Cutting costs, improving health care starts with learning from errors and talking with patients

Law enforcement and medical care have a lot in common. The people in these fields make life and death decisions that most of us will never face; and they both work in complex environments where mistakes are easy to make but carry serious, even lethal, consequences.

Law enforcement and medical care workers work in high-stress, low thank-you environments and, as a result, share some organizational characteristics. One of those characteristics is the development of a culture that has elements of “us vs. them” mixed in with professional and organizational pride.

The cultural similarities have been clearly visible in the area of mistakes. Both law enforcement and medical care organizations have tended to “circle the wagons” when mistakes are made.

This was, in part, an experience-based reaction. More often than not, a mistake would bring a small army of Monday-morning quarterbacks, news media types, insurers, politicians and tort lawyers to the scene, looking for someone to blame and, possibly, to sue.

By the mid-1990s, though, the medical care environment began to change and economics began to find its voice in the discussions. Containing the accelerating costs of medical care was on everyone’s mind.

The first hints of systemic change in the area of medical mistakes and how they were dealt with came in the 1990s when research indicated that post-error apologies did not increase the number or size of malpractice suits.

Physicians and health care institutions had been so traumatized by the tort lawyers, ballooning jury awards, and soaring insurance premiums that they naturally became defensive and felt they could not speak freely with patients or families. Doctors stopped expressing regret or apologizing when things went wrong, in the belief, somewhat exaggerated, that it could be used against them in court. Litigation strategy laid waste to the natural, human side of patient communications.

The atmosphere did not change overnight but it did change. Capping liability damages caught the public’s attention as a method to reduce medical care costs. States, including Washington, began passing laws to exclude physician’s apologies from being considered as evidence in court. Some passed laws mandating the disclosure of errors.

The biggest change, though, resulted when economics met medical practice. From an economics standpoint, there is a strong connection between containing medical liability costs and reducing the overall number of medical errors.

A major effort to improve patient communications when errors are made is underway in Washington state in a large, grant-based, HealthPact Forum project under the care and direction of Dr. Thomas Gallagher, associate professor of medicine and of bioethics and humanities at the University of Washington. He is coordinating and assisting efforts in this type of patient communications at major hospitals and clinics across the state.

He has plenty to do. Despite the atmospheric and legal changes, organizations move slowly. As he said in his remarks to the inaugural HealthPact Forum meeting, “Research highlights the persistent gap between our expectations for disclosure and current practice. Studies suggest that about one-third of harmful errors are disclosed to patients.”

The situation described by Dr. Gallagher tells us that economics can provide the brute force, but nothing short of a cultural change would restructure the medical care system so that it could improve the overall quality of patient care.

No two people are more aware of that than Dr. Lawrence Schecter and Paula Bradlee. Schecter is chief medical officer for Providence Regional Medical Center in Everett and Paula Bradlee is the director of organizational quality. They are working to change the parts of medical care culture that can get in the way of providing the best possible patient care.

They are also working together on the Washington HealthPact Forum project at Providence Regional. From their standpoint the timing of this project, which is really just getting underway, could not be better. As Schecter says, “The HealthPact project is crystallization, a realization of what we already been working on in the areas of transparency, disclosure and training. The project gave our efforts additional credibility and provided some very useful tools to drive change.”

Bradlee’s responsibilities put her on the leading edge of some of those changes. She says that the guiding principles are that, “We prevent errors by learning from them; and we improve patient care by learning from patients and their families. We are using the Patient Advisory Council more and more to identify issues that can help us improve overall patient care.”

The medical care story is far from over, and the overall economics of providing health care remains a dismal picture. Of course, that makes it all the sweeter when we seem to be winning one battle; making things better through positive changes in disclosure and patient communications.

James McCusker is a Bothell economist, educator and consultant. He also writes a monthly column for the Snohomish County Business Journal.

Editor’s note

This is the second of a two-part series exploring how errors are dealt with in law enforcement and health care organizations. Read the first part at tinyurl.com/HeraldMcCusker.

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