What will their legacy be?

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A danger of being “Thinker in Residence” for several months here in the state of Victoria, Australia, is the danger of diagnostic anchoring–too quickly reaching conclusions about the state of the health care system–followed by confirmation bias–valuing only those observations that support the conclusion you’ve reached, while ignoring other data.  With cognitive errors of this sort, the best defense in avoiding them is to be aware of their existence.  So, I’ve tried assiduously to be careful during my visit here.  But the time has come to offer my considered view on several matters.

In a recent blog post, I noted that the extensive program of traffic safety run by the Transport Accident Commission is an example of the strong sense of communitarianism that pervades this society.  I suggested that a future column would explore whether this communitarian view within Victorian society carries over into health care–whether there is a comparable commitment “towards zero” with regard to preventable harm in hospitals.

I conclude, with some sadness, that the answer is “no.”

At a meeting with a high government official, I was asked how the the situation with regard to quality and safety in this state compares with other jurisdictions I’ve visited around the world.  I answered that the situation was comparable.  The offical seemed satisfied with that answer.  I was too polite to point out that satisfaction was not the appropriate response.  As I often note, there is no virtue in benchmarking yourself to a substandard norm.  In most of the developed nations, the situation with regard to quality and safety can best be described as islands of excellence in a sea of mediocrity.  That such is also the case in Victoria should be no cause for contentment–for the simple reason that this state has the potential to do better.

What’s behind the failure to act decisively in the communitarian manner exemplified by the TAC in the transportation arena?  A hint was given in a meeting with a senior official in a private hospital system, when I asked if there were any efforts to share advances in quality and safety among the region’s hospitals:

“We won’t share what we learn about quality and safety improvement because that information gives us a competitive advantage, e.g. with regard to reducing lengths of stay, which has a direct impact on our finances.”

I was shocked by this statement, but several of my more knowledgeable colleagues were not when I mentioned the reply to them.

Contrast this attitude with that of several pediatric hospitals in the Midwest United States:  “We compete on everything, but we don’t compete on quality and safety.”

Like many other countries, increasing health care costs vis-a-vis available public tax-generated money and private health care premiums are big issues here.  There is a tendency for those in government and those in the industry to list financial issues as the primary ones facing the health sector.  That, in turn likely leads to the kind of comment made above about competition.

But such competitive forces and the narrow priorities drawn from them are not compatible with the underlying purposes of the hospitals and people working in them.  Nor are they compatible, if the public understood fully, with what would be the expectations and demands of the populace.

In his marvelous book Legacy, James Kerr writes about the greatest rugby team on earth, and notes:

In answer to the question, “What is the All Blacks’ competitive advantage?”, key is the ability to manage their culture and central narrative by attaching the players’ personal meaning to a higher purpose.  It is the identity of the team that matters–not so much what the All Blacks do, but who they are, what they stand for, and why they exist.”

What happens when hospital leadership focuses so intensely on money and competitive standing?  A former trainee from Boston put it this way:

The absence of a sense of purpose of this kind is toxic. For instance, if you have an advertising campaign that emphasizes our kindness or humanity, but we have no policies or practices that distinguish our kindness or goodness from anyone else’s, it may be persuasive to our market as a branding tactic, but it’s actively alienating to those of us who work within this system. 

Kerr paraphrases Jim Collins’ Good to Great by noting that “When enthusiastic and rigorously adhered to, a dramatic, compelling purpose is a fundamental driver of the companies that go from good to great.”

So an irony is that, while many health care institutions seek competitive advantage, they will not achieve what is possible even on that front because they fail to focus sufficiently on the public good aspects of their business.  They give their doctors and nurses insufficient reason to have a fulfilling sense of purpose that could in turn make a huge difference on the commercial front.

Here, of course, the penalty for a lack of purpose is worse than the commercial consequences.  People are dying and are being harmed in Victoria’s hospitals to a greater extent than is necessary.

As noted earlier, the TAC is not content with even 300 traffic fatalities per year and instead helps the people of the state move that number towards zero. In contrast, in the health care arena, the number is far greater and yet there is a systemic failure to acknowledge the problem.  Government agencies fail to cooperate on solving it to the extent commensurate with the public health hazard.  No one proposes a standard of zero preventable harm for the Victoria hospitals.  Instead, the focus is solely on sentinel events, which are just the tip of the iceberg with regard to preventable harm.

Hospitals themselves fail to work together on the issue.  The various colleges representing the doctors’ specialty groups have not addressed it in a meaningful way.  The medical schools, likewise, do not work together on making longitudinal training quality and safety and clinical process improvement part of a shared curriculum.

It may be that that the nascent patient quality and safety movement in Victoria will grow and help nudge government and health sector leaders to make elimination of preventable harm a priority activity comparable to eliminating traffic deaths.  In the meantime, unfortunately, self-satisfaction reigns and harm persists.  The people of Victoria deserve better.