Peter Pronovost is a physician and patient safety leader at the Johns Hopkins School of Medicine. He’s a major thinker in the patient safety movement and has a great deal of influence on how people think about patient safety in the US and around the globe. Pronovost has just published a book entitled Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care From Inside Out. Pronovost’s work was also discussed at length in Atul Gawande’s Checklist Manifesto.
Safe Patients, Smart Hospitals merits a close reading and a careful analysis, which is what I intend to do on this website over the next week or so.
I’d like to begin with a discussion of Pronovost’s views on the safety movement in aviation known as Crew Resource Management (CRM) — which has now evolved into what is called Threat and Error Management (TEM). I am, in fact, working with an airline pilot who teaches CRM, Patrick Mendenhall, and medical educator, Bonnie O’Connor on a new book entitled Come Fly With Me. This book takes an in-depth look at the culture transformation that occurred in aviation and explores its lessons for health care.
We are writing this book because we are convinced that the aviation safety movement is poorly understood and that a better understanding of what happened in aviation could significantly advance patient safety. Pronovost’s book is a good example of this phenomenon. While it contains many brilliant suggestions for change, the author gets some fundamental things wrong about the aviation safety movement and its applicability to hospital and health care.
Consider, for example, what he has to say about the use of checklists in aviation. After explaining that he looked closely at the use of checklists in aviation, the author writes that, “There were also significant differences between medicine and aviation. In aviation the general acceptance that humans are fallible was fundamental to the checklist’s success. Once this truth had been universally accepted, the industry was able to design systems that could prevent or catch inevitable errors before they caused harm, or minimize harm from errors that were not identified.”
There are several problems with this assertion. First of all, in aviation, checklists are part of a much larger system that is intended to prevent, catch or trap errors. While checklists are central, they are certainly not all there is to it. Indeed, CRM/TEM is a very sophisticated system of training that includes how pilots and captains are selected, orientation and recurrent training, instruction in communication, negotiation, conflict resolution skills, instruction of other crew members, serious assessment of skill and competence and technical proficiency and much, much more.
Secondly, the universal recognition and acceptance of human fallibility did not proceed the universal use of checklists. It was the other way round – checklists were imposed on pilots who failed utterly to recognize such fallibility. Once it became clear to researchers and other aviation experts and company leaders that accidents were the result of people willing to take unacceptable risks because they refused to admit to and thus learn from errors, CRM training began. Pilots who dismissed it as “charm school,” or a “Communist plot” to erode their authority were forced to attend these trainings because it was required of them, first by their companies and then by the government. Now, thirty years later, fallibility is universally accepted. Pronovost is right there. But when aviation was, thirty years ago, where medicine is today, checklists started to become the de facto law of the land because the leaders of the industry (i.e company executives and government regulators) refused to coddle pilots who thought they had the power of Zeus when, in fact, they had the wings and hubris of Icarus.
In his concluding comments on the aviation model, Provonost also asserts that “Medicine is infinitely more complex than aviation. The amount of information that a doctor must retain to practice medicine is mind-boggling. To put this in perspective, what a pilot needs to know to fly a specific aircraft, say a Boeing 747, is the equivalent of what a doctor must remember to perform one single procedure.” With this, and another paragraph Provonost goes on to talk about the aviation model and his own use of checklists.
This comment is worth considering because it is a very common medical response to the aviation safety model. I have heard countless physicians explain why the aviation safety movement can’t really be all that helpful because medicine is so much more complicated. While Provonost may not intend that as his message, I think it’s important to consider this line of thinking. What it does is set up a kind of competition between medicine and aviation that takes us down a path which those interested in patient safety should avoid.
The issue is not which industry is more complex, more stressful and more challenging. To enter into a competition between pilots and physicians is to hold patient safety hostage to an exercise that is as foolish as it is futile. I am sure pilots could explain for hours how complex, stressful and challenging is their work. I can hear it now.
Pilot to surgeon – “You try doing what you do at 36,000 feet, in the middle of turbulence, with one engine out and 300 passengers and six flght attendants in the cabin.”
Suregon to pilot – “That’s nothing. You try operating on 12 people in a day, when you’ve been up for hours…”
You get the point. Who wins? Definitely not the patient.
