As part of a continuing series on safety problems at Parkland Memorial Hospital, the Dallas Morning News asked Vanderbilt Professor Ranga Ramanujam, who researches operational failures in high-risk work settings, what a new Parkland CEO should to to help fix the hospital’s problems. This post is adapted from that op-ed.
Most people know Parkland Memorial Hospital in Dallas for its heroic efforts to help save the life of President John F. Kennedy after he was shot in November 1963.
Fifty years later, Parkland is once again drawing national attention, only this time, not for its service to the nation, but rather for its woeful record of violating basic patient safety procedures.
In August 2011, the hospital received a damning 600-page report issued by federal and state regulators detailing scene after painful scene of chaos and confusion. Emergency room patients were repeatedly placed in soiled bedding, children were discharged without proper medical screening, and unqualified medical residents were treating patients. In one instance, on-site regulators were forced to intervene to help lost patients seeking medical attention who were left wandering the halls.
In short, there have been few — if any — instances of such a large, high profile public hospital facing similar funding cuts for regularly placing patients in “immediate jeopardy” as a result of the facility’s systemic violation of basic safety practices.
But the truth is that even without the scathing reports issued by the Centers for Medicare & Medicaid Services, Parkland would have been in crisis. Like most public hospitals, Parkland is an anachronism that has been propped up by a too-important-to-fail mentality.
In an environment that includes a shrinking margin for medical errors, relentless pressure to cut costs, uncertainty over how to implement the Affordable Care Act, and acute physician and nursing shortages, the status quo is no longer good enough. Safety is more than a matter of operating for a long period without major adverse events — that’s just getting lucky. Instead, safety must be purposefully managed throughout every layer of an institution.
And doing that requires a fundamental shift in today’s health care organizations. Issues of quality and safety are intensely local and as such, they are not items that can be managed from a suite of executive offices.
Rather, the hospital of the 21st century demands that management build and maintain organizations designed to encourage what former Treasury Secretary and Alcoa chairman Paul O’Neill calls habitual excellence. Hospital leadership teams should seek to build an organizational infrastructure where employee engagement and continuous improvement are paramount. Improving care for patients can be brought about only by identifying and solving problems in the delivery of that care.
Hospital CEOs must start these transformations by expanding their traditional definitions of success. While financial outcomes and regulatory compliance remain crucial, management must also set audacious goals around employee engagement, communication and learning.
Patient safety is more likely when clinical employees are treated with respect and dignity, when they’re given the necessary resources to carry out their work, when they are recognized for their contributions, and when they are afforded physical and psychological safety. When these critical preconditions are absent or go unmet, and hospital employees are not meaningfully engaged in their work, patients face dangers that are all too real — as Parkland and the people it serves discovered.
While the idea of employee engagement may strike some as too squishy or touchy-feely, in the case of medical institutions nothing could be further from the truth. By some estimates, as many as 44,000 patients die each year in U.S. hospitals as a result of medical error — the equivalent of a 9/11-type attack happening each month. That means workplace satisfaction literally becomes a matter of life and death in a clinical setting, a fact that every hospital CEO needs to fully comprehend.
CEOs must also recognize that change is not easy, especially in an entrenched culture like medicine where doctors typically go unchallenged by nurses and other staff members. Resistance and setbacks are almost guaranteed.
But with time and effort this will change. It starts at the top. Executives must be as attuned to quality and safety metrics as they are to profits and losses. This means undertaking things like frequent employee surveys and ensuring that senior leadership engages in regular walk-arounds. It may also require new team clinical structures that include physicians, nurses, pharmacists and dietitians who are jointly reviewing cases on a daily basis. There must also be mechanisms that enable and encourage employees to report medical errors and other safety issues.
Parkland’s challenges may seem more daunting than those of most other public hospitals. But they come with even greater opportunity for Parkland to lead the way forward for other institutions. Whoever lands in the top job at Parkland should have a mind-set not of fixing a long list of problems but rather of redesigning structures and processes in a way that delivers care that is safer, more cost-effective and, most important, patient-focused.
The need to implement effective health care organizations has become as pressing as the need for medical breakthroughs. Safety is too important to be left to chance.