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Quality of Healthcare Experts Continue To Try To Put A Square Peg Into A Round Hole

Greenville, SC (PRWEB) December 04, 2013

Dr. Williams, ( using just a few examples, illustrates how such efforts have been, and will continue to be ineffective because the healthcare system lacks the key element successful industrial systems must have in order to survive, an organizational structure.

Dr. Lucian Leape, Co-Leader of the prestigious 1990 study that originated the estimate of 98,000 needless hospital deaths annually, and also an active participant in the Institute of Medicine (IOM) To Err Is Human Report 2000 appeared as a witness before the Senate Committee on Health, Education, Labor, and Pensions on January 26, 2000. Leape’s prepared testimony at that hearing assured those Senate members that quality of healthcare experts would be able to adopt safety measures from “safe industries, such as commercial aviation, chemical manufacturing, and nuclear power.”

Dr. Mark Chassin, President and CEO of the Joint Commission is quoted in his Oct. 9, 2013 Leadership Blog ( “High reliability science is the study of organizations in industries like commercial aviation and nuclear power that operate under hazardous conditions while maintaining safety levels that are far better than those of health care. The Milbank Quarterly recently published an article that I wrote with the late Jerod M. Loeb, PhD., executive vice president of the Division of Healthcare Quality Evaluation at The Joint Commission. The article, “High-Reliability Health Care: Getting There From Here,” discusses the High-Reliability Health Care Maturity Model – a framework for improvement that is the basis for an assessment tool that The Joint Commission is developing. The tool is currently being pilot tested by the South Carolina Safe Care Commitment, a collaboration between the South Carolina Hospital Association and the Joint Commission Center for Transforming Healthcare.”

Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine held the Forum on Emerging Topics in Patient Safety ( Pronovost said about that Sept. 2013 conference, “Despite tremendous efforts and enthusiasm to reduce preventable harm, the science of improving patient safety remains in its infancy, with few examples of widespread success. To significantly accelerate the pace of progress, the Armstrong Institute, in conjunction with the World Health Organization, will be convening patient safety experts and thought leaders from all sectors that influence health care. The event aims to discover new ways of thinking about how to meet key patient safety challenges of the next five to 10 years, as well as to identify untapped opportunities for collaboration that can speed improvement. We also hope to learn from the experiences of other high-risk fields, such as space travel and nuclear power, about how to hard wire safety into an organization.”

Thirteen years after Leape’s assurance to a Senate committee other quality of healthcare experts are continuing to use phrases such as, “the science of improving patient safety remains in its infancy, with few examples of widespread success”, and “We also hope to learn from the experiences of other high-risk fields.” Also, thirteen years later needless hospital deaths are now estimated to be somewhere between 200,000 and 400,000 annually, and with 10-20X that number of non-fatal medical errors.

Williams, in Find The Black Box, describes why there is still no evidence of an increase in patient safety in healthcare stemming from safety measures taken from other high-risk industries and why no such patient safety improvements will be forthcoming in the future. The answer to their continuing failure lies in the last three words in Pronovost’s
quote “We also hope to learn from the experiences of other high-risk fields, such as space travel and nuclear power, about how to hard wire safety into an organization”.

Williams describes how the current healthcare system lacks an organizational structure necessary for such safety measures to be dispersed throughout that system, and why those positive attempts to improve patient safety have been ineffective. The escalating rate of needless hospital deaths during the past two decades since that original 1990 estimate of 98,000 deaths supplies sufficient evidence of how efforts since the beginning of this century have proven to be ineffective.

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