In situations where lives are at stake, it is critical to follow best practices and to be disciplined about keeping any possible errors in check. So it’s surprising that standard procedures are so commonly disregarded in hospitals–not washing hands or changing gloves, improperly sterilizing instruments, failing to check arm bands, etc.
In The normalization of deviance in healthcare delivery, John Banja uses examples to discuss how rule-breaking becomes normalized. A rule is broken so many times that the practice becomes routine. Newcomers to the institution, following the example of their peers and superiors, learn to rationalize the practice and so it perpetuates.
Example #3: A case related to the author by a physician nicely illustrates how deviations become normalized:
When I was a third-year medical student, I was observing what turned into a very difficult surgery. About 2 hours into it and after experiencing a series of frustrations, the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask. Instead of his requesting or being offered a sterile replacement, he just froze for a few seconds while everyone else in the operating room stared at him. The surgeon then continued operating. Five minutes later he did it again and still no one did anything. I was very puzzled, but when I asked one of the nurses about it after the operation, she said, “Oh, no big deal. We’ll just load the patient with antibiotics and he’ll do fine.” And, in fact, that is what happened; the patient recovered nicely.
Thus the problem is not limited to individuals acting recklessly, but concerns the social structure within the organization. The problem is not the surgeon making an unconscious mistake under pressure, the problem is no one else speaking up.
Banja outlines a spectrum of these systemic failures and then provides recommendations for how hospitals can address them. Though the scope of the article is limited to what existing hospitals can do to improve, I found many of the examples suggested design failures within our broader health system, beyond the scope of individual hospitals.
Example #4: A catastrophic negligence case that the author participated in as an expert witness involved an anesthesiologist’s turning off a ventilator at the request of a surgeon who wanted to take an x-ray of the patient’s abdomen. The ventilator was to be off for only a few seconds, but the anesthesiologist forgot to turn it back on, or thought he turned it back on but had not. The patient was without oxygen for a long enough time to cause her to experience global anoxia, which plunged her into a vegetative state. She never recovered, was disconnected from artificial ventilation 9 days later, and then died 2 days after that. It was later discovered that the anesthesia alarms and monitoring equipment in the operating room had been deliberately programmed to a “suspend indefinite” mode such that the anesthesiologist was not alerted to the ventilator problem. Tragically, the very instrumentality that was in place to prevent such a horror was disabled, possibly because the operating room staff found the constant beeping irritating and annoying.
Hospitals are filled with constant beeping. Beeping may satisfy the “requirements” of an individual device, but in viewing the hospital environment as a whole, it is clearly a design failure to have hundreds of machines beeping for attention. It is not conducive to careful work or to healing.
Example #7: Dr. Smith’s penmanship is frequently illegible, but he becomes very testy and sometimes downright insulting when a nurse asks him to clarify what he’s written down. So, rather than ask him, the annoyed nurse will proceed to the nurse’s station, consult with another nurse or two, and collectively try to decipher Dr. Smith’s scrawl.
Here the social status system is implicated. Doctors go to school for years, accumulating large student debts, and then they do years of internships and residencies where they barely sleep and have no free time. On top, this is extremely competitive. There are more people who want to become doctors than the system will let become doctors. Consequently, the profession is considered extremely elite. This status imbalance can intimidate the “non-elites” from directly addressing a critical issue as in the above example and the surgeon example.
Consider when a hospital’s misbehaving, but only, neurosurgeon is left to his problematic behaviors because administrators fear he will leave if confronted with his unprofessionalism. Admittedly, the neurosurgeon’s departure could represent a financial blow to the hospital, not only from the standpoint of lost revenues from neurosurgical procedures, but also from the lost opportunity for neurosurgical consultations, referrals, or admissions to or from other units (e.g., neurology, oncology, rehabilitation medicine). It is easy to understand how a hospital’s administration might shrink from initiating remedial, not to mention disciplinary, measures against him.
Perhaps our emphasis on hospitals as the means to address our health concerns is problematic. The doctors and nurses who work in a hospital are of course concerned with the individuals they treat. They want to make people healthy. This is why they became doctors and nurses. But as an institution, a hospital is incentivized to not understand the root of a patient’s problem. A hospital is incentivized to treat symptoms, to bounce patients through a bureaucracy ordering as many tests and treatments as it can.
Hospitals attract resources because they are big buildings. Every day I walk past Bank of America Plaza at Zuckerberg Trauma Center. Big buildings attract millions of dollars in donations. This is not to fault the donors or the hospitals seeking donations. Both are trying to help people. But as a systemic trend, this can detract from considering alternatives to hospitals.
We are so conditioned to think of hospitals as the only way to get better when we’re sick that it’s hard to think of alternative systems for maintaining our health.
One idea is to reverse the trend toward concentrating all of our medical knowledge within a scarce number of people who can make it through the certifications, competition, lack of sleep, etc. required to become a doctor. The “barefoot doctors” of China were farmers who received a year of training in medical care. They were then sent back to the rural areas where they continued being farmers but also provided health education, first aid, primary medical care, post-illness followup, etc. to their peers. Because they were peers rather than elites, people felt comfortable talking to them about their health concerns. And because barefoot doctors were not a scarce resource (China’s goal was one competent health worker per 100 people), the health system was accessible. A comfortable and accessible medical system are necessary for effective preventive care.
Another idea is to reverse the trend toward commoditizing nurses. Buurtzorg (Dutch for “neighborhood care”) is an organization comprised of autonomous teams, each of 10 to 12 nurses. Each team is responsible for the home care of 50 to 60 patients in a given neighborhood. The teams are fully autonomous–not taking orders from a bureaucratic pyramid above them. They are thus able to use their best judgement to provide the best possible care. Often this involves identifying health issues that an impersonal health system could never notice. From Reinventing Organizations:
Care is no longer fragmented. Whenever possible, things are planned so that a patient always sees the same one or two nurses. Nurses take time to sit down, drink a cup of coffee, and get to know the patients and their history and preferences. Over the course of days and weeks, deep trust can take root in the relationship. Care is no longer reduced to a shot or a bandage―patients can be seen and honored in their wholeness, with attention paid not only to their physical needs, but also their emotional, relational, and spiritual ones. Take the case of a nurse who senses that a proud older lady has stopped inviting friends to visit because she feels bad about her sickly appearance. The nurse might arrange a home visit from a hairdresser, or she might call the lady’s daughter to suggest buying some new clothes.