The thing to remember here is that stressful, challenging work is not relative. I can assure you that in the 3 minutes and 42 seconds that transpired while Captain Chesley Sullenberger and his first officer were landing US Airways flight 1549 in the Hudson, the one thought that did not pass through their minds was ,”Oh my this could be so much worse, I could be a neurosurgeon.”
Similarly, no surgeon dealing with a patient going South in the OR is thinking, “This could be so much worse, I could be trying to land a plane with 400 people in the back and no landing gear.”
What is relevant from the patient safety point of view is the following. Safety and teamwork have become the norm in an industry in which solo aviators were socialized to think of themselves as “captain/kings,” and refused to listen to the input of crew members. Crew members were so cowed by the authority of the autocratic captain that they did not share critical information with sufficient urgency. As a result of this dynamic people died – all too often. The industry was not only characterized by a universal commitment to toxic hierarchy, it was also characterized by the interface of human beings and advanced technology, by high levels of stress, and intense amounts of unpredictability and variation. Passengers were introduced into this brew and depended on the judgments of the “experts” for their very lives. The question is not is performing a single procedure more complex than flying a 747. The question we all need to ask, is how did aviation do it and what lessons can health care learn from this complex example of cultural transformation?
As I said earlier, nurses and patient advocates all over the country may be tempted to breathe a huge sigh of relief after news that a Texas jury acquitted nurse Anne Winkler after she was arrested and tried for reporting physician misconduct to the Texas Medical Board. The case had drawn national attention, because, Mitchell’s conviction as the Texas Medical Board argued, would have had a “significant chilling impact” on health care workers’ willingness to report unsafe medical practice. With last Thursday’s verdict it seems the chill is gone.
Not so fast.
Although this acquittal is very good news indeed, serious issues still remain unaddressed. Namely the fact that Mitchell, like many other nurses and lower level health care workers, was fired when patient safety concerns that involved those higher up on the medical ladder. Like many other nurses, she is still without a job, and this verdict doesn’t alter an all too typical hospital industry response one iota.
This particular case – which is by no means an isolated one – began last spring when two experienced nurses who had worked at the hospital for decades –Anne Mitchell and her colleague Vickilyn Galle — became concerned about a physician, Rolando G. Arafiles Jr. at their hospital, Winkler County Hospital in West Texas. Arafiles, who had joined the staff in 2008, was performing surgical procedures without having surgical admitting privileges, had been prescribing medications improperly, and was trying to sell patients herbal supplements. They talked to their the administrators of their public hospital, and were told that the administrators were too concerned about their ability to recruit physicians to rural institutions to act on them. Since both Mitchell and Galle worked in patient safety roles, they felt they had no choice but to report their concerns to the state board of medicine.
The Sheriff of Winkler County – a former patient and personal friend of the Arafiles – got hold of what should have been anonymous Medical Board documents and then arrested the RNs involved for utilizing official documents for non-official purposes, a felony in the state of Texas. Fortunately the jury recognized that the subsequent trial wrecked of conflicts of interest – not to mention violations of Texas Whistleblower protection statute. Unfortunately, the acquittal does not address the fact that the default position of Winkler County Hospital was when in doubt fire or muzzle the nurse.
This default position seems to be an industry standard. Hospitals seem to worry more about keeping doctors happy no matter what happens to the other employees who are also critical to the delivery of safe patient care.
In 2002, an experienced nurse at Huntington Memorial Hospital in Pasadena, California dared to disagree with a first year doctor in training about a patient safety issue. When he complained about her “insubordination,” the hospital, which has signed on to major patient safety initiatives, fired her. She was also reported to the state Board of Nursing, which fined her $8000 and put her on probation for two years. Massachusetts has passed a whistlblower protection law – after Barry Adams, a nurse at Youville Hospital was fired for reporting problems that led to patient deaths. Nonetheless many nurses still face management retaliation when reporting concerns about a hospital higher up. The same is also true in other countries. In Australia and Canada, nurses were practically hounded out of their professions when they reported physicians whose incompetence or malpractice was responsible for the deaths of dozens of patients.
Even though, Anne Mitchell was acquitted, nurses and other hospital employees may still be too intimidated by the possibility of retaliation to risk publically advocating for patients. Texas has a whistleblower statute, but Winkler County Hospital’s action has hardly reinforced the message that whistleblowers will be protected. Mitchell and Galle are now suing the hospital, sheriff and county attorney. But will this acquittal, followed by a private lawsuit be enough to convince hospitals to support any and every employee who tries to protect patients from harm?
