I have been looking on the web for evidence that professional healthcare societies in Kansas acknowledge that medical errors are a serious problem. I did find one statement on the website of the Kansas Healthcare Collaborative (KHC, an organization formed by the Kansas Hospital Association and the Kansas Medical Society). On the For Consumers page is the statement Medical errors cause tens of thousands of deaths each year. But you can help. Get more involved with your health care. (They provide link to the Agency for Healthcare Research and Quality, but it is broken. It should go here.)
It is good to see the epidemic of medical errors has, in this small way, been publicly acknowledged by a professional healthcare society in Kansas. And I completely agree that patients should be doing whatever they can to help reduce errors. But ultimately, the responsibility for reducing errors lies with healthcare workers and healthcare organizations. And the leaders of those healthcare organizations.
I poked around some more on the KHC website and found this page about the the Kansas Hospital Engagement Network. At the bottom of that page are slides from HEN Week Presentations in Chicago back in May 2012, including slides from a presentation titled Leading Change / Bucking the Trend, by Jim Conway. Might this be about leadership? It was. And one particular slide caught my attention. It had the phrase “Creative tension” and referenced a paper from the journal Sloan Management Review.
I looked up the paper, titled The Leader’s New Work: Building Learning Organization, by Peter M Senge, published in the fall of 1990. Here are the main points of the paper:
- An organization in which “the top thinks and the local acts” will not adapt well to change because it is not allowing its members to innovate and respond quickly. Because members are focused on performing for someone else’s approval instead of a long-term vision their performance will be mediocre.
- The most successful organizations are learning organizations. There are two types of learning: adaptive learning and generative learning. Adaptive learning will result in changes to cope with new situations. Generative learning goes much farther. It requires a new way of looking at the world, is systems-based, and sets the foundation for creating new products, systems, and processes.
- Our view of a leader is traditionally someone who is viewed as charismatic, sets the direction for an organization, and makes key decisions. But leaders of learning organizations dont fit this traditional view. Instead, they are have three roles: They are designers of an organization by setting core values and a purpose that will guide future decisions. They are teachers that help people to restructure their views of reality to see beyond the superficial conditions and events into the underlying causes of problems — and therefore to see new possibilities for shaping the future. They are stewards who serve both the people they lead and the larger mission of their organization.
- The key to learning in a learning organization is creative tension. Creative tension results from clearly seeing where an organization wants to be (vision) and recognizing the truth about where they are now (current reality). It can be resolved in two ways: raising current reality toward the vision or lowering the vision toward current reality.
I see strong parallels between the prevention and disclosure of medical errors and the ideas summarized above:
- A hospital in which “the top thinks and the local acts” will be out-of-touch with what is happening at the level of patient care. Staff members who are aware they have deficiencies in teamwork and patient safety probably also have ideas about how to improve teamwork and patient safety. Therefore, those at the top need to walk the hallways, listen to the staff, and restructure policies and resources accordingly.
- Medical errors are an opportunity to learn. They are a chance to not only have team discussions that may lead to changes to procedures and responsibilities, but an opportunity to reexamine the assumptions underlying those procedures and responsibilities. Out of this can come learning. And I can tell you from personal experience that the victims of medical errors (and their families) need evidence that this learning has taken place. Not a vague statement. Not a feel-good phrase that sounds like it was written by a marketing department. But an authentic, substantial, two-way conversation.
- The leader of a healthcare organization can be a designer by establishing a culture of safety and respect for patients, a teacher by helping physicians and staff to examine the reality of medical errors in their organization, and a steward by dedicating herself to providing safe and honest healthcare.
- Creative tension? Well if creative tension is good, it seems disclosing medical errors would be a great way to generate some creative tension within a healthcare organization.