Thursday, April 7, 2011

The Danes consider going public with medical errors

And now a final report from the Copenhagen conference. By the way, it was entitled, "Fremtidens Hospitalsledelse", or "Future Hospital Management." I was asked to present our experience at BIDMC with regard to quality and safety improvement and transparency of clinical outcomes. Regular readers will have seen much of that history here.

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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