Paul Kivela, M.D.

Healthcare is changing and we have to adjust to remain competitive in the market place. Our community deserves it. Our patients deserve it. We need to demand it.

It is time that we adjust our Quality Assurance, Peer Review, Performance Improvement and move to a system of “just culture.”  Joint Commission and many other organizations did presentations on the importance of “just culture” but it isn’t clear how or if those programs were ever established.

The airline industry, nuclear power industry, military and even healthcare have endorsed this approach. Dr. Lucian Leape, one of the leading experts of healthcare in quality and a Professor at Harvard School of Public Health testified before Congress in 1998 and famously told them “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” To go further on this theme, Don Norman, appropriately decreed, “People make errors, which leads to accidents.   Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Actually, the problem is seldom the fault of the individual; it is often the fault of the system. Change the people without changing the system and the problems continue.”

A “just culture” is about designing and improving safe systems and not about trying to identify and punish individuals. Yet the main committees we have at most hospitals are peer review committees. Many of the cases referred to Peer Review are infrequently reckless behavior but more frequently a failure of the process inappropriately identified as a personnel issue. Furthermore, the Joint Commission similarly believes that through this process if reckless behavior is potentially identified, the review should be conducted by an outside disinterested party to assure impartial and knowledgeable analysis.

I respectfully believe that we need to change our focus. The medical staff should insist that the medical and surgical peer review committees be immediately transitioned to medical and surgical process review committee. This way medical staff and nursing can immediately refer problems where processes can be evaluated and problems can be addressed, identified, and changed.

This will hopefully improve morale, restore camaraderie, strengthen teamwork and most importantly advance patient care. Lucian Leape identified this problem in 1998. Fifteen years has been too long to wait.