Q: Despite all the talk and all the hand wringing over the astoundingly high numbers, we haven't made much of a dent. How can that be?
Dr. Rothfield — One of the problems is that try as we might to create systems that are infallible — that make it impossible to make mistakes — there are really no human-proof systems in health care. Ultimately, we rely on the vigilance of providers who may unwittingly make errors. People are always going to make mistakes. We also have people who make decisions to bypass policies, procedures and rules that are in place to keep patients safe. They're not trying to hurt anybody. They may just be trying to be more efficient. But they engage in risky behavior. And sometimes people are just reckless — though fortunately not very often. But it happens and our patients pay the price for it.
Q: Does that mean the human factor can't be overcome?
Dr. Rothfield — As much as we'd like a magic bullet, for many of these challenges, the solutions are cultural and social, not technical. For example, there was a lot of excitement about implementing checklists a couple of years ago, but we continue to have issues. Why? Because it's really a function of culture and leadership that make checklists work. As a theory, it sounds great, but the implementation is much trickier. It involves changing the way people interact and the way they feel about their work.
Q: What are some of the cultural and social factors?
Dr. Rothfield — We need to switch from a craft model in which doctors are completely autonomous to having doctors understand that they're part of a team, and that what other people do is just as important as what they do. The way I like to say it is that the person taking out the trash is just as important as the person taking out the gallbladder. But that's not the kind of social construct our hospitals have developed. Until we have physicians playing more of a leadership role, things aren't going to change.
Q: Where are doctors coming up short?
Dr. Rothfield — For a lot of doctors, quality and safety are someone else's job. Doctors are raised on a steady diet of autonomy, hierarchy and competition. It's a sea change to be told to think of yourself as a member of a team, and that you should implement best practices that have been developed by other people, especially when you're doing something that you think is working just fine. But it won't be until we get to that level of standardization that we're going to make a difference. Every other industry has figured out that variation yields terrible results.
Q: And doctors need to step up?
Dr. Rothfield — We need physicians to lead in a lot of these areas. To turn the tide with patient safety, we need them to get more training and to learn how to be effective leaders. We're inclined to put them in leadership positions, but the reality is that leadership usually isn't something you're born with. Its something you learn. It's a series of practices and behaviors that bring people together to rally around a common goal. It's being able to share that vision and get people to come along willingly. It's not about using authority to compel people to do things.
Q: Is there a growing emphasis on leadership skills in medical schools?
Dr. Rothfield — I think there are pockets where that is happening, but it's not the defining feature of medical education. Until we get to where physicians not only communicate effectively with patients, but also understand their roles as leaders, we're not going to have a lot of progress. It all comes down to communication. We know it's the underlying thread in the overwhelming majority of patient safety events. Until we get that piece right, we're not going to fix the problem.
Q: Is the trend toward transparency likely to have a significant impact?
Dr. Rothfield — The problem is people don't shop for health care the way they shop for cars. If you're getting a new car, you spend hours poring over it, figuring out what you want. But most people are afraid of healthcare services. They don't shop as hard or as carefully for their doctor or their hospital, or with the same discernment, as they do when they shop for a new refrigerator or new tires.
Q: What's the tipping point — what will finally bring the number of injuries and deaths from preventable medical errors down to an acceptable level?
Dr. Rothfield — The tipping point will be when healthcare organizations take full risk for their outcomes — when outcomes determine what they get paid. That's happening now in a small way around the CMS penalties for outcomes, but it won't be until every penny is at risk for safety and quality that organizations will get 100% behind making quality job 1.