Written by Andy Smith, MTM publisher

Curriculum

The recent issue of MT will, sadly, be the last for the foreseeable future.

We will continue to monitor the healthcare sector to find evidence and demonstrated desire of the sector to improve the lot of patients and practitioners. As we all know, this requires more than just the last 20 years of words, but documented action and change. We will also continue to support the simulation and training companies with news of their latest developments and communicate that to the healthcare community via a monthly newsletter.

The newsletter will also provide information about safety-critical sectors and their actions and processes to improve safety and what their businesses see as critical steps for improvement. For an idea of what this will look like, please click here.

As we change the way we serve the healthcare community, it is appropriate to consider how healthcare has changed, how far it has come, and what needs to happen now to transform for the future.

Since the US ‘To Err is Human’ report in 1999, there has been more openness, but only limited improvement in patient outcomes; however, looking at the numbers from that report of between 48,000 and 98,000 avoidable deaths a year, to the recent report from the Leapfrog Group of around 160,000 avoidable deaths a year, it would indicate that healthcare has become worse in the intervening 20-plus years.

Perception is perhaps reality, and all who choose to call themselves caring healthcare professionals should bear that in mind and speak out for reform. Unfortunately, they are now less likely to be believed by patients, families and perhaps more critically — politicians. These politicians are increasingly aware that large numbers of their constituents are being harmed and are being asked by these patients and family members what they are doing about it.

In addition, everyone accepts that the current cost of healthcare in the US is unsustainable, and those who chose Obama Care are beginning to realize that the associated costs and continued demands for more funding have not improved care. Where government has already taken control of national healthcare systems, voters and patients are realizing that the never-ending calls for more expenditure and continually declining standards of service indicates a problem that might need a different solution.

So, what to do?

The healthcare ‘service’ itself is too important to be left to clinicians; the provision of care must be left to them, but they cannot be left to self-police their community. If you disagree with that, I would refer you to the 160,000 avoidable deaths and the 1 million harmed, every year. (US only; multiple millions globally).

Despite the definition of ‘never events’ and the work done on the ‘eight common root causes of medical error’ the simple fact is that these errors and root causes are repeated year on year, and the community response is “healthcare is special or complex”. One hospital may learn the lessons of a particular incident, and for a time its patients are relatively safer, until complacency takes over and the same thing happens again. In the meantime, other hospitals will make essentially the same errors, and staff will likely never know of issues unless they have experienced them within their unit, possibly in their hospital, but probably not within their hospital group. Everyone keeps quiet.

Hospitals and healthcare professionals do not seem able to learn from their errors. What is the excuse for that? Other industries share experiences, improve their procedures and fix problems. Healthcare does not. Should government provide a national communication system similar to what the airlines benefit from, to alert hospitals and staff to issues, near misses and incidents?

Zero-tolerance policies have worked elsewhere. Pedestrian deaths due to motor vehicles in Sweden are an example. A zero-tolerance policy toward avoidable patient deaths was the subject of a recent Joint Commission paper. This went on to say something to the effect that healthcare was special/complex/siloed and so this would take 20 years. That renders it absolutely meaningless as most people in positions of power will be retired well before that ‘deadline.’ Who would drive it?

A zero-tolerance policy that is effective within three years would get attention, and though it may not be fully successful, would drive massive improvement. This is perhaps where government should act; it has in every other safety domain, and it should in healthcare. A zero-tolerance policy toward abusive, badly-behaved staff that is imposed by hospitals and hospital groups would improve the working atmosphere and staff teamwork. Have we seen any, and do they result in real pain/cost to the culprits?

In all occupations, the relative numbers of those providing a service to ‘clients’ and those providing the administration to their service providers, the ‘teeth to tail ratio’, is a critical measure of efficiency. Whether healthcare is government run, run as a for-profit or a not-for-profit business, it should be measured on its efficiency. It was argued recently that real change to the US sector would jeopardize job growth and might threaten 1.8 million jobs. After a recent minor procedure that ended up with me receiving four separate invoices, it is obvious that the teeth to tail ratio in the US is very poor. Though it would be hard for those affected, in a country with effectively full employment, those people would rapidly find other employment.

In the education and training sphere nothing will really improve unless the change is mandatory and universal. No exclusions for ‘special’ staff, hospitals or schools. The results of that change must be assessed and fed back for ongoing improvement. Continual personal improvement and education is claimed as an aim by all clinicians, but they are not well served, and the wider community should not accept CMEs as a credible way of providing that improvement and education.

Healthcare event organisers would be outraged at that comment, more likely worried, as those so-called benefits are offered as a way of justifying attendance, and their bottom line would be under threat. Were they to offer real training courses on site from which the participants could emerge, having received real training and assessment that truly covered a real year-on-year training program, we could all see improvement. Producing a big program of so-called peer-reviewed papers is far easier, which brings me to the ‘peer review’ process. Anyone can get their paper or presentation accepted by a peer-reviewed journal or program somewhere. However, the process is flawed, and the information presented is often incorrect and becomes the ‘value judgement’ of the reviewers.

Simulation is of course a very valuable training tool, but the job of a supplier of simulation or a promoter of simulation technology and techniques is not simply to do more simulation, but to support the community toward better outcomes. That of course sometimes means saying things that are unpopular to simulation clients, which businesses are usually unwilling to say. The simulations provided need to be linked to desirable outcomes and improved abilities. Those who claim to be their representatives, at least those in the US (SSIH), and in Europe (SESAM), are largely run by academics and clinicians, so we can expect little in the way of practical short-term support from them.

The next five years will be telling. More technology will impact us than ever before, and its impact will be profound. By 2022, 54% of global employees will require significant re- and up-skilling, many of them for long periods of time. Healthcare will be no exception if it is to deploy that technology safely. It could do what it has previously done: deploy the technology with minimal training and care for safety, charge patients more to be practiced upon, and simply add yet more harm.

Is that the best we can do? Are we, as individuals or politicians, and you, as members of a profession, prepared to go along with this nineteenth-century approach? On the evidence to date, it appears that many are because ‘healthcare is special and complex’.