Medical Training Magazine – Final Issue

Written by Andy Smith, MTM publisher

Therecent issue of MT will, sadly, be the last for the foreseeable future.

Wewill continue to monitor the healthcare sector to find evidence anddemonstrated desire of the sector to improve the lot of patients andpractitioners. As we all know, this requires more than just the last 20 yearsof words, but documented action and change. We will also continue to supportthe simulation and training companies with news of their latest developmentsand communicate that to the healthcare community via a monthly newsletter.

Thenewsletter will also provide information about safety-critical sectors andtheir actions and processes to improve safety and what their businesses see ascritical steps for improvement. For an idea of what this will look like, please click here.

As we change the way we serve the healthcare community, it isappropriate to consider how healthcare has changed, how far it has come, andwhat needs to happen now to transform for the future.

Since the US ‘To Err is Human’ report in 1999, there has beenmore openness, but only limited improvement in patient outcomes; however,looking at the numbers from that report of between 48,000 and 98,000 avoidabledeaths a year, to the recent report from the Leapfrog Group ofaround 160,000 avoidable deaths a year, it would indicate that healthcare hasbecome worse in the intervening 20-plus years.

Perception is perhaps reality, and all who choose to callthemselves caring healthcare professionals should bear that in mind and speakout for reform. Unfortunately, they are now less likely to be believed bypatients, families and perhaps more critically — politicians. These politiciansare increasingly aware that large numbers of their constituents are beingharmed and are being asked by these patients and family members what they aredoing about it.

In addition, everyone accepts that the current cost of healthcarein the US is unsustainable, and those who chose Obama Care are beginning torealize that the associated costs and continued demands for more funding havenot improved care. Where government has already taken control of nationalhealthcare systems, voters and patients are realizing that the never-endingcalls for more expenditure and continually declining standards of serviceindicates a problem that might need a different solution.

So, what to do?

The healthcare ‘service’ itself is too important to be leftto clinicians; the provision of care must be left to them, but they cannot beleft to self-police their community. If you disagree with that, I would referyou to the 160,000 avoidable deaths and the 1 million harmed, every year. (USonly; multiple millions globally).

Despite the definition of ‘never events’ and the work doneon the ‘eight common root causes of medical error’ the simple fact is thatthese errors and root causes are repeated year on year, and the communityresponse is “healthcare is special or complex”. One hospital may learn thelessons of a particular incident, and for a time its patients are relativelysafer, until complacency takes over and the same thing happens again. In themeantime, other hospitals will make essentially the same errors, and staff willlikely never know of issues unless they have experienced them within theirunit, possibly in their hospital, but probably not within their hospital group.Everyone keeps quiet.

Hospitals and healthcare professionals do not seem able tolearn from their errors. What is the excuse for that? Other industries shareexperiences, improve their procedures and fix problems. Healthcare does not.Should government provide a national communication system similar to what theairlines benefit from, to alert hospitals and staff to issues, near misses andincidents?

Zero-tolerance policies have worked elsewhere. Pedestriandeaths due to motor vehicles in Sweden are an example. A zero-tolerance policytoward avoidable patient deaths was the subject of a recent Joint Commissionpaper. This went on to say something to the effect that healthcare wasspecial/complex/siloed and so this would take 20 years. That renders itabsolutely meaningless as most people in positions of power will be retiredwell before that ‘deadline.’ Who would drive it?

A zero-tolerance policy that is effective within three yearswould get attention, and though it may not be fully successful, would drivemassive improvement. This is perhaps where government should act; it has inevery other safety domain, and it should in healthcare. A zero-tolerance policytoward abusive, badly-behaved staff that is imposed by hospitals and hospitalgroups would improve the working atmosphere and staff teamwork. Have we seenany, and do they result in real pain/cost to the culprits?

In all occupations, the relative numbers of those providing a service to ‘clients’ and those providing the administration to their service providers, the ‘teeth to tail ratio’, is a critical measure of efficiency. Whether healthcare is government run, run as a for-profit or a not-for-profit business, it should be measured on its efficiency. It was argued recently that real change to the US sector would jeopardize job growth and might threaten 1.8 million jobs. After a recent minor procedure that ended up with me receiving four separate invoices, it is obvious that the teeth to tail ratio in the US is very poor. Though it would be hard for those affected, in a country with effectively full employment, those people would rapidly find other employment.

In the education and training sphere nothing will reallyimprove unless the change is mandatory and universal. No exclusions for‘special’ staff, hospitals or schools. The results of that change must beassessed and fed back for ongoing improvement. Continual personal improvementand education is claimed as an aim by all clinicians, but they are not wellserved, and the wider community should not accept CMEs as a credible way ofproviding that improvement and education.

Healthcare event organisers would be outraged at thatcomment, more likely worried, as those so-called benefits are offered as a wayof justifying attendance, and their bottom line would be under threat. Werethey to offer real training courses on site from which the participants couldemerge, having received real training and assessment that truly covered a realyear-on-year training program, we could all see improvement. Producing a bigprogram of so-called peer-reviewed papers is far easier, which brings me to the‘peer review’ process. Anyone can get their paper or presentation accepted by apeer-reviewed journal or program somewhere. However, the process is flawed, andthe information presented is often incorrect and becomes the ‘value judgement’of the reviewers.

Simulation is of course a very valuable training tool, butthe job of a supplier of simulation or a promoter of simulation technology andtechniques is not simply to do more simulation, but to support the communitytoward better outcomes. That of course sometimes means saying things that areunpopular to simulation clients, which businesses are usually unwilling to say.The simulations provided need to be linked to desirable outcomes and improvedabilities. Those who claim to be their representatives, at least those in theUS (SSIH), and in Europe (SESAM), are largely run by academics and clinicians,so we can expect little in the way of practical short-term support from them.

The next five years will be telling. More technology will impactus than ever before, and its impact will be profound. By 2022, 54% of globalemployees will require significant re- and up-skilling, many of them for longperiods of time. Healthcare will be no exception if it is to deploy thattechnology safely. It could do what it has previously done: deploy thetechnology with minimal training and care for safety, charge patients more tobe practiced upon, and simply add yet more harm.

Is that the best we can do? Are we, as individuals orpoliticians, and you, as members of a profession, prepared to go along withthis nineteenth-century approach? On the evidence to date, it appears that manyare because ‘healthcare is special and complex’.