Wednesday, April 01, 2009

Trusting Institutions over Individuals

Americans are not alone in finding it difficult to address the issue of quality in health care. .

The March 29 issue of The Sunday Telegraph, Britain’s largest newspaper, carried a two-page spread titled “Death rates that NHS did not want to share.”

The paper had earlier revealed that the death rate at Stafford Hospital was 27% above expectations. The March 29 article revealed that there were 10 other hospitals that had death rates worse than Stafford’s.

The article included a number of “horror stories” about such things as Friday night stroke victims having to wait until Monday for a CAT scan and a weekend ectopic pregnancy being sent home until surgery could be arranged for the following week.

A short side article discussed how one hospital (unnamed) saved 255 lives by using checklists.

Five letters from readers expressed opinions as to what should be done to remedy the situation in the problem hospitals. In summary form, they were:

- Restore the all-powerful matron (chief nurse).
- Have hospitals run by matrons and doctors.
- Implement “fundamental nursing standards.”
- Make use of “ruthless, independent inspectors.”
- Have hospitals run by clinicians, not bureaucrats.

As would probably have been the case in the U.S. as well, nobody seemed to notice the contradiction. The letter-writers want to entrust things to individuals. Checklists, on the other hand, are institutionally determined protocols that override the preferences of individual clinicians.

Dealing effectively with the quality issue requires that we learn to trust institutions over individuals and that institutions become worthy of that trust..

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