Insights August 2011

Experiencing patient safety first hand

Hugh MacLeod


This may be little more than common sense, but there is nothing like a little unplanned field work to confirm its importance.  I didn’t think part of my orientation would be to inadvertently spend my first five days as the CEO of CPSI in a hospital.  This was my first time ever as a patient and it was an eye opener. I got to see and feel firsthand the complexity of a hospital system: a busy ER, people on stretchers in hallways waiting for a bed (23 hours in my case), confined quarters, equipment/supplies stacked everywhere, multiple tests, and the tireless efforts of front line providers.

When you are in an environment that is not your own, among strangers, often unable to leave the confined space where you have been stationed to heal, you become engaged in the lives of those around you. At first my curiosity began and ended with my own prognosis but before long I found myself intertwined with everything in my proximity.

In a room partitioned only by curtains, privacy and at times dignity go out the window. It is interesting that a government rightly obsessed with privacy on so many levels institutionalizes an astonishing lack of patient privacy in its own facilities. As a small consolation, the absence of privacy makes equally violated bedfellows. 

We were all sick and all would have rather been somewhere else. I was in a large teaching hospital in a big city where the chance of running into anyone I knew was minimal. I wondered what it would be like to be in a hospital in a small town where the fact that everyone knows everyone else is both a community-building virtue and a privacy-challenging limitation.  

In any event, there we were, and I found it extremely difficult to distance myself from the agony, obstacles and progress of those around me. Our difficulties and illnesses became common knowledge as did our treatment and progress. I began to observe the activity inside my room:  I was part patient, part amateur medical anthropologist, part informal counsellor. I watched and listened to the care provided to those around me. I learned about their medications, diets, diagnoses and prognoses. I witnessed the interactions with doctors, nurses, food providers, and housekeepers. I was there when there was no one else. I saw the blank stares of roommates trying to make sense of their predicament.

For many, understanding patient safety from the patient’s perspective is critical to achieving success in their own organizations.
I urge all senior decision makers, planners, policy makers,   theory experts, tool kit designers, anyone who wants to make a difference in healthcare to ….spend time on the wards, have conversations, see and feel what it is really like.

Lessons learned during my hospital stay:

I saw great team work and team breakdown. I received very good care, but I also experienced how things can go wrong and potential harm. They gave me food when the care plan called for fasting. There was confusion over medication and incomplete charting on the wall. The signs above the sink across from my bed implored providers to wash their hands.  Yet after SARS, C difficile, and a century and a half of research, few did.  On numerous occasions gloves were not changed between patient interventions. I began to wonder if the gloves were for the exclusive protection of the caregiver, not the patient. 

I lived the gap between the theory and practice of patient empowerment.  I was a relatively informed patient, but I found it difficult to ask safety related questions. I wanted people to wash their hands but did not want to annoy while I was vulnerable and needed their care. I was in no position to take my business elsewhere.  What haunted me the most was how my vulnerability stripped me of my autonomy, my power.  I was on my back and helpless. 

I also saw and felt the impact of unruly, misplaced and aggressive patient expectations and behaviours. I saw positive and negative family behaviour and its potential impact on  care.

Any economist who persists in believing that healthcare is a market product just like any other has not spent any time as a patient.  You give up your body and power to an institution and a team of strangers.   They have all of the technical knowledge and you are scared.  The last thing you are is a shopper and bargaining agent. 

There is nothing new in what I experienced – it is the reality of being a patient in a system that struggles to get things right.  Perfection is unattainable, but we will never approach perfection unless we commit to settling for nothing less.

Success = Soft Side

Healthcare is in one sense the realm of science and technology – often described as the “hard” side.  However, it is possible to excel at the hard side and fail to achieve good quality and safety outcomes.  Where this occurs, the cause is failure on the so-called soft side:  the irreducible human elements of complex service organizations.  Here is where ego, role modeling, integrity, teamwork, communications, attitude, commitment, readiness to change, and a host of other variables come into play. 

Persistent and frequent patient safety incidents are symptoms of deeper trouble. The healthcare delivery system is only as safe as its weakest patient safety link. The weak link is usually a hidden pattern embedded in the soft side, the domain of systems transformation.

The real healthcare organization that you work in is not the official organizational chart. Organizational charts are static images that imply rigid turf boundaries, whereas high-performing organizations are as dynamic and fluid as the external environment around them. Fundamentally health system organizations are a web of relationships, conversations and decisions among people. 

Lets look at the airline industry and how its differs from us in relationship patterns. There is much to learn from aviation, but compared to health care it is elegantly simple.  The pilot and co-pilot have checklists that apply in every circumstance.  They work in a closed environment to which entry is strictly controlled.  They do not interface with each and every passenger and do not customize their service to address the uniqueness of what each passenger presents. In fact, the pilot is formally protected from contacts and interruptions.  The proportion of their job that is technocratic and automated is much higher than in health care.

Commercial airliners literally fly themselves most of the time.  Yes, there are things health care can learn from aviation:  the absence of hierarchy in making safety decisions, standardization of equipment and supplies, simulation exercises, the importance of data, and the optimal use of technology.  But it is misleading to assert that if only it would get its act together, health care could be just like aviation.  They are fundamentally different in character and complexity; if aviation is checkers, health care is multi-dimensional chess.    

Success therefore requires balance:  by all means strive for scientific and technocratic excellence, but pay attention to – and measure – the relational and behavioural side, making sure it is supported by a foundation of truth and strong values. 

Success = Real Values + Truth

Organizational culture – its customs, traditions, and practices – plays out in day-to-day power and political relationships. We need a new conversation about and critical appraisal of how patient-resident-client focused we really are.  And we have to be clear about the difference between responsibility and accountability. 

Collectively we must look the truth in the face if we are to prevent harm. There is no greater enemy of improvement than indifference to failure.  The challenge for all is to lead, manage, guide and coach others through a patient safety transformation process.  This goes much deeper than tinkering with structure and adopting the right rhetoric.  It is a sustained effort to embed safety as a defining imperative that permeates both individual behaviour and organizational culture. Our biggest mistake is turning a blind eye to variations in quality and patient safety practices within and between organizations and never evaluating them seriously from a behavioural perspective. And this becomes a recipe for substandard quality and patient safety. We need to stop convincing ourselves that the remedy is more money, more technology and more staff, and look within ourselves and our organizations for the courage to change.

To be sure, we are making incremental progress, but meanwhile the toll of harm rises.  It is time for a sense of urgency. It’s time for tidal waves of change - aggressive and committed action from every individual working in the system: the front lines, management, and leadership in healthcare organizations; and from government. 

My professional and personal experience with patient safety allowed me to see clearly what it really takes to transform our patient safety culture into a culture of which we can be proud. I want to leave you with three observations:

  1. Context is everything - while the capacity to change exists in every individual and every organization it must align with the organizational history, sense of urgency, readiness for change, culture, and degrees of leadership commitment.
  2. Denial is our greatest threat – there is a gap between the patient safety outcomes we see on paper and what patients and providers experience. Silence, unawareness, indifference, and complacency are the greatest enemies of improvement.
  3. It is all about relationships – honest and open relationships between all involved in care together with a culture that supports healthy interactions and is rooted in true values are the sources to achieve excellence.


About the Author(s)

Hugh MacLeod is Chief Executive Officer of the Canadian Patient Safety Institute


This essay was taken from an article by Hugh MacLeod published in Canadian Journal of Respiratory Therapy 2010; 46 (4): 41-45 titled Working Together for Safe, Efficient and Quality Care: Time to Start Improvement Tidal Waves Today


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