Part of the story was our decision to widely publicize a wrong side surgery throughout our hospital in July of 2008. The result was a concentrated effort by dozens of people to evaluate what had gone wrong and to implement changes in our pre-op procedures.
I explained that the decision by our Chiefs to go public with the event took less than five minutes of discussion -- and that five years earlier, it would likely also have taken five minutes, but with the opposite result. The point was that a change in organizational culture takes time. There is an old expression, "Culture eats strategy for lunch." I think there is a lot to that, and I explained that the comfort our people felt with transparency was key to many improvements that led to an enhanced level of quality and safety.
Then, for fun, I used the polling electronics at the conference to ask the attendees whether they thought that their hospital would broadly publicize and disclose the kind of medical error that I had described. Here are the results:
This is quite different from the results at the Risky Business conference in London last year, where only a handful of 300 attendees gave a positive reply. Why the difference? Passage of time? An audience, here, that comprised more senior level people? A cultural difference between Britons and Danes? You can suggest your own theory.
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