Our national hospital Quality Improvement system is broken, endangering patients’ lives every day.
When I saw the recent New York Times article – NYT: Medicare Study finds only One in Seven care errors reported, few addressed),
sadly, I was not at all surprised.
As an experienced inpatient staff Nurse, such a reality has been obvious to myself and my colleagues for years now. In my experience Nurses overwhelmingly take errors extremely seriously, and do their absolute best to avoid them and address them. They do so under the distracting burden of a very complex, rapidly changing, and often self-contradicting jungle of customer, professional, ethical, institutional, regulatory, and insurance demands. Current Quality Initiatives (QIs) are designed in a way that has largely satisfied regulators – they have produced the appearance of doing everything possible. They are not, in fact, designed in a way apt to ever produce substantive improvements in practice. Thus my non surprise at those study results.
Why? Good intentions are deflected by overpowering conflicts of interest. As with all such conflicts, none of what I will describe is about people willfully deciding to do wrong – given such powerful incentives, their decisions are strongly influenced in the wrong direction on average, regardless of their good intentions. This is why conflicts of interest are so often banned.
These perverse incentives affect both front-line staff, management, and regulators. As a whole they powerfully discourage fruitful QI participation:
At the staff level, we see 1) Awkward & time-consuming error reporting tools – who has the time?, and what care tasks must Nurses short-change to file those reports? We see no time allotted to error reporting, so Nurses have to work for free after hours, demand extra pay for extra time and risk conflict with management, or cannibalize time from other important functions, if and when they decide to file error reports; 2) Institutional investigation of error reports consumes more Nursing time, still without any relief from other tasks, 3) An ongoing bias towards attributing Nursing errors to individual Nurse failures, largely ‘remedied,’ if at all, by in-house training, which costs institutions potentially nothing, as they can simply demand yet a little more time from busy Nurses out of the same total pool, and 4) QI is too narrowly focused – every error occurs in a context, and anything that makes work more tedious, inefficient, or distracting contributes to all errors, yet in practice reports of such issues are largely suppressed as not appropriate uses of QI reporting systems.
Paradoxically, because QI requires Nurses to squeeze the same workload into less time, meanwhile distracted by fear of blame for errors and/or overwork, it adds more stress, pressure, and distraction, resulting in an inevitable increase in errors, which will be of course be addressed with more ‘investigate & train.’ It is hard to describe just how demoralizing it is to any conscientious staff Nurse that QI, of all things, itself contributes to errors which, in turn, it attributes to Nurse ignorance or sloppy practice. It feels something like having a bully trip you, only to blame you for falling.
Also paradoxically, the article cited above itself blames QI failings on individual staff error – e.g. intentional omission for fear of blame, or Nurses; ignorance as to what to report.
Nurses largely know full well what harms patients, and what actions are errors, better, it seems at times, than do those regulating us. The article ignores the crucial context – too much work in too little time. Documentation and other paper demands growing steadily, now often hours per eight-hour shift. Even as it grows, we see no additional time allotted for it – partially to save money, and partially because the demands have grown incrementally, like raindrops falling – each change seems too small to matter, but as a group they now amount to a flood. Each new non-care demand, and the time it takes to orient to each new demand or change in rules, contributes that much more to overwork and thus errors – hardly optimal, especially when the demands are made ostensibly to reduce errors.
Proposed solutions to our QI failings, too, focus on blaming individual care givers – e.g. lists of reportable issues to educate presumably ignorant staff, which will inevitably involve meetings about the new lists, training, more regulations, and thus more paperwork: more time and energy stripped from the bedside, all in the name of quality. Is it really so unreasonable for nurses to feel blamed, when that is actually what typically happens, even at the QI level, even at the level of QI research?
Given this environment, it hardly comes as a surprise that most errors go unnoticed and/or unreported. Within the current reality, Nursing care would simply grind to a halt if total error reporting were achieved – using the DHHS study as a rough guide, total reporting would involve a 600% – seven fold! – increase in QI demands on Nursing time and energy, which would cause an artificial staffing crisis that would increase errors, requiring yet more reporting etc. – an untenable positive feedback loop. The care system would crash. We should feel fortunate indeed that Nurses have shown the good judgement to serve their patients as best they can in such an imperfect world, instead of putting regulator’s needs and appearances first.
Most people hardly realize just how often, every day, Nurses make do, with often heroic efforts, to make our chaotic and dysfunctional health care ‘system’ to continue to function and serve patient needs, only to see those efforts allow the same system to avoid improving itself, and for it to blame Nurses for its failings.
Managers too have powerful disincentives: 1) The face the prospect of that seven-fold workload increase and the resulting staffing crunch if they successfully encourage total error reporting, 2) The more substantive their proposed response to an error, the more layers of bureaucracy become involved, and the more risk to precious time and budgets, 3) The prospect that they too will face individual blame if and when their unit reports more errors than do other units, as will happen if they are more than usually successful in encouraging error reports – on the other hand, a manager with less reported errors will always look better on paper, and 4) Whenever they attribute errors to solely human error it asks little of their time and budgets, but if they propose a systems issues, it adds a demanding project with unknown costs to their busy lives and budgets, and exposes them to criticism and scrutiny as a result, and 5) As savvy professionals, managers know full well not to waste precious time on efforts not apt to cost much and achieve little.
Therefore, it is impossible and/or actually dangerous to patients that QI projects as currently formulated meet their goals.
Quality improvement will never reach anywhere near its potential until we make a few necessary improvements: 1) We streamline it to reduce individual cost of participation, 2) We allot staff and management time to it without short-changing other responsibilities, and 3) We take the entire process outside of institutional management structures – given otherwise unavoidable conflicts of interest, self-regulation is inherently designed to serve appearances and the convenience of those regulated first, not patient needs. Errors are simply far too sensitive a topic for people from different hierarchical levels to ever cooperate freely and openly. People at every level, I am confident (and I an certain regarding staff nurses) know of problems they feel too threatened or busy to pass on upwards, as described above, or have reported only to be rebuffed or blamed. Either way, QI systems encourage a reluctance to report errors.
Without outside intervention, it seems at best a remote possibility that any of these factors will ever be addressed, as proposals 1) and 2) would cost time & money, and 3) would of course be rather threatening to health care bureaucracies everywhere.
Unfortunately, regulators too are human beings and thus have their own conflicts: any substantive approach to this issue will of course be met by corporate and professional resistance, i.e. an angry swarm of lobbyists, scary advertisements, etc. Thus to take real action requires work and a substantial risk of criticism, with unclear benefit.
So the central question is this: as a nation, will we continue to wring our hands and study this issue as we have done for years, allowing dangerous errors to persist, or will we take up the challenge and truly address health care errors effectively?
I encourage Nurses, patients, and all those for whom quality health care matters, to raise this issues with their Congressional delegations, Presidential candidates, etc.
This is too important an issue to languish any longer.