The first time I was a boss, I had to, of course, do a budget.

I liked everything else better. The budget, to be sure, was a necessity but boring. Nothing new or creative to be done there, I thought. We were trailblazing, or trying to, clinically. The clinical side was much more interesting.

The doctor who led this institution sat me down and said, “A budget is one of the most important creative and constructive opportunities you have as a leader. You can shape behavior with a budget. You can discourage it or encourage it. Your budget will only achieve what you plan for it to. This is not math class. You are not just plugging in numbers.”

Hmm…News to me.

He said, “I know what your vision is for your part of this but tell me again.” I did.

“OK. Now we are going to make that into a budget and you will see the magic of budgeting in making vision reality.”

Aha.

Much of health care is about forms, reports and other formal documents which either make bored people’s eyes go up to the ceiling (”Please, not that again…) or worried (Please, don’t let that go on my record…) or irritated.

No one should underestimate a piece of paper, or its digital cousin, in the health care system.

In this Doctor and Patient column for The New York Times, Pauline W. Chen, M.D., is writing about patient safety and why improving it can be so tough.  This information comes from a study published in the Joint Commission Journal of Quality and Safety.

One small example. In a study discussed in the column, many teaching hospital residents were told about patient safety issues but not how to report them or where the forms to do so were. A piece of paper. The good doctor who took time to teach me about the real power of paper in health care could do a lot of good were he available to teach medical students about how to report safety issues. This was a man who really could make a piece of paper do the work it was supposed to do—be it a budget, medical record or university report. He knew it was a key to changing behavior if used properly.

If patient safety reports were used as they could be, lives would be saved or spared preventable complications. But in the history of medicine, reports have far more often been used against someone than they have for effective change. Being put “on report” is not anything any nurse wants on record.

Good practitioners have have honest disagreements about a clinical management problem. One got the outcome—the patient lived. The other sees the close call that the patient had—and makes a “save” into a huge fight. It is no wonder, one health care professional at a time, patient safety issues can seem overwhelming.

Patient safety issues cause the public to wonder, what are they thinking?

I make no apologies for any patient safety issues but there is an answer to that question.

They have more and more to think about each year. Technology adds work on top of the regular work they were used to. Medical care divides and re-divides into narrower and narrower sub-specialties, coordinating care safely because more of a challenge.

We can pay lip service to the importance of patient safety in America, as we do. Or, we can get serious.

Dr. Chen’s column shows how hard that would be.

The New York Times

…”Young doctors are being educated in a toxic culture,” said Dr. Lucian L. Leape, a leading patient safety expert at the Harvard School of Public Health who was chairman of the report’s committee. “The current environment is hierarchical, stressful for the individual, driven by the fee-for-service payment system and humiliating, all of which works against improving patient safety.” To ensure safer health care, doctors-in-training need time to reflect on their actions, a sense of community with colleagues and other health care workers, and the support to engage freely in disclosing errors. (Emphasis added)

“Remarkably, medical schools and clinical training programs have long neglected patient safety in their required curriculum, but in the last few years, several institutions have tried to do so, with varying degrees of success. Many have had difficulty finding financial support, supportive leadership and experienced physician-teachers with formal training in patient safety. (Emphasis added)

“And without appropriate expertise and leadership, institutions are at risk of overlooking even the obvious. In the study of residents and incident reports, for example, researchers found that hospital administrators and educators had told most of the trainees about the importance of patient safety. “But the residents were not told about the procedure for filling out incident reports or even where they could find the forms,” said Rangaraj Ramanujam, an associate professor of management at the Owen Graduate School of Management at Vanderbilt University in Nashville and senior author of the study. “It seems procedural and mundane, but in terms of shaping behavior, this kind of basic information is pretty important.” (Emphasis added)

Source: New York Times, March 11, 2010

Reference: Joint Commission Journal on Quality and Patient Safety, Volume 36, Number 1, January 2010 , pp. 36-42(7)