Day 2: Transparency, Negotiation, John Nance

My take-home points and remaining questions from today:

1. Transparency is critical when dealing with medical errors. We are doomed to repeat mistakes if we don’t learn from the past. Barriers exist, but when the focus is re-centered on patients, money and professional integrity fall into the right place.

What the patients and families want to hear after medical errors

  • Recognition: investigation
  • The truth
  • Regret: apology if necessary
  • Prevention of similar harm to others
  • Remedy (“benevolent gestures”)

2. Strategic negotiation:

  • Always remember the best alternative
  • Solving their problem is part of your problem.
  • Having lived in countries where haggling is a daily, routine occurrence, I felt well-prepared for Hamilton Real Estate case as a buyer. Ultimately I decided to call off the negotiation because the other party had the key information which I assumed was not in their possession. This new information significantly increased the value of the property, and even though I pitched the anchor first successfully, the negotiating price range was too good to be true. My suspicion was justified because throughout the negotiations I could not find the reason why the other company did not want to hold on to it and claim the massive profit. I needed to find out whether there were defects or unseen problems with the property. In the end my suspicion preempted a possibly bilaterally lucrative deal, but I could not proceed without resolving the concern.
  • The difference in outcome became readily transparent when we dealt with The Parwood Contract, where both parties needed to create value, as compared to claiming value. Clarifying and understanding what was behind respective positions, trying to resolve both sides of the coin simultaneously where our and their interests became interlocked, we were able to work in a much more positive environment where differences did not drive us apart but rather served as a key source of value in negotiation.

3. John Nance: Why Hospitals Should Fly

    • I had read the book, and it quickly became one of my favorite books on patient safety. I took notes, reviewed them and summarized them for the class expecting an inspirational discussion. It was helpful to review stuff from the book, but I was disappointed about the total lack of opportunities for discussion.
    • Just two of my questions (and I’m sure more question marks would have popped up in my head through adequate discussion):
      • Page 2: The book embraces the human fallibility and proposes an infallible system that can minimize human factors. However, one of the keys to creating such infallible system is achieving a system without any “bad apple.” At the same time, per the author a critical mass of people is required to be able to roll on with the necessary cultural change, and the imaginary St. Michael’s Hospital is saturated with only good apples. Embracing human fallibility here then assumes that most people, if not everyone, in the organization can be infallibly devoted to the ideal safety system. Jack the CEO had to fire/hire people to get the “right mix,” but I don’t believe that is even remotely realistic. I feel that the system needs to embrace human fallibility more deeply and have to find ways to work with some so-so apples.
      • Page 136: Most of tools and tactics introduced are readily applicable to bottom-up approaches as well as mid-level staffs. However, the book clearly mentions that top-down approach is essential and without it the system/culture will not be sustainable. The only thing said in this regard was “as long as the changes can be made without financial collapse, it is the right thing to do.” I wouldn’t say this is the strongest argument and does not provide any assurance that whatever we do, without top-down support, will mean anything in the long run. I can still be a positive deviant in however small sphere of influences I carry. I admire Mother Teresa who admitted that her efforts did not make significant change, but still without it the ocean will be one drop less. But this is not enough for me.

4. Cleveland Clinic empathy video series: takes me back to where I should be. Such a powerful reminder that we are humans devoted to the wellness of our fellow beings.

5. We have learned to take the system apart through transparency and promote patient safety through Swiss cheese model, collegial interactive team, barrierless communication, etc. I felt that one of the key take-home points was not to place blame on someone but rather take the mistake as a symptom of a systemic disease. The temptation is great and it is just so easy to do, however, hearing speakers highlight and blame certain physicians for disruptive, ill-tempered, or dishonest behaviors did not seem to fit into this learning objective. It is a slippery slope.

Personally, I have never encountered such physician as those mentioned today, although I have heard enough stories in my 3 years of med school to be convinced that they exist. At the same time, what is the point of sharing those extreme examples to students who have followed their desire to learn more about patient safety? What can I do about them? Absolutely nothing. It’s a problem that will require a top-down approach, and it represents an outlier of the bell curve. The real culprit, if we have to blame, involves age-old curriculum, hospital culture (not just physician culture), and political/legal environment.

The docs I have been exposed to have been caring, humble, and patient-focused. I should not have to state that like everybody else in the hospital most of the physicians are good people with good intentions. Instead we should devote all our attention to the system and processes that makes these people produce undesirable outcomes. The case studies involving a missing sponge after surgery illustrates the point; it was not the team with an ill-tempered physician that caused the harm, but rather the team with a well-respected physician. It is really insightful to learn about principles, tools, negotiation strategies that have made difference in outcome and culture. The journey of U of Illinois hospital or MedStar system through various medical errors is enlightening. I would like to focus more on these ordinary people bringing about extraordinary things, because that’s our playground.