I will meet you there. -Rumi
Dr. Jon Stanger ended his talk Thursday,"Beyond Right and Wrong: Six Parables for Medical Ethics" with this quote.
I can't help but reflect on Jon's talk and wonder about the implications of applying this thinking to the creation of a safe and just culture at CCRMC?
With the publication of the 2000 Institute of Medicine (IOM) report, "To Err is Human," patient safety and quality improvement have taken a prominent position in provider and public attention. There is now a prevailing acceptance that medical injury due to complications of treatment is occuring at an alarming rate. According to a 2009 publication by Lucian Leape, medical injury continues to affect approximately 10% of hospitalized patients, causing tens of thousands of preventable deaths each year.
Leape, commonly recognized as the father of the modern patient safety movement in the United States, calls for a departure from a culture of blame to a culture of safety. The organizing principle he says, is that the cause is not bad people, it is bad systems. It is further noted and supported by the work of many safety experts that to transform to a safe and just culture, we must engage in work in the following six areas:
1. We need to move from looking at errors as individual failures to realizing they are caused by system failures;To further complicate matters, systems for identifying and learning from patient safety events need to be improved. Safety reporting systems are often laborious and cumbersome. Health care providers express fear that findings may be used against them in court or harm their professional reputations. Many factors, such as concerns about sharing confidential data across facilities or State lines, limit the ability to aggregate data in sufficient numbers to rapidly identify important risks and hazards in the delivery of patient care. More work is also needed to develop measures that capture the underlying processes and conditions that lead to adverse events and the practices that are most effective in mitigating them.(AHRQ, NHQR 2009)
2. We must move from a punitive environment to a just culture;
3. We move from secrecy to transparency;
4. Care changes from being provider (doctors) centered to being patient-centered;
5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork;
6. Accountability is universal and reciprocal, not top-down.Leape L.Errors in medicine. Clinica Chimica Acta,6 June 2009,404(1)2-5
It can feel very complicated and even overwhelming at times. Yet I wonder if the highest walls we must climb are within ourselves? Although it's tempting to think fixing the individual pieces of our system is the way forward, we are not here to merely fix/optimize our current system. I have experienced many distractions along my journey but none more powerful than my own beliefs about what is possible, what I am capable of and what we are capable of. To settle is not an option. If we fall down seven times, we will get up eight. We are here to transform our system, to find the field. We are here to make a new world.