Insights October 2013

This “balcony of personal reflection” is getting crowded and is alive with conversations. We hope our message will not be misinterpreted, for we believe, more than ever, that we are making considerable patient safety and quality headway.

The Ghost of Healthcare Consciousness appears and offers the following:

“Time for action: stop the never-ending meetings, stop the never-ending studies and stop the never-ending data collection. Stop the never-ending meetings to discuss the never-ending studies and the never-ending data collection. Stop the never-ending dance that has nurses pirouetting around doctors and the never-ending dance of management and doctors twirling around patients. Stop your territorial divides and self-absorbed behaviours and mindsets.” 

At times, our healthcare system appears immobilized by our Canadian psyche, hesitancy and political correctness. Perhaps we could all learn something from Frederick Southwick, who stated in his book Critically Ill:  A  5-Point  Plan  to  Cure  Healthcare  Delivery: “… jump  into  the  water rather than tip-toe  around the shoreline.”

When will we progress beyond hesitancy and embrace action? Hundreds of patients died needlessly while we sat comfortably, for a two-day conference, discussing how best to save them. As these very words are written, more patients will have succumbed to harm.

The Ghost of Healthcare Consciousness once again intervenes and says:

“Silence, unawareness, indifference and complacency are the greatest enemies of patient safety improvement. It is time to find the balance between no blame and accountability. Let me cite two examples: At a number of hospitals, hand hygiene rates hover between 45-70% and it’s a huge celebration when they top 80%. Each ward has an alcohol gel dispenser situated every couple of feet along with glossy posters of smiling clinical leaders cleaning their hands. Failure to wash hands and improve hand hygiene rates is not a systems problem, it is an accountability problem.

Let me give you another example: antibiotic prophylaxis for prevention of surgical site infection. Is the antibiotic infused within 60 minutes of skin being cut? Most surgeries require a single dose of an antibiotic post-op, but many patients are inappropriately treated. Post-op surgical infections are drivers of prolonged LOS, readmission, ER visits within 7 days of discharge and home care wound management volumes. Again, this is an accountability issue.”

Healthcare workers that hesitate to challenge the individuals or factors known to perpetuate cycles of harm, end up preserving the disastrous results we face today. Until healthcare workers make a stand, vowing to ensure that they, and all healthcare providers, follow safety protocols in their entirety, the lives of patients will continue to be deeply affected or lost. What we need in healthcare today are heroes. Individuals that no longer turn a blind eye or self-justify improper or lazy behaviour. A change towards a safer healthcare system will include small, incremental changes on a personal level by those working in the trenches, on the front lines, in the offices and in the operating rooms.

Healthcare is a touch business. It’s all about relationships. With the next interaction you have, ask yourself this question: “What would I like if I were in this situation?” Then, just like the Nike commercial instructs “just do it!” and get up tomorrow and “just do it!” again!

Everyone has the power to make small and meaningful changes. Everyone has the power to create accumulative change. Everyone has the power to change the dynamics of their workplace. Let us take direction from the answer to one simple question: “What would we want if we were the ones on the receiving end?” Sustainable change starts small, it starts on the inside, and it starts with you.

Three recommendations for your consideration:

  1. Legislation, high-level policy documents, accountability frameworks, and funding mechanisms incorporate quality and patient safety targets and expectations. Governments signal that quality and patient safety is a core value and aspiration with expectations enshrined in effective legislation, regulation and policy.
  2. Governments communicate to regulation, licensure, and accreditation authorities the importance of making quality and patient safety a core expectation and requirement. Quality and patient safety becomes a central element of public reporting processes with a progressive legislative and policy framework for disclosure of error and overall quality and patient safety performance reporting.
  3. At the organizational level there is a culture of disclosure of patient safety incidents with processes in place to develop this culture to avoid under-reporting. The organization walks the talk of a non-blaming culture that seeks lessons for improvement from quality and patient safety incidents rather than perpetrators to punish. 

We close with a comment posted by Susan Morrow on the essay “Danger of Simplification”:

“… complexity consists of defining boundaries, seeding the space, paying attention to the patterns that emerge, providing stimulus to the desired patterns and dampening the undesired patterns. Perhaps what is needed are a few more tools in the leadership toolbox.”

Join the conversation posted today: Three Patient and Family Voices: Dare to DreamListening to Me and Stop Tiptoeing Around What Matters

And what would the care provider voice say about our conversation so far? Next week’s conversation titled:“Three Care Provider Voices: Art of Caring with the Science of Cure, Where Has the Voice of Nursing Leadership Gone and Unravelling and Reconfiguring 100 Years of Tradition

Click here
 to see the First Series of Ghost Busting essays.
Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Eighteen emails from Mothers, Fathers, Brothers, Sisters, Aunts, Uncles, Grandparents, Patients on the essay “The Patient Voice A Value Game Changer" and, Hugh MacLeod, CEO Canadian Patient Safety Institute … Patient, Father, Husband, Brother, Grandfather … Concerned Citizen.


The Canadian Patient Safety Institute (CPSI exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. We envision safe healthcare for all Canadians and are driven to inspire extraordinary improvement in patient safety and quality. To help address many of the challenges mentioned in the essay above the Canadian Patient Safety Institute has tools and resources such as: Patient Safety Incident Analysis and Canadian Disclosure Guidelines. If you would like information about Patients for Patient Safety Canada – please contact  


Southwick, F. 2012. Critically IIl: A 5-Point Plan to Cure Healthcare Delivery. Boomerang Books.

Morrow, S. 2013. Website posting on essay: “Danger of Simplification.” Longwoods Ghost Busting Essays


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