human errorYesterday, 5 different MyMT members sent me the link to this article.

Medical Errors are Third Leading Cause of Death in the U.S.

I have one former member entirely frustrated with my quality management focus because he believes this, and I think it is worth noting "I just see the flaw in your thinking that I perceive to be at the root of why you're not getting anywhere with your argument.  I don't disagree with your argument, I disagree with the idea that making this argument will ever motivate them to action.  It hasn't yet (to my knowledge), and I have therefore concluded that it likely won't."

This gentleman and I have gone around and around about his points, and I say this.  You can't fix what you don't measure.  I believe that.  I worked in that environment for 22 years, healthcare quality improvement.  I see what you can accomplish when you go about addressing problems in a logical way that removes subjective opining.

Second, The Joint Commission is not averse to the premise for which I have been promoting, "the inclusion of healthcare documentation in their quality management standards."  Not one of them has said this is off base.  They have expressed the idea for these things to come through a particular pipeline that gets this topic on the table.  This will take time, and it is.  Our job is to continue the conversation so that it doesn't die.  Let me remind you, the medical staff is already subjected to quality management principles in at least the following areas from The Joint Commission standards - the use of blood products, indications for surgery/procedures, indications for admission to the hospital, the use of pharmaceuticals with a high focus on antibiotics, infection control, a minimal set of documentation rules (that aren't followed very closely, IMO), any iatrogenic events, all deaths, especially unexpected deaths and whatever individual facilities decide to objectively monitor.  In the hospital setting, there are extensive processes in place for the purpose of reviewing clinical activities.  What is not included in quality management teachings and proceedings are non-clinical areas (medical records, central supply, admitting, all administrative areas, engineering, IT).  It seems contradictory to promote that "you can't fix what you don't measure" in clinical areas, but not in non-clinical areas.  The same premise exists.  That is, understanding how to manage and mitigate errors, how to identify real and potential areas, analyze them, and improve that data.  This certainly includes physician behavior.

Change takes time.  We are promoting the idea that an entire healthcare documentation process in a very large country with lots of political gestures be changed.  That doesn't happen overnight.  I thought my big ideas would be welcomed with open arms too.  Ha!  Not so much.  I was naive in thinking that.

Back to the article.

I saw many conversations cropping up yesterday about this article from the perspective that, "See all those bad errors that doctors make?  We, the wonderful MTs are better at that than they are."  I say that off the cuff, but it is an overwhelming behavior and outlook from our industry's professionals.

This is a silliness that I am frustrated with, the notion that one set of human beings (MTs) are less likely to make errors than another set of human beings (doctors, scribes, nurses).  We are a group of people with skills that are all over the place, who, for the most part, are not even a certified profession, and, in the end, we are human.

The continued arguments about how much better we are than "them" keeps us stuck.  Yesterday, I sent out a Daily Dose Newsletter.  I proofed that article in MailChimp.  Then, I always send a test to myself and re-read it.  Later in the day, I read it on my phone as people started replying to me about other issues.  I found two typos.  We are not good proofreaders of our own work.

My responder wants to convince me that doctors are arrogant jerks that need a finger shaking and that until I believe that, I will get nowhere with my effort.  I'm pretty sure that will get us nowhere, regardless of my opinion, and it is irrelevant in the management of quality, for QM principles look to mitigate errors, and certainly, if we have an arrogant physician who does sloppy work, that will be vetted out in the process, but to chase after his/her arrogance and/or sloppiness, from a subjective place, what would we do with that?  If we collect data that shows physician behavior results in errors, a medical director may eventually get to that with him/her.  Again, the medical staff is already heavily immersed in quality management proceedings (for over 30 years).  We want to extend that to the documentation arena.

So.

I will continue to promote the idea of quality management principles in healthcare documentation, whether errors come from MTs, doctors, nurses, scribes, straight transcription, VR platforms, EHR systems, paper charts, or rocks with chisels.  Let all the processes and providers do their thing.  I am promoting the analysis of it all by objective means.  I continue to believe we are spinning wheels by focusing on trying to stop technology or operations that we feel disregards our profession or by suggesting that one type of professional makes more error than we do, or that somehow we are immune to that.  We need to get in the game of becoming experts at evaluating the quality, managing the errors of, not only our traditional transcription proceedings (those processes, alone, I disagree with), but to extend that to all systems, not by focusing on discrediting those professionals or platforms.  One may work well in one environment and not in another.  We want to get in the game of being the quality managers of that.

If you think my thinking is flawed, please do start your own campaign.

At the end of the article, this is said, and I quote,

"The authors wrote while "human error is inevitable" and "we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility and consequences."

That is EXACTLY my point.

Leave a Reply

Your email address will not be published.

*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>