Improving Communication & Creating Positive Workplaces, am currently writing a core textbook for nurses with F.A. Davis Publishing Co., have produced several youtubes that speak to the issue at hand as well as many blogposts (Links at the bottom of this post.)
I’m writing because I believe that the “Science of Safety” must be balanced with what I call the “Art of Safety” and although several testimonials touched on elements of this, my sense was that the push for more data and matrices and research overshadowed some extremely important and interrelated points that I would like to elaborate on.
First, healthcare is provided by humans and as such is a complex adaptive system. Command and control, although has it’s place in healthcare, is not the only answer, yet the temptation especially within the medical world that is traditionally hierarchal and evidence-based is to pursue data. This, by itself will never solve the problems we have. Human beings adapt and change and learn. Complexity science tells us that the relationships we have as professionals and with patients and families will impact all outcomes.When we nurture these natural tendencies we get great ideas, collaborative teamwork, patient-centered care which is safer and more rewarding to work in. When we ignore or repress them we get resistance, alignments, poor communication, burnout, and unsafe care. As Joanne Disch, PhD, RN, FAAN pointed out in her testimony, the underlying leading root causes of serious medical errors according to tracking and investigation by the Joint Commission of ‘sentinel events’ are human factors, communication, and leadership. These are true year after year after year! If you look at the subcategories of these root causes you will see they are filled with examples of people skills that involve communication and collaboration. Understanding this relationship between people skills aka soft skills and sentinel events, is absolutely essential for long-term meaningful changes that will make care safer!
We must set the stage for optimal collaboration to emerge in the moment. We do this by building respectful workplaces and providing in-depth and interactive communication training that includes facilitated coaching with real world scenarios. TeamSTEPPS and Crew Resource Management are both helpful processes as well as a new technique entering the field, Medical Improv which has an exciting focus on building emotional intelligence, critical thinking, and positive relationships. (see youtube link below.) Checklists have their place and I commend Dr. Pronovost and colleagues for his work here, yet we must look deeper to understand why they work while realizing that having a checklist for everything we do will dilute their effectiveness whereas being able to rely on each other’s expertise and the relationships that support that ideal will enhance every intervention.
Second, when we apply the ‘science of safety’ without considering human behavior or the ‘art of safety’ we spend resources on treating a symptom rather than the cause of a safety-related problem. What happens, and I believe this is a primary reason for overall lack of progress in patient safety, is that the symptom improves but the underlying problem, unchecked simply creates another symptom. For instance, consider the ‘handwashing’ conundrum and Hospital Acquired Infections HAIs. Let’s say a medical-surgical unit brought down their spread of HAIs following focused training on handwashing and increased organizational pressure to wash hands per protocol and the infection rate goes down. “We” walk away feeling like we have fixed the problem. But, what if the underlying problem has to do with understaffing and/or workplace bullying and these issues are not addressed? This might result in a shift in priorities leading to less HAIs, but are we asking what is not getting done, what new cracks exist in the system, or what other shortcuts staff might be taking? Are there more falls? More back injuries for workers? More nurse turnover? In my per diem role in long term care, I can not do everything the way I am supposed to. I do not have the resources to support nursing interventions the way I have learned to provide them. So, when organizational mandates force me to follow one set of guidelines more closely, or I have 100 urgent things to do but only time to do 60 of them according to protocols something has to give. It is an exhausting and stressful erosion of professional standards that compromise safe, quality care and rewards of providing it. I believe many doctors, nurses, physical therapists, occupational therapists, clinical social workers, and para professionals can relate.
Please understand that I am not against research, but rather for balancing the science of safety with the art of safety. This means:
- Creating workplace cultures where open and honest communication and respectful relationships are the norms.
- Ensuring enough staff with the skill mix necessary.
- Insisting on leadership which empowers frontline staff with problem solving responsibility
- Providing resources that support the work that nurses, doctors, and others trying so hard to do.
If you’ll spend some time on this blog, in particular with these blogposts and youtubes you’ll gain a deeper understanding of problems we face in fixing healthcare and why 15 years later we are still limping along.
- Shortcuts in Medication Administration: Why We Do it Wrong When We Know How to Do It Right (And We Do)
- Through the Eyes of the Workforce
- Do we Dare Question the Use of Checklists? Even if Better Understanding Leads to Better Use of Them?
- “Beyond the Checklist”
- When Simple Things Like Repositioning Patients are Not So Simple & Why We Should Be Talking Openly About Them
- Is Respecting the Complexity of Nursing an Inconvenient Truth?
- Food for thought on HCAHPS: Should Hospitals Increase Nurse Staffing or Buy Better TV sets? (by Jim Murphy)
- Properties of Complex Adaptive Systems & Relevance to People Skills: Part I-Adaptability Part II: The Butterfly effect, Part III: Emergent Behavior.
- Staff Conflict & Patient Complaints: Which of These Sample Cases is Too Familiar & How Can Medical Improv Help?
- Different Ways of Doing Root Cause Analysis: What Makes One More Effective than Others and What Healthcare Professionals and Patient Advocates Should Know (part III out of V on RCA by Bob Latino CEO of Reliability Inc.)
- Interruption Awareness: A Nursing Minute for Patient Safety
- Why is Communication So Hard for Healthcare Professionals?
- Medical Improv: Learning Experiences that Promote Safe Care, Patient Satisfaction, & Rewarding Careers. (Sponsored by Judy White, SPHR, GPHR and co-facilitated by Stephanie Frederick, M.Ed, RN)
Beth Boynton, RN, MS