Forgiveness, Trust and a Culture of Quality

In this video presentation, Paul F. Levy, recent CEO for the Beth Israel Deaconess Medical Center in Boston, makes a case for forgiveness in the culture of a medical institution striving for quality care. I suppose that to somehow punish a physician or other care provider for a serious mistake may be safe behavior for an administrator. People tend to admire active administrators who can make decisive decisions. But the quality of the services provided by a caregiver is more evident in the pattern of his or her work than in the exception. Physicians tend not to identify the mistakes and near-misses of others, realizing that they each are imperfect and may someday make a mistake. A culture of punishment does not promote a culture of trust, which is necessary to create continual learning and improvement.

Comparative Effectiveness Research

Having recently been accepted into the MPH Informatics program at Georgia Health Sciences University I visited the campus recently to speak with a program administrator and a faculty member. We tentatively decided that my capstone research would relate to comparative effectiveness research (CER) and possibly to the modeling and simulation of clinical pathways in the context of CER. So it is likely that my posts here will become the evidence of my learning about CER.

In the following video editorial George Lundbery, MD, Editor-at-Large of MedPage today, (http://www.medpagetoday.com/) suggests that physicians may resist change in how they treat patients with particular conditions for reason of multiple motivations including money, collegial medical relationships and an aversion to simple remedies.

For what it may be worth, my initial impression is that physicians and others are likely to see evidence-based clinical pathways as a threat to professional autonomy. In the presence of a prescribed clinical pathway physicians may have to justify deviations from the pathway, which can be time consuming and annoying, especially when the physician has sound reasons for not following the evidence-based pathway in the cases of particular patients. If there were a compete set of clinical pathways it would only be by way of "deviance" that continued learning could happen. We are not at risk that through universal compliance with evidence-based pathwyas we will lose the opportunity to learn through variety of physicians' decisions.

As I anticipate my capstone research I hope to discover ways to model and simulate the financial and other implications of alternative clinical pathways in some identified clinical domain. I anticipate finding that no single pathway is optimal in light of every relevant value. I think too often references to the combination of population-based health care and patient-centered medical care are glossed to make it appear that both can be optimized at the same time. I think Dr. Lundbery's editorial suggests that it not as simple as understanding such trade-offs. There is the burden of precedent and comfort with existing practices and cultures that benefit multiple stakeholders. I am not sure his word, "courage" is quite the right word in this context, but perhaps it is.

Toward a Complex Adaptive Health Community

The "One-click Download" at this URL will display a paper titled, "The Wiki and the Blog: Toward a Complex Adaptive Intelligence Community" by D. Calvin Andrus of the Central Intelligence Agency. The paper was published in Studies in Intelligence, Volume 49, Number 3 in September of 2005.

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=755904

The essence of the paper is that Web 2.0 tools including wikis and blogs can be used in organizations as effective means of knowledge sharing. The author attempts to make ties to information theory and complexity theory to say that systems (organizations) can be designed to promote the emergence of knowledge from within rather than from above. As I teach courses in Public Administration I try to help my students understand the importance of "connecting the dots," as, for example, in case work. Because of their hierarchical structures bureaucratic organizations often do not facilitate the flow of information throughout and among agencies. Networks can facilitate information flow more effectively, but there is no assurance that information will flow where it is needed without a culture that encourages sharing and some means of shaping information flows. I liken this to hydrology and landscaping. Good landscaping usually does not have to depend upon sump pumps to control the flow of water. Good landscaping "helps" water find where it "need to be" rather than controlling it by force. In organizations there needs to be a means by which people can signal to others what information they need and what information they do not need. Information flows through social networks that are shaped by personal relations as well as defined roles.

Like the CIA and other intelligence organizations, healthcare organizations are information intensive. Decisions must often be made quickly by people who may not have immediate access to all the information available within the system. The flow of vital information is shaped by organizational cultures and by traditional professional roles. Patients are sometimes seen as passive recipients of care rather than as key information resources. In fact, success or failure is largely in the hands of patients who may or may not comply with care directives. Cost containment is also larely in the hands of patients.

I believe the key word in the title of the paper by Andrus is, "toward." Intelligence agencies do not yet always "connect the dots" quickly enough. For all the virtues of emergence, it is a slow path to design. Healthcare institutions are complex adaptive communities. To the degree what we can "landscape the cultures" in which healthcare services are provided we can improve the quality of care. There are multiple kinds of barriers to information flow in healthcare organizations. Design solutions are not exclusively structural or technological. People need to think before they click on the "send to all" button. We need to become more aware of the systemic consequences of how we share (or not share) information. We need to become more aware of how attitudes, professional roles, and other aspects of culture affect informtion flow and health outcomes.