Wednesday, December 26, 2007

Culture Change

How would you like to be the head of a hospital that got written up nationally because of three cases in which its neurosurgeons operated on the wrong side of the patient’s head?

Well, the CEO of Rhode Island Hospital just had that experience. The story was reported by Michelle R. Smith of the Associated Press. I read it earlier this month in The Arizona Republic.

“Wrong-site surgery” is what is now called a “never event.” A “never event” is an event that is never supposed to happen and there are established procedures, including checklists, to prevent it. In the Rhode Island Hospital cases, those procedures were in place, but not followed.

As was stated by one of the experts interviewed for the story, this is a cultural issue. Traditionally, the authority of the surgeon in the operating room has been absolute, not to be questioned by anybody. Now the never-event prevention protocol includes authorizing nurses to stop the surgery if established procedures are not being followed and holding them accountable if they fail to do so. You have to be an old hand in health care to understand what a big deal that is.

Culture change is painful, but it is what real health care reform is all about and the Rhode Island Hospital story is a salient case in point.

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