hospital organization: a few comments

As part of my RWJ research, I’ve been thinking a lot about patient safety. One example that sticks with me is from Peter Pronovosts and Eric Vohr’s book on patient safety, Safe Patients, Smart Hospitals. In one incident, he recalls that a patient undergoing surgery developed a latex allergy, which means that patient reacts badly to the surgeon’s gloves. Pronovost was the anesthesiologist and recommended that the surgeon change to non-latex gloves. The surgeon refused and the patient continued to have a reaction. If the surgeon did not immediately change gloves, the patient’s allergic reaction would escalate and the patient would die. Flummoxed by the surgeon’s refusal to change gloves, Pronovost tries to reason with him – changing gloves is a cheap and easy thing to do.  If he’s wrong, then nothing is lost. The patient is already having a reaction to something. If he’s right, the patient won’t die. The surgeon refused to change gloves. Pronovost only won when he threatened to call the hospital administration and disrupt the surgery. The surgeon relented, changed gloves, and the patient completed the procedure without any more problems.

This got me thinking: what kind of organization allows it employees to routinely ignore experts and others with “on the ground” knowledge? The answer: hospitals. Pronovost reports on something that is very common in medical practice: attending physicians and surgeons are encouraged to take a highly antagonistic stance toward subordinates. Nurses, medical students, residents, and even other lower ranked surgeons rarely are allowed to add their views on a particular patient or case. Many hospital employees live in fear of the surgeons and physicians they help. It’s not limited to the top of the chain. Even junior nurses live in fear of senior nurses. This isn’t a huge secret, and it’s been written about before, but I’m glad Pronovost is making a serious effort to link this toxic culture to patient safety.

On a deeper level, what sort of organization would allow people to develop such toxic relationships? I don’t have a complete answer, but I think some of it has to do with a combination of high professional autonomy and a garbage can structure. Hospitals, as far as I can tell, aren’t organizations that make one product with a centrally controlled assembly line. Instead, they are a place were “problems” (patients) drift from place to place  (ICU, regular, OR, etc) where they might be “solved” (stop showing symptoms) by some random assortment of people who have limited attention (the physicians, nurses, and surgeons). Each physician isn’t in charge of a patient, they do specific procedures and pass the problem along to other people.

Combine that with extreme professional autonomy and you get toxic culture. Each person has a small domain and limited time, but they have little connection to each other and a lot of stress. It’s litte surprise that toxic culture emerges since people are loosely connected and no superiors who monitor them.