Nurses and anyone interested in high quality patient care is probably breathing a sign of relief today, after yesterday’s acquittal of nurse Anne Mitchell, who was charged with a felony after reporting a physician to the Texas Medical Board. http://www.latimes.com/news/nationworld/nation/wire/sns-ap-us-texas-nurse-acquitted,0,1220344.storyWarning to all — don’t sigh too soon. Mitchell’s acquittal only addresses part of the problem — the outrageous conduct of the Sheriff of Winkler County and the state of Texas for allowing him to continue with his harassment of an RN trying to do her duty to advocate for patient care. The fact remains, Mitchell is still out of a job, not to mentions thousands of dollars and immeasurable quantities of pain and suffering. While this sheriff hopefully has a very black eye and the county should be reconsidering his employment, nurses and anyone else worried about patient care still has a lot to worry about. Hospitals are still firing nurses who try to take on so called superiors in the so-called hospital food chain –which is far more toxic than nourishing. Nurses or any other nonelite player — and this includes junior doctors — will still be worried about reporting patient safety threats, if their reward is getting fired and potentially facing massive legal bills should their conduct be criminalized. Even if it’s not criminalized, there is a disturbing pattern of killing the messenger — at least from the employment point of view. More on this later. But for now, nurses and other patient safety advocates should be sending letters to Winkler County Hospital demanding that Winkler be reinstated, along with the other nurses who supported her. I believe the State of Texas Nurses Association is filling a suit against the hospital and the sheriff. Hooray for them. Folks need to rememeber this is not a narrow nursing issue, it’s about the future of patient safety.
I just attended a fascinating meeting at the Swiss consulate in Boston at which three Swiss health care experts spoke about the Swiss health care system. One was Thomas Zeltner, who was the Chief of the Office of Public Health in Switzerland, another was Beatrice Despland, who is a lawyer who is an expert in health policy and Blaise Guinchard, professor at La Source Nursing School in Lausanne. Americans really should consider the Swiss model along with many other European models of health as they debate the future of their health care system. I will talk about this more later. T. R. Reid, in his book Healing America, has written about the Swiss system. His comments are extremely interesting. http://www.washingtonpost.com/wp-dyn/content/article/2009/08/21/AR2009082101778.html
I don’t know if alot of people in the patient safety movement or nursing know about what’s going on in Texas, but they should. Today the Sunday New York Times ran a story about a nurse in Texas, Anne Mitchell, who reported a physician for disturbing practice and was, in turn, indicted by the state for her courageous action and now potentially faces ten years in jail. The story is amazing and I will write about it more in the coming days. http://www.nytimes.com/2010/02/07/us/07nurses.html?ref=us. This kind of institutional or governmental retaliation against nurses is not uncommon. A nurse in Pasadena, who worked at Huntington Memorial Hospital was fired for insubordination when she told an intern that it was unsafe to intubate a patient on a medical floor and arranged to have the patient transferred to the ICU. She was fired and then fined by the state board of nursing.
I want to find out many more details about the Texas case, but this kind of action against RNs– or anyone else for that matter — who reports a physician or hospital higher up will have a chilling effect on patient safety. It is completely antithetical to the no-blame culture that is the only kind that will foster patient safety. It sends a message to any so-called subordinate — you challenge superiors at the risk of your career, even, in this case, your freedom. This case reminds me of one that happened in Australia several years ago, when nurse Toni Hoffman in Queensland, blew the whistle on a surgeon who was responsible for the deaths of many patients. Before she was proved right, she was hounded by the state medical association, her hospital, and even some Queensland political representatives. http://www.ourbodiesourblog.org/blog/2009/04/intensive-care-nurse-toni-hoffman, (The book Sick To Death was written about the case, http://search.barnesandnoble.com/Sick-to-Death/Hedley-Thomas/e/9781741148817 Hoffman wrote a story in my new book, When Chicken Soup Isn’t Enough: Stories of Nurses Standing Up for Themselves, Their Patients and Their Profession, which will be published by Cornell University Press in April. http://www.cornellpress.cornell.edu/cup_searchbar_list.taf?searchtype=book&keyword=When+Chicken+Soup+Isn%27t+Enough. Patient advocates and nurses need to find out more about this case and do something about it. Like write the governor of Texas!!