This is the final section in this rather old article that I wrote. As I look at it again, I realize that we have continued to make progress, but we still have a long way to go.
Acceptance:
Despite the difficulty of the task, encouraging work is being done in improving medical quality and patient safety. Coalitions of public purchasers and large employers have been created with a goal of consolidating the voice of the purchaser and to engage consumers and clinicians toward improving the quality of health care. This coalition is known as the Leapfrog Group and while the impact of this group has been modest thus far, it, along with other organizations, provide needed attention to the problem of medical errors. These groups have offered some initial interventions that might aid in error reduction. Another established initiative is the 100,000 lives campaign. This was launched by the Institute for Healthcare Improvement and has engaged over 3000 US hospitals with the goal of avoiding 100,000 unnecessary deaths largely through the adoption of six evidence-based interventions that are know to reduce harm and death when they are reliably implemented [Berwick DM, Clakins DR, McCannon CJ, Hackbarth AD: The 100,000 lives campaign: Setting a goal and a deadline for improving health care quality. JAMA 2006;295: 324-327]. Initial successes led this group to greatly expand their goals to ive Million Lives. Insurance companies increasingly base increased payments on quality of care provided. These are just a few examples of people and institutions stepping up to try and improve the way in which health care is developed. This is not to imply that the path is easy or that great success has yet been achieved, it just means that some people have accepted that the quality of care that we try and provide is not always up to the standard that we may wish.
The beauty of acceptance is that it allows us to move on and function within a new and different reality. For a patient at the end of life this may allow the opportunity to realize a life-long dream or renew family ties. For the health system this may mean redefining everything from how physicians are trained, to the system in which that training is applied. While many groups are developing proactive and positive steps in developing strategies for error reduction, significant strides are difficult if many physicians remain firmly fixed in denial. Refusing to accept that patients are harmed by our current system and subsequent anger at those patients when they seek compensation for their injuries cannot be our answer. Supporting legislation that blocks the ability of patients to litigate may allow us to remain comfortably in denial about the harms we cause, but it will not allow us to fulfill the oaths we take to provide the best care to our patients. Prolonged denial and obstruction of the steps needed to improve the quality of the care we provide is already leading policy leaders to create legislation forcing hospitals to report data on certain benchmarks considered to be markers of quality. An effort is being made to put a good face on these reporting mandates by a promise to pay for the best performance, but is this really the way that the health system wants to be “led” to better quality? Recognizing that improving quality may require a new way of paying for healthcare should not mean that providers should accept government mandates that equate quality with a checklist of process measures. We can do better than this, but first we have to accept that at least some of what we are currently doing is simply not good enough. And we have to be willing to actively be part of solutions to create a safer system.
Since the release of the IOM report progress in decreasing medical errors has been modest. It would be a tragedy if in another 10 or 20 years a second (or even third) report must be titled To Err is Still Human. Now you know what the five stages of death and dying have to do with medical errors.
Table 1: Kubler-Ross’ five stages of dying
In her 1969 book, On Death and Dying [On Death & Dying, (Simon & Schuster/Touchstone), 1969], Swiss-born psychiatrist Elizabeth Kubler-Ross outlined the five stages of grief of someone who is dying:
• Denial and isolation: “This is not happening to me.”
• Anger: “How dare God do this to me.”
• Bargaining: “Just let me live to see my son graduate.”
• Depression: “I can’t bear to face going through this, putting my family through this.”
• Acceptance: “I’m ready, I don’t want to struggle anymore.”
References:
- Institute of Medicine, To Err is Human: Building A Safer Health System (Washington, D.C.: National Academies Press, 1999
- McGlynn EA, Asch SM, Adams J, et al.: The Quality of Health Care Delivered in the United States. N Eng J Med 2003; 348:2635-45
- National Committee for Quality Assurance, State of Health Care Quality 2004 (Washington, D.C.: NCQA, Sept 2004
- Bernstein, S.J., E.A. McGlynn, A.L. Siu, et al., “The Appropriateness of Hysterectomy. A Comparison of Care in Seven Health Plans. Health Maintenance Organization Quality of Care Consortium,” Journal of the American Medical Association 269(18):2398-402, May 12, 1993
- Wennberg JE, Cooper MM, eds., The Quality of Medical Care in the United States: A Report on the Medicare Program, The Dartmouth Atlas of Health Care 1999 (Chicago: American Health Association Press, 1999)
- Fisher ES, et al.: Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health service Research 2000; 34:1351-1362
- Jha AK, Li Z, Orav EJ, et al.: Care in U.S. Hospitals – The Hospital Quality Alliance Program. N Eng J Med 2005; 353:265-74