Hospitals Should Embrace What They Learned In Kindergarten
I have been intrigued by numerous articles written recently on how hospital administrators are looking to other industries to learn how to adopt processes to reduce errors and improve quality of care. One recent example is that of hospitals learning from the manufacturing sector and adopting their lean manufacturing techniques to improve the efficient flow of patients through their systems and to cut down on errors. Another article, following the publication of an Oxford University study in the British medical journal Quality and Safety in Health Care, says hospitals are looking to learn new tricks from the auto racing industry to improve operations and patient safety. Then there’s Atul Gawande’s new book The Checklist Manifesto, which shows how straightforward checklists like those used by airline pilots can reduce errors in the operating room, at the bedside, and in many other situations.
As I have come across these instances of hospitals trying to learn from outside industries, I couldn’t help but be reminded of that old poem by Robert Fulghum called “All I Really Need to Know I Learned in Kindergarten.” Here is an excerpt:
All I Really Need To Know about how to live and what to do
and how to be I learned in kindergarten. These are the things I learned:
Don’t hit people.
Put things back where you found them.
Clean up your own mess.
Don’t take things that aren’t yours.
Say you’re sorry when you hurt somebody.
Wash your hands before you eat.
Warm cookies and cold milk are good for you.
The poem ends with:
And it is still true, no matter how old you
are—when you go out into the world, it is best
to hold hands and stick together.
In thinking about this classic of 1990s pop psychology, it struck me that while high technology fields such as auto racing, airlines, and manufacturing can offer some important ideas about process management to America’s hospitals, many of the ideas for how to run a high quality hospital were first learned in kindergarten—but just didn’t stick.
1) Share everything. If hospitals did a better job of sharing data between caregivers, departments, and families, the process of care delivery would be vastly improved. Yes, this can be done with the electronic medical records (EMR) systems that everyone is talking about, but if kindergarteners know the importance of sharing, why is it so controversial for hospitals, many of which are still noodling about whether they need to adopt technology to manage patient information? According to the 21st Annual 2010 HIMSS Leadership Survey, only 22 percent of hospitals have EMR systems fully implemented across their entire organization and another 26 percent have EMRs implemented in one facility of their hospital system. That means that more than 50 percent aren’t in a position to effectively share data about patients to maximize quality of care and eliminate redundancies and error.
2) Put things back where you found them. This is a good one for the surgical suite, where there is a terrible problem of surgical sponges and other accoutrements accidentally being left inside of patients. Estimates have varied as to whether this happens in 1 out of every 1000 surgeries or 1 out of every 18,000 surgeries, but with about 50 million surgeries occurring each year in the U.S., it is a big number either way. Physicians and nurses are required to count the number of sponges that go in and then count them again on the way out. While new technologies such as radio-frequency tags and bar codes exist to perform this function more effectively, most hospitals still do this the old fashioned way—manually. The problems come in when doctor and nurse disagree over the accuracy of the count on the way out, and this is where the mistakes are often made. This process must be improved through the application of technology to take the chance out of it.
3) Wash your hands before you eat. I’ll add a slight change: wash your hands before you touch a patient, This is another basic kindergarten skill that everyone in hospitals should know. Hospital-induced infections are among the highest cost medical errors out there, accounting for an estimated 98,000 deaths per year. Did any of you catch that September 16 article in The Health Care Blog entitled “NYC Train Station Bathroom Yields Cleaner Hands than Hospitals“? In the article Michael Millenson, a visiting scholar at the Northwestern Kellogg School of Management, compared data from a recent survey of public bathroom hygiene in the U.S. to hand hygiene compliance rates in U.S. hospitals, and found that “the guy who just used the toilet at Grand Central Station is … way more likely to have clean hands than the guy walking up to your bed at the local hospital.” If you weren’t nauseous when you got the hospital, this ought to make you throw up for sure.
4) Say you’re sorry when you hurt someone. That’s an oldie, but goodie—you probably started hearing it even before kindergarten. So why do physicians and hospitals decline to apply this basic rule? 35 states have laws offering at least partial legal protection to physicians who apologize to the patient or their family after causing an adverse event. Unfortunately, medical malpractice liability carriers are not quite so empathetic and typically advise physicians against an implied admission of guilt that may be construed from such an apology. This is a shame, because a fair amount of research has been done to prove that when hospitals and physicians apologize for their medical errors, claims can decline by as much as 40 percent and liability settlements are considerably lower than in cases where no apology was offered.
In an article in the AMA publication American Medical News, Douglas B. Wojcieszak (the founder of the Sorry Works! Coalition, which promotes the apology, disclosure and compensation concept among physicians, insurers and hospitals) estimates that only 5 to 10 percent of hospitals nationally are taking the “I’m sorry” approach. Wojcieszak adds that many hospitals decline to publicize their adherence to this policy out of fear of drawing attention from trial lawyers (who are apparently lingering outside the ER having chased an ambulance to the hospital); nothing like institutionalized lack of transparency to warm the heart. Everyone suffers from fear and embarrassment when they commit an act that warrants an apology; just ask any kindergartener. However, when it is well documented that this small act of civility could dramatically improve our healthcare system, you would think that this life lesson would spread more quickly to our nation’s hospitals. For this one, no technology is even required.
While many successful industries can offer lessons in quality improvement that can significantly improve hospital operations, I contend that some of these lessons are quite simple and flow from the well-accepted tenets of decent human behavior. You don’t need a high-priced hospital consultant to tell people to wash their hands or apologize when they hurt someone. Although it turns out you do need one to make sure they actually do it—maybe kindergarten teachers could improve their pay grade by moonlighting on the inpatient floor to counsel physicians and nurses?
There’s one more lesson in the Fulghum poem, and it’s best directed to patients and their families as they walk up to the hospital admissions desk: hold hands and stick together. If you don’t watch out for yourself and your loved ones when being treated in the hospital, there is a good chance that no one else will.