Sunday, November 1, 2009

On Possibility: Why 'to settle' can lead to harm

Ten years ago the Institute of Medicine released To Err Is Human: Building a Safer Health System the seminal report that shared with the world that in the United States each year there are up to 98,000 deaths due to medical error, 7% of patients suffer a medication error and in addition to unacceptable human suffering and loss of life these errors may be up $50 billion in total costs.

The report was supported by several leaders such as Don Berwick and Lucian Leape had been talking about the defect prone system of production we call US Health Care.

Several reports followed including CROSSING THE QUALITY CHASM: A New Health System for the 21st Century.

So where are we today? Have we improved?

Earlier this year I noted...
I often feel like a radical and even outlandish at times. I look back just a few years ago. I remember when there were no red lines on the wall behind the beds. How did we know what 30 degrees looked like? What was a bundle? I remember when we didn't believe it possible to go months (even years in some cases) without a Ventilator-Associated Pneumonia. I remember when I believed the only rapid response was known as a "code blue." Why would I think otherwise? It's how I was trained.

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 one test at a time.

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 the science of improvement and reliable design, I do believe.

So having disclosed my bias toward improvement as science and as the way forward, why is it that improvement still feels like it's regarded as a "soft" or support activity? Why does it still feel as if it's perhaps not the real work of saving lives? Why is it I still wonder if I am naive, outlandish, emotional, passionate, an extremist, or a purist when it comes to driving defects and non-value added activity out of what we do and focusing on our mission which is "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 states that Behavior is a function of the Person and his or her Environment .[1]

George Halvorson describes in his book Health Care Will Not Reform Itself, The alternative to courage and focused action is a continuation and probably a worsening of the status quo.
It takes acceptance, willingness, courage, caring and honesty to engage in a change effort [2]. I would add it also takes constancy of purpose and discipline. There are many distractions along the way and the force of the status quo is strong. Many have mastered the current state and their power or position is derived from that mastery. To seek a new order, to resist the urge to settle, to lead a transformation effort, is indeed the work of the courageous and 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.

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