This post is an aside from the ongoing discussion of Wisconsin and Catholic Social doctrine, but one that will perhaps feed into it. You may not know that since 10 years ago, there has been a significantly increased emphasis on patient safety in hospitals. A study published back then, Crossing the Quality Chasm, began a whole set of mandatory safety initiatives from Federal and State governments, as well as from accrediting organizations. The reason was that studies the were published about 11 to 12 years ago showed that medical errors killed more people in the USA every year than automobile accidents. This was an incredibly large figure. So programs were started to lower medical errors. These program resulted in vastly increased paperwork and treatment delays, all aimed at reducing errors. For instance, before every surgery, in the actual surgical suite with the patient there and asleep, the surgical team must completely come to a stop. During that stop, all patient identifiers must be rechecked, the chart is rechecked, the medication dosages are rechecked, etc., all to make sure that a surgical error is not committed. This is actually a very good procedure. Nevertheless, time and paperwork is added, for as we know, if it is not checked off in writing, a lawyer somewhere will claim that it was not done and their patient is entitled to become a millionaire.
So, one would expect that 10 years later, medical errors would have decreased. Well, they have but …. The “but” is that as a result of 10 years of experience, we have become better at measuring medical errors. And, while the latest study published does show that the medical errors from back then have decreased, our better measuring techniques show that there were many non-lethal errors that were not being spotted. The April edition of Health Affairs published a study showing that medical errors (lethal and non-lethal) occur in one out of every three hospital admissions. As someone who works in a hospital, I have seen many non-lethal medical errors, some of them minor. But, I have also seen errors that were serious, such as what is called WBIT (Wrong Blood In Tube). That error means that the wrong patient’s blood was drawn. That is, patient A was drawn but the label on the tube was for patient B. This often occurs if a phlebotomist is in a hurry and does not check the patient’s identification properly. That should never ever happen, but it does, every month, all over the USA. Another common site for this to happen is the ER. You have all seen in TV shows what can happen if a multiple patient trauma incident comes into the ER. In that hectic setting, blood may be drawn for lab testing, and the tubes handed off to a nurse or other person to label. But, if that person does not label the tubes right there and immediately, or in their rush pulls the wrong labels without rechecking the patient, it is all too easy for a mistake to be made. And that happens every month all over the USA. In many hospitals the ER is the largest source of WBIT.
But, there has also been one other trends in hospitals that has helped to keep the trend going, and that is one that is not talked about. I mentioned last paragraph about the phlebotomist who draws the blood being in a hurry and not checking identification as well as he/she could. The solution is to tell them to slow down right? The answer is that they cannot both slow down and keep their job. Many of you know that at many call centers, those who answer the phone have a quota of how many people they must process per time. For instance, at one insurance call center–who shall not be named–the phone center staff is supposed to average no more than 3 minutes per client. The emphasis is on speed. And, as you may have noticed, many call centers are staffed so that it is difficult for you to get through immediately, you are almost always placed on a queue. A phlebotomist is on the same exact system.
That type of metric is now applied to hospitals as well. Laboratories, wards, and phlebotomy stations are staffed by way of a medical metric. That phlebotomist, or that clinical laboratory scientist, is supposed to turn out so many patients or so many lab tests per hour. Nurses are supposed to be able to supervise and take care of so many patients per nurse per ward. The metric controls all staffing, and the metric is designed to keep the minimum number of people necessary to run a hospital, assuming that they work at 90% efficiency. Even at a factory (or a call center) the metric is weighed towards minimizing labor costs. This sounds good in theory, and works well in manufacturing jobs. But, as you can tell with call centers, it means that the worker is always on the edge of overload. And, people are not products, though that is how the metric treats them. Thus, in a manufacturing job, if there is a small percentage of wasted product, that can be acceptable. That is, there is a trade off between worker efficiency and wasted product. If you push the efficiency too high, the wasted product increases. People are not machines, and they cannot keep an undivided focus the way a machine can. Even at the old-fashioned auto assembly lines, the rates at which automobiles pass by is designed to balance efficiency versus wastage. But still, if you have ever watched a documentary TV show about assembly lines, the work can be brutal. The TV show Undercover Boss recently showed a boss who could not keep up the rate at which his own assembly line was going, and was actually “let go” as a result, by a supervisor who did not know that he was letting go his own boss! Only then did his boss realize the brutal expectations he had placed on his own workers.
But what works on things can be a disaster when applied to people. Call center personnel almost never get a happy phone call, and it is not simply because the person has a problem. By the time they navigate a phone tree designed to weed people out from a personal response, and by the time they navigate a queue that builds up because the center is staffed for 3 minutes per client, the client is rightfully angry and it is the worker, not the CEO or the shareholders, who receives the brunt of the anger for something for which they are not responsible. But, in the medical field that same metric leads to tragic and–sadly–sometimes deadly results. And, that is the metric that is at work in your hospital.
Right now in the USA, there is a shortage of nurses, a shortage of histologists, a shortage of clinical laboratory scientists. In the blood bank, the national shortage of blood bank workers is estimated at 10% and expected to grow as the baby boomer blood bankers begin to retire. These shortages only feed into the medical error problem. Remember that hospitals are now staffed by that metric I mentioned. So, imagine that if blood bankers have a 10% shortage, using a metric designed to keep people working at near full capacity, then a current blood banker is working himself/herself to exhaustion. Now, imagine nurses facing even worse shortages in many hospitals. Their shortage is often above 10%. That means that the nurse who cares for you in a hospital is chronically overworked. This is a recipe for medical errors. It is also a recipe for an increasing shortage, as nurses and clinical laboratory scientists drop out and as recruitment of replacements (i.e. students) becomes increasingly difficult because of the working conditions.
And so, the USA is seeing problems with wastage in the medical field. Except that the wastage is human lives not simply product. And, some of that wastage is in clinical laboratory scientists, nurses, phlebotomists, etc. You see, the type of person that goes into a medical field is one that is normally concerned about people. The psychological cost to a medical professional who commits a medical error is as severe, and sometimes more so, than any discipline that they might receive. And that is on top of the psychological pressure of knowing that if they commit a medical error, they might well get fired on the spot. Particularly in blood bank and the specialties in nursing that work in intensive areas (ER, surgery, ICU, etc.), the rule is often one mistake and you are fired. This is not necessarily a bad rule, unless the staffing is such that these areas are chronically overworked. By the way, when you see a TV show about emergency rooms or about laboratories (CSI, etc.), please realize that all those places are overstaffed according to the metric. It is no wonder that there are increasing shortages of people willing to work some of these areas.
Let me now bring this in to the whole area of Catholic social doctrine. Many of these metrics came in through the push to lower healthcare costs. What is one of the best way to lower costs? Why keep worker salaries down and worker rolls low. The metric is designed to keep personnel costs as low as possible, so that shareholders may receive a payout. Hm, did I mention that a large proportion of hospitals in the USA are now owned by health conglomerates? And, in those conglomerates, the top officials (CEO’s , CFO’s, etc.) are often paid every bit as lavishly as some of the other storied CEO’s that you read about. However, whereas in the financial fields you can lose your life’s savings while the CEO still gets his/her high pay with bonuses, in the medical field you can lose your life.
===MORE TO COME===
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