Why 'to settle' can lead to harm

If something seems impossible, is it really? Or is it just hard to imagine?

Ten years ago the Institute of Medicine released To Err Is Human: Building a Safer Health System, the influential report that shared with the world that in the United States each year there are up to 98,000 deaths due to medical error. For example, 7% of patients suffer an error in medication – many of these life-threatening. In addition to causing unacceptable human suffering and loss of life, these errors may result in upwards of $50 billion in total costs. Other important reports followed, including Crossing the Quality Chasm: A New Health System for the 21st Century. The reports seemed to successfully end a period of denial, bringing a variety of stakeholders together. It was an awakening, not only validating those who had been speaking out for so long about quality and patient safety, but also spawning a movement that called upon and motivated improvers from all over the world seeking to change the status quo.

Where do we stand today?

In May of this year, the Agency for Healthcare Research and Quality (AHRQ) published the National Healthcare Quality Report (National Healthcare Quality Report 2008">NHQR) and the National Healthcare Disparities Report (National Healthcare Disparities Report 2008 ">NHDR). These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. The reports present, in chart form, the latest available findings on quality of and access to health care.

In short:

• Healthcare is suboptimal and continues to improve at a slow pace.
• Reporting of hospital quality is leading to improvement, but safety is lagging.
• Health care quality measurement is evolving, but much work remains.
• Disparities persist in health care quality and access.
• Magnitude and patterns are different within sub populations.
• Some disparities exist across multiple priority populations.

Although we are seeing some gains in improvement, we are challenged to sustain our gains and accelerate our efforts. The reports draw on lessons learned from other sectors about improvement.

Some common themes presented in the reports:

•Constancy of purpose is essential
There is no quick fix, we must remain disciplined in our approach with continued vigilance
• We must form Partnerships
Simultaneous efforts are required by multiple stakeholders
• Measurement is vital to improvement
Focus on quality, focus on results

Change begins with each of us

Earlier this year I noted that I sometimes feel like a radical or perhaps even outlandish in my thinking at times. It was only a few years ago, there were no red lines on the wall behind the beds – how could anyone providing patient care ever guess at what 30 degrees looked like? What was a Bundle? There were no months without a Ventilator Associated Pneumonia (VAP). When I reflect on it now, it feels like in some cases, we almost seemed to plan care knowing that assisted breathing was inevitably, or at least understandably, going to be accompanied by pneumonia. It was hardly imaginable that we could go months without a VAP. Now VAPs are a rare occurrence. When I was initially trained as a nurse- not my formal school-based training, but the ward/unit training which was something different altogether -I was taught that our 'rapid response' was commonly known as a Code Blue, a team of highly skilled clinicians that rushed to a patient in need of respiratory or cardiac rescue/resuscitation. Now we have rapid response teams (Medical Emergency Teams, RRTs, etc..) that rapidly bring extra needed assessment and care to patients when they first exhibit signs that may precede a dangerous decline in health.

Thankfully, things are changing here and everywhere. I find strength in the stories from the bedside of others who are committed to improving health care. I'm not sure I would have ever identified myself as a skeptic, but I can say without reservation, that when it comes to improving health care through the use of improvement science, I do believe.

Refusing to settle

So having disclosed my bias toward improvement science as the way forward, why is it that improvement continues to feel as though it is regarded as a "soft" or support activity? It continues to be an after thought as if it's not the real work of saving lives. I refuse to accept that notion. To improve is to save lives. I am proud to be labeled naïve, outlandish, emotional, passionate, an extremist, or a purist when it comes to driving defects and non-value added activity out of what we do. Standing with you all of you, who are dedicated to serving our community, I will continue to focus on and realize our mission to care for and improve the health of all people in Contra Costa County with special attention to those who are most vulnerable to health problems.

B=ƒ(P,E), is not actually a mathematical equation representing quantifiable relationships but rather a heuristic designed by psychologist Kurt Lewin. It attempts to illustrate that behavior is a function of the person and his or her environment. George Halvorson in his book Health Care Will Not Reform Itself, states "the alternative to courage and focused action is a continuation and probably a worsening of the status quo."

Many will agree that it takes acceptance, willingness, courage, caring and honesty to engage in a change effort. I believe that it also takes constancy of purpose and discipline. There are many distractions along the way and the force of the status quo and pervasive nature of the health care industry's hierarchical culture can seem impossibly strong. Many have mastered the current state and their power or position and self-image may be derived from that mastery. I believe that to seek a new order, to resist the urge to 'settle' and to stand up and lead a transformation effort, is indeed the work of the courageous. However, the first step is to change ourselves, which may be the most frightening of all. Many will retreat to the status quo. Many will settle.

I will not.

What will you do?