Changing the culture in healthcare - part 1

In 1995 two independent surveys (Tito, Wilson) revealed that being admitted to a hospital in this country was the most dangerous event in the life of the average Australian.

Since then there have been media exposures of problems in Canberra Hospital, King Edward Memorial Hospital in Perth, the Macarthur Area Health Service (Camden and Campbelltown Hospitals), Illawarra Health’s pathology - and it is even alleged that a single doctor in Bundaberg Hospital has been the cause of 88 deaths and 14 serious injuries.

According to John Menadue AO, “Bundaberg Hospital is the tip of a very large iceberg. The risk from terrorism is miniscule by comparison [to medical error]."

Tip of a very large iceberg! The nurses at Macarthur AHS who blew the whistle used the same words. What is going on? What follows are three clues.

The accreditation farce

In the accreditation process, performance assessments are made by external surveyors. The approach indicates that there is a greater fear of treading on toes than there is concern for patient safety:

• the procedure is basically to make an observation and then put a tick in a box. Probing the culture of a health organisation is avoided. For example, there is no box which is labeled: “Clear of political intrigue which could render this department dysfunctional.”
• a service is given months of notice in advance that an inspection is coming. Inspection is, thus, confined to the image presented by the management on the day of inspection;
• if the service is found wanting by the assessors with proper management practices clearly beyond the understanding of its current managers, that same management is given a reprieve and allowed months to meet the set criteria.

Do you as a potential patient find the above hard to believe? Here is an extract from Quadrant magazine and which was quoted in the February 6, 2006 issue of the Medical Journal of Australia. This is a description of an accredited hospital:

It is virtually impossible to describe the ingrained evasiveness, the compulsive buck-passing, the deliberately obfuscatory language, the strategic amnesia, and the mechanical reciting of rules to excuse the inexcusable displayed by the Bundaberg Hospital administrative staff …

There have been so many external structures set up to look into quality and safety in health care over recent years that health care staff cynically refer to the “health standards industry”. The action has been mainly to create the delusion of productivity with a seemingly countless number of meetings and generating a seemingly inexhaustible stream of printed paper.

Out of this Ivory Tower, and apparently seeking ever more complexity to justify its own existence, the “health standards industry” devises processes which stressed staff have no time to implement.

In 2007, the system is promising reform, but refuses to acknowledge that external inspections can only ever be superficial and that only the staff-on-the-ground know exactly how their service is performing. And yet, nothing is done to guarantee witness protection from covert reprisals. It is dangerous to stick one’s hand up.

Staff grievances are unwelcome

Public health in this country is about 150-years-old. There are currently more than 300,000 employees in public hospitals and community health centres. The total number of individuals working in the system over the past 150 years would probably be well over two million.