Quality , patient safety , and culture : ‘ We have met the enemy and he is us ’ — Pogo

T he director of every intensive care unit is constantly faced with the task of improving the quality and efficiency of the care delivered to the critically ill patients in his or her charge. The very concept of “quality” has always been problematic: defining and measuring “quality” health care has always been difficult, while improving it, or, for that matter, effecting any change in medicine, has historically been easier said than done. The quality movement in medicine was initiated by Florence Nightingale when she undertook the first audits of hospital mortality rates and began a campaign to collect uniform hospital and surgical statistics so that the “laws which regulate diseased action would become better known, the results of particular methods of treatment, as well of special operations, would be better ascertained than they are at present. ” (1) Although her pioneering work was championed by the International Statistical Congress of London, the medical community was less than impressed and change came slowly and belatedly. After all, she was a woman and not a physician. Fifty years later, Ernest Amory Codman, an innovative Boston surgeon who was as confrontational as Nightingale was reclusive, dedicated his career to the challenge of improving quality. In 1910, he went public with his “End Results Idea. ” As Codman stated, this “was merely the common-sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future” (2). This concept proved to be spectacularly unpopular within the medical community. In 1914, shortly after proposing an even more radical program for evaluating the performance of surgeons, the Massachusetts General Hospital revoked his staff privileges and he was expelled from the Massachusetts Medical Society. Codman himself predicted that several generations of physicians would come and go before his efforts would be recognized and translated into meaningful improvements in patient care and outcomes (3). He was, of course, incorrigibly optimistic (4). Many efforts to implement quality measures have met with stubborn resistance from even the most well-intentioned practitioners and there has been little to show in the way of substantial improvements. As the cost of health care has risen, numerous studies began to point out the financial cost of low-quality care and medical errors (5). Indeed, the business case for quality has been made repeatedly, a prime example being the formation of the Leapfrog Group by the Business Roundtable in November 2000 (6). A major shift in the quality movement took place in 1999 with the publication of “To Err Is Human: Building a Safer Health System” by the Institute of Medicine (7). This report estimated that as many as 98,000 Americans died annually of preventable medical errors. This ushered in the era of patient safety. Spurred on by this report and the growing awareness of the immense human and financial costs of medical errors and less than optimal quality care, governmental agencies, accrediting bodies, nonprofit organizations, and hospitals poured substantial resources into efforts to improve patient safety. Whether these efforts have made a difference is unclear. A recent study by the Office of the Inspector General for the Department of Health and Human Services (8) found that one of every seven Medicare beneficiaries who is hospitalized is harmed as a result of systemic problems with healthcare delivery. Unexpected adverse events added some $4.4 billion to annual healthcare costs and contributed to some 180,000 deaths per year. The study also noted that in the month of October 2008, 134,000 Medicare patients experienced at least one adverse event with at least 44% of them being preventable. This study is depressingly similar to the retrospective study of 2341 admissions in ten hospitals in North Carolina from 2002 through 2007, which found that there were 25 harmful events per 100 admissions. Over this 7-yr period, there were no significant reductions in either the overall event rate or the preventable event rate (9). Although medicine has been notoriously famous for resistance to change, the lack of progress on the quality front is astounding. Robert H. Brook, one of the founders of the modern academic quality movement, recently acknowledged this and declared “the end of the quality improvement movement” as we know it (10). In the face of this resounding lack of progress, what are the physician and nurse directors of intensive care units to do? Why is change so difficult to implement? The problem, of course, lies within our own environments, or as Pogo said, we have met the enemy and he is us. We need to examine ourselves and our own unique cultures. Although organizational psychology and culture are not taught in medical schools, we are fortunate in that we have colleagues in the social sciences who have taken an interest in our world and examined it (11). Indeed, although there is a substantial body of literature regarding corporate cultures and behaviors, there has been growing interest in the unique culture of medicine and hospitals, which proves to be significantly more complex, if not more interesting. Edgar Schein, who is generally credited with creating the phrase “corporate culture,” defines organizational culture as: “A pattern of shared basic assumptions that was learned by a group as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, there*See also p. 934.