Dr. David Gelber who writes the Heard in the OR blog recently had a must-read post published on KevinMD entitled “Rigid regulation can become detrimental to patient care.” Anyone and everyone involved in or affected by America’s healthcare system should read this article. It clearly illustrates exactly the type of good intentions that are sending patient, doctors and nurses further and further down the Road to Hellth on a daily basis. We especially recommend reading the comment by “dropspinner” in the comment section. It’s impossible to count the number of times that we’ve relied on nurses to do the right thing and use the intelligence and common sense God gave them. To see their efforts, and those of their physician colleagues, reduced to being forced to brainlessly do what administrators have told them to do “because those are the rules” is a terrible indictment of our healthcare leadership.
If you haven’t yet read Dr. Gelber’s post, read it now to follow the rest of the discussion.
How can we reform this type of bureaucratic and legal nonsense? (It is, after all, putting people at risk to no good end and costing us a fortune to maintain.) One step that would help is to adopt something like the “basic speed law” in lieu of all hard-and-fast rules of the type Dr. Gelber describes. (For those of you who don’t remember it from the driver’s ed course you took years ago, the basic speed law is that, regardless of the posted speed limit, you must never drive faster than is safe.) The underlying logic of the basic speed law is that the people who built the roads tell users how fast they can expect to drive to be safe under normal circumstances. However if the circumstances are aren’t cookie cutter, than the people on the scene are expected to use their best judgement based upon the particular circumstances that they’re encountering at the time.
Let’s re-state that. The basic speed law doesn’t tell you how fast to drive. Instead it gives you some technical data and limits, and then asks you to use good judgement based upon your specific circumstances. The basic speed law was created many decades ago, and has never been questioned or changed in all of that time. Why? Because the smart people who created our highway system understood and accepted that only those who are on the scene and directly involved can ultimately make the correct decision about what is “safe”.
Now how would we apply this to medicine?
We suggest that American healthcare adopt something we’re going to call the “Basic Safety Law” when it comes to crafting all rules and regulations used throughout the healthcare system. It reads as follows:
“When crafting any rule or regulation that directly or indirectly affects patient care, never make the rule more rigid than is safe. Always permit exceptions as necessary based upon the best clinical judgement of the clinician in charge.”
Here’s an example. The first situation Dr. Gelber describes is as follows:
The antibiotic I had ordered was Cefazolin, perfectly appropriate for the scheduled operation. The nurse informed me that, because there was the possibility the operation could be converted to open, she also had to receive Metronidazole in addition to the Cefazolin. I told her that the particular antibiotics she was insisting be administered were indicated if the patient was undergoing colo-rectal surgery, but all that was needed in this particular case was the Cefazolin. She replied that she was following the SCIP protocol and she would get in trouble if I didn’t order the Metronidazole. Not wanting to argue with the SCIP police, I ordered the additional antibiotic.
Under The Road to Hellth healthcare regulation Basic Safety Law (BSL) approach, the new rule will read: “If there is a possibility that the operation could be coverted to open, the patient should receive Metronidazole in addition to the Cefazolin unless the surgeon in charge of the procedure deems it to be medically appropriate not to do so.”
The consequences of this change are relatively obvious. For the purpose of safety, if the surgeon is unsure about what the appropriate antibiotic would be under the circumstances, the guidelines are there. However if the surgeon knows of a different strategy that is equally sound medically, there is room to improvise. What’s to keep surgeons from disregarding the guideline’s advice willy-nilly? Two things. The first is that, contrary to the apparent beliefs of most government and hospital administrators, the vast majority of doctors really do care about their patients and want to do well by them. Second, the existence of such a rule increases both the real and perceived consequences of making the wrong choice.
As example #2, consider this portion of Dr. Gelber’s story:
Two nights later I was on call for the Emergency Room. I received a call at about 10:30 pm from the ER physician requesting that I immediately come to the ER to attend to a Level I trauma that had just arrived. He took the time to explain that the trauma was a BB gun shot to the shoulder area and that a Chest X-Ray had already been done which was normal except for the BB which could be seen overlying the right clavicle (collarbone). He added that there was a small amount of swelling over the area the BB had penetrated, but otherwise everything was normal. My logical response was “Why do I need to come in to see a patient who obviously can be discharged home with an ice pack, antibiotics and pain med?” I was told by the nurse in charge that once a patient has been declared a “Level I” trauma I was mandated to see the patient within 30 minutes and only I, as the trauma surgeon on call, could make the decision to downgrade the trauma level. The trauma protocol clearly states that all penetrating wounds to the thorax be classified as “Level I”. The fact that this particular patient did not have a penetrating injury to his thorax was deemed irrelevant by the nurse who made the decision. The fact that the ER physician had evaluated the patient and determined that there was no significant injury was also deemed immaterial.
Here the trauma level had clearly been mistakenly assigned. In this case, the BSL would be applied as follows: “The trauma surgeon on call shall see a Level 1 trauma patient within 30 minutes unless the trauma surgeon and attending ER physician agree that the trauma level had originally been assigned in error.”
Similar logic can easily be applied to the other situations the good doctor has described.
Why don’t we have a “basic safety law” approach already? There are two reasons. The first, as Dr. Gelber has already described, is that many of the people making this rules don’t know what the heck they’re talking about. They’re not medically trained, and it is frankly irresponsible to place them in the position of making rules for doctors and nurses to follow. Second, the administrators and (well, bureaucrats) making these rules are too lazy to think in terms of “what if”. It is far, far easier to make inappropriately rigid rules and let others deal with the consequences. They can get away with not-quite-murder-but-closer-than-one-would-like, because there are no standards of quality for administrative work in healthcare. Think about it. It should be inexcusable that any patient should be placed in danger or that excessive resources should be used because a “medical” administrator can’t be bothered to build flexibility into their written (or unwritten) policies.
No one is minding the minders.
This is no way to run a healthcare system. EVERY rule and regulation that affects medical care needs to be specifically designed so that it can be overridden by the appropriate medical personnel. Furthermore, every rule and regulation should be subjected to review and comment at regular intervals. This would give those affected a guaranteed means of asking that it be revised or discarded based upon both experience in the field and the latest medical and scientific evidence.
Our lives and those of our families and children are too precious to trust to shoddy, rigid rules and regulations.