The New Health Dialogue

Last week I discussed the work of Joseph S. Bujak and Tom Atchison on how to successfully engage with physicians. That same day, the Minneapolis-St. Paul Star Tribune published this story describing the trials and tribulations of Minnesota's state-wide journey toward fewer errors. In fact, the numbers are rising.

Minnesota hospitals say that the rising errors are likely a result of better reporting. During a recent 12-month period, 18 people died and about 100 were seriously injured as a result of medical mistakes, accidents, or negligence; a majority of both deaths and injuries were due to falls. Additionally, 77 surgical errors were reported, including 21 operations on the wrong body part and 2 on the wrong body (err, patient).

What's going on?

Minnesota Health Commissioner Sanne Magnan said that changing the attitudes among hospital staff has proved harder than adding new safety procedures. "We underestimated what it took to create change," she said...Hospital executives and safety directors said they've learned some lessons about changing hospital culture. While most physicians accept new safety procedures, buy-in is not universal, according to a survey that accompanied the report. Surgeons in particular are not always open to being questioned, they said, and others in the operating rooms may hesitate to speak up even if they think an error is about to occur.

Dr. Don Kennerly, Chief Patient Safety Officer at the Baylor Health Care System, recommended a book to us called Managing the Unexpected by Karl E. Weick and Kathleen M. Sutcliffe. It tells its readers what they can learn from high-reliability organizations, like airlines and nuclear plants, where one small mistake can be catastrophic. Here's one piece of advice:

Speak up. Just because you see something, don't assume that someone else sees it too. In a world of multiple realities and multiple expectations, one person's signal is another person's noise. Don't voluntarily withhold dissent. When you do, you reduce the system's ability to detect the unexpected. If people were scared to speak up to you, how would you know that? Ask them? Would they tell you? Be sure you model speaking up.

Unfortunately, sometimes even speaking up doesn't cut it. We just need to remember the tragic 1982 plane crash into the 14th Street bridge. Leaders need to acknowledge the perspective of their subordinates in order to achieve high reliability.

The important takeaway is this: Minnesota hospitals want to be better. A lot of things are going wrong, but they are being honest about it. Not all hospitals in our nation are as reform-minded.