Prof. Bryan Sexton
I am going to use him as an example. But first I am going to apologize to him and everyone like him. I also use Lucian Leape as an example. It should not be taken as personal criticism. I am grateful for all the work both of them have done and are continuing to do. But there is a problem.
Some say that Prof. Bryan Sexton is the world’s leading expert on patient safety culture. That is why he is a good example of the problem.
According to his bio at www.physicianwell-being.com “he spends his time . . . finding practical ways of getting busy caregivers to do the right thing.”
That has been the foundation of the patient safety movement for 160 years. It was 160 years ago that it was discovered that washing hands saves lives. The problem ever since has been viewed as how to get caregivers to do it.
160 years is long enough for any human without a conflict of interest to figure out that that approach is not working.
The reason health care professionals do not do things like wash hands is that the patient community does not know when they don't. When patients know, patients will go somewhere else where they do wash their hands. Unfortunately, medicine is dedicated to making sure that patients do not find out. It always has been and always will be in their interests to deceive themselves and everyone else about this.
Do you know of any nurse who is aware of having caused the infection that killed a patient? Or disabled a patient? Or perhaps many patients?
No one knows.
No one knows because the record is created by health care professionals and they report almost nothing of what goes wrong (see Medical Reporting, a page on this site) and are in denial of that. They are so much in denial that they take umbrage if you try to inform them of it. There really is no point in trying to inform them.
A Culture Rich in Reporting
that which defeats their self-interest?
There never has been and never will be a culture that causes people to take better care of others than those others will take care of themselves when able to. No "culture rich in reporting" or "culture of respect" or "culture of safety" can equal what will be accomplished by people looking out of themselves.
Isn't this why no democracy ever has experienced famine? Isn't it because people take better care of themselves than elites do.
Having patients know who is infecting patients, or not serving them well in other ways, is not in the interest of health care professionals. Caregivers never will be good sources of the information necessary for this no matter what culture is created in medicine.
People and institutions gravitate towards their own interest. If the patient community can see where good and affordable care is, they will go there. Good and affordable care might not come from a facility with whatever is deemed to be a "good" culture. It might come from a facility that merely has people who have become good caregivers because for the first time, as a result of the information collected about them by patients, they themselves can see when they are not doing their jobs well. At present their ability to see that is small while their ability to believe whatever makes themselves comfortable is large. If the nurse who was present for every fatal infection in a hospital last year found that out about him/herself, if that nurse did not clean up his/her act, don't patients deserve to know that?
Currently, all the mechanisms that could enable patients to find that out make sure that no patient ever does. For instance, the physician who probably is the most frequently disciplined doctor in the USA is listed by number in the National Practitioner Data Bank, a repository of reports on malpractice payments and disciplinary actions involving doctors and dentists. But no one is allowed to corollate that number with information that could identify the practitioner.
"Protecting the worst offenders in the medical community is chilling,” said Charles Ornstein, president of the Association of Health Care Journalists and a senior reporter with the nonprofit news organization ProPublica (at this link in the Kansas City Star). But no patient can find out who these people are.
Instead of enabling patients to learn enough to make decisions that actually are informed, the patient safety advocates in medicine imagine that they can make medicine so safe that an ignorant population will have no need to understand their own health care. The "explosion" of information they say they have made available is the kind of information necessary for a med student to pass tests, not the kind that enables patients to make safe choices. To make safe choices patients need to know the who, what and where of safety and effectiveness and affordability.
Instead we micromanage caregivers to try to get them to wash their hands.
I am not happy about how much this sounds like I am vilifying Dr. Sexton. We would want him doing his good work even after the paradigm shift necessary to make patients safe. The problem is not him. It is the world that imagines that work like his is the solution. He is considered the world's leading expert on patient safety culture because the world still imagines that ignorant patients being led by the nose though medicine by wise and selfless saints can make them safe.
The bio of J. Bryan Sexton, PhD is at this link. Among other things it says that he has captured the wisdom of frontline caregivers through rigorous assessments of safety culture and teamwork. His research instruments have been used around the world in over 2500 hospitals, so he is an impressive man. He has studied teamwork and safety practices in high risk environments such as the commercial aviation cockpit, the operating room, and the intensive care unit. That is all good work and I'm glad he is doing it.
But the catch is in the line that says that he spends his time . . . finding practical ways of getting busy caregivers to do the right thing.
And When It Is Not Practical?
He believes in teamwork and a safety culture, saying that “you are better off changing the situation, than trying to change human nature.”
No argument there. But the situation that needs to be changed is the one in which patients cannot get the information they need in order to know which caregivers are safe and which are affordable and which are just plain dangerous. Teamwork is great, but some teams are good and some are not. (And all teams unite against people who are not on their team when threatened, say by a patient complaining about being injured by an incompetent or untrustworth team member. Good luck to any victim of that team in need of honest records in order to get treatment for the injuries.)
Changing the culture within medicine is not going to turn caregivers into selfless saints who report it when they intentionally harm patients. If your systems cannot capture information about intentional harm, they cannot capture anything worth maintaining the system for.
How long do we have to watch patients die before we learn to stop listening to health care professionals who make no more sense than to brush off that concern (as with "That's another thing entirely") instead of understanding why it the first thing any patient safety initiative must address?
The fact that they don't see that is all that one needs to know to understand that they never will make patients safe.
It is time
The situation that needs to be changed is the one preventing the patient community from being able to look out for its own interests, enabling it to see where care is safe and effective and affordable and where it isn't.
We can get the information necessary to do that, but not from the community of professional caregivers. The self-interested lens through which they see leaves them unable to recognize what needs to be reported to make patients safe. There is no point in trying to get them to understand that. Even if they did, they still would be self-interested humans looking through the same self-interested lens. That is not what they believe about themselves, but
What they don't believe kills patients
We need to accept that we cannot change caregivers or their culture in a way that will make it safe for patients to be ignorant. If just 10% of patients become smart that will make it so that caregivers who are bad go out of business, just like in other businesses. If a donut shop makes bad donuts, they go out of business because people can determine when donuts are bad. Medicine currently has information about itself locked up so tightly that patients cannot figure out when it is good and when it is bad. Even injured patients get duped into believing that they got great care.
We can fix that without changing the culture or the ethics or the motivations of the humans working in health care. We can fix it without talking to the caregiving community about anything. We can do it by knowing about them what they never will understand about themselves even when we tell them. The information to do that exists. The means to collect that information exists. And we can collect it without their cooperation.
Trying to motivate and micromanage health care professionals is a fool's errand. We need something like Community Patient Agencies so that patients can stop being fools.
My apologies to Dr. Sexton. I hope he keeps doing what he is doing.