In the seminal Institute of Medicine (IOM) report, "An NTSB for Healthcare", a central question is posed:
Not Why an NTSB for Healthcare ... Why Not?
We believe that the question regarding an NTSB for healthcare is not why...but why not!The Safety Leaders site has more great material than you can believe - its carefully selected, well structured and crafted; and finely targeted to various interest groups. It doesn't rely on assertion and dogma, but forceful and compelling hard-evidence from Healthcare and other high risk fields.
In response to "Why not an NTSB for Healthcare", answers come from Change Management with insight form Human Behaviour and Organisational Dynamics.
The primary answer is:
- What's in it for me?
- What's the upside of doing this, of changing how I work?
- Are there consequences for not doing this?
- What's the downside of ignoring or not doing this, or continuing "Business as Usual"?
"There is no reason we can't do that in Healthcare"
The first answer to the most of the "Why not" questions, the practitioner, manager and Board answer is simple:
- Why not? Because we don't have to.
What are the blocks, active and passive, to change?Reframing this question:
- Who has the most to win or lose from maintaining the current Status Quo?
- Who are the gatekeepers, individual, organisational and political, that can either enforce the current Status Quo, or prevent/limit change?
To underline this point, consider the insights in, and impact of, the seminal article by IHI CEO, Don Berwick, over 15 years ago:
Berwick D. A primer on leading the improvement of systems. BMJ 1996;
Good systems are designed deliberately to produce high quality work.
By eliminating waste, delay and the need to redo substandard work, they achieve long-term cost effectiveness."
The Central Law of Improvement: every system is perfectly designed to achieve the results it achievesWhat has changed since 1996? Was there a revolution?
Quality Improvement is still an outlier activity. Medical Healthcare continues to kill and maim more people each year without seemingly garnering attention or comment. The "Doctor as God" Medical Culture continues unabated and new entrants are sill inculcated into it.
But the worst thing of all, the cost of Medical Healthcare, in absolute and relative terms, continues to rise unchecked.
The AMA is the primary gatekeeper to Medical Healthcare in the USA: it has the resources and ability to block any and all changes. At some point, there will be a showdown: the current Status Quo versus Change and Improvement.
There is another important difference between Aviation and Healthcare than must be addressed before there can be any systemic changes in the US Medical Healthcare system:
There are very few personal consequences of "poor performance" or "failures" for Doctors.
- There is never an reason for a Professional to repeat, or allow, Known Errors, Faults and Failures.
While this happens, all the incumbents that profit from maintaing the Status Quo will remain as active, vocal and trenchant Roadblocks to Change.
The path to "an NTSB for Healthcare" lies through Politics and a broad social demand for change, not empty promises and window dressing.