The Alligator Allegory reads:
“ The objective of all dedicated employees should be:
To thoroughly analyze all situations,
Anticipate all problems prior to their occurrence,
Have answers for these problems,
Move swiftly to solve these problems when called upon.
However, when you are up to your ass in alligators, it is difficult to remind yourself that your initial objective was to drain the swamp.”
Steven Spears in “Chasing the Rabbit” makes the point that in high velocity organizations senior staff must exhibit an openness to acknowledging when a system isn’t working and when mistakes are made. We don’t do this at all well in medicine. Hospitals and professional staffs are discouraged from looking for and reporting errors. There are many reasons for these behaviors, which, in the long run, will hinder our attempts to improve quality, safety and efficiency of health care. One of the most quoted hindrances to transparency in looking at errors is the fear of legal reprisal, in the form of “Medical Malpractice” exposure. However, the culture in medicine where the physician and, increasingly, the nurse are expected to “analyze all situations and have solutions to all problems before they arise” makes finding an error an admission of incompetence. Reporting an error may bring a torrent of blame from supervisors or teachers.
“Fix the Problem, not the Blame”, read a plaque above the head of one of the most revered hospital administrators in Chicago. To date, we haven’t been able to internalize that sentiment. There are also time constraints. Almost uniformly when an error is reported, the reporter has to make time to follow up and help with investigation of the incident. What should systems do to try to help undo the “code of silence”? There is no “easy” solution. The legal climate isn’t likely to be changed. However, in many states there is a way around discovery, because minutes of quality improvement committees are not “discoverable”. The Federal Patient Safety and Quality Improvement Act of 2005 – PL 109-41 includes protections in this area. However, some state laws also apply to these activities. AHRQ has a website devoted to Patient Safety Organizations and associated federal regulations.. Institutions or systems can encourage an atmosphere of openness, acknowledge that the system is NOT perfect and reward the reporting of inefficiencies or errors in the system. The enterprise can also authorize people to bring solutions to problems to supervisors, experts, or committees. (What ever happened to the suggestion box? It could even be a virtual suggestion box in the employee portal for most enterprises). Institutions can hold blameless people who do commit an error and acknowledge the error promptly. Clearly this wouldn’t hold for repeated instances of similar errors by the same person.
If organizations don’t develop a culture of real process improvement, we will continue to do the same thing over and over again. Three levers for improvement are:
- Acknowledge that errors can and do occur
- Authorize staff to look for and report errors
- Hold staff blameless when occasional errors are found and reported.
A corollary to this last lever is that staff should be held accountable for repeated errors that are not addressed and corrected.
Solving problems by transparency and openness will only help align staff, physicians and institutions into a more effective system and improve patient outcomes These outcomes would include mortality, readmissions, cost and patient satisfaction.