Our background and experience is in agriculture, food production, processing and retail. In our world, we are not allowed to (nor would we want to) produce or process food in a federally inspected (and now more often provincially inspected) facility unless we can show a Hazard Analysis Critical Control Points (HACCP) plan to address every known risk to the safety (health/disease) of the product while it moves through our facilities and out the door. If something happens that shows an unanticipated risk, we must revise our HACCP plan immediately to account for and plan against such an event happening again. HACCP was developed decades ago for use by NASA after it experienced early disasters in the pursuit of outer space travel. It has been used in the food industry for more than 30 years. No such system with this over-arching plan and associated discipline is used in our health treatment system.
Today, there are only some bits and pieces of processes to learn and put in place improvements, in different parts and levels of the treatment system. There is no carefully planned and disciplined system of learning from adverse events or even “near misses” and then translating what is learned across or up and down the system. Too often, errors go unreported, and/or uninvestigated or if they are, it is behind a curtain of secrecy, or a wall of legal protection. Even if there is an investigation that has some public character, it takes years for it to get to the finish line (we still don’t have the last information about one of Greg’s doctor’s actions) and the information we have been given on others is “confidential”. One process that can bring the facts to the public is a Judge led Public Fatality Inquiry. There are few of these done (can you remember the last one?) and the majority of them focus on events around criminal’s treatment or an adverse event involving someone under the government’s care. We requested (and this was supported by others) an inquiry into Greg’s death but it was denied months later by the Office of the Chief Medical Examiner in a very short letter without explanation.
A “high performing” “team-based” system (see Priority #1) would rapidly identify and investigate all adverse events to quickly learn what had happened and why, and to immediately put in place steps to ensure it could not happen again. It would also share these findings and action plans across all parts of the system in order to have others avoid having the same or even a similar adverse event from happening to their patients.
“The best way to honour a person who has been harmed by a healthcare failure is to do everything possible to learn from that failure so that it will not be repeated.”
We believe that in order to ensure that adverse events are properly investigated and the lessons learned from them are implemented, a third-party investigatory team or agency must be empowered to investigate any event it judges is warranted. It must be a “third party” because the long history of deny and defend is too entrenched to allow good public investigations to occur by doctors or other providers themselves. Another avenue where actions of concern or failures are noted would be the offices of the Alberta Health Advocates. These dedicated people should be able to bring forward issues or events to the investigators as well.
As soon as this 3rd party investigatory team or agency is established and empowered (and the need for this is immediate), it should quickly begin examining and publicly report on all aspects of severe adverse events (death or lifelong harm). It also must develop a robust reporting system to ensure effective communication with all different levels of the system. This group’s mandate should also extend to quickly share with others, what was learned and what this means for revisions to “best practice” operations or activities. Associated deadlines must be set for the completion of these actions. It is also very important in these severe adverse events, to have suspended the license or operating authority of the associated players or facilities until the investigation is complete and go-forward corrections to the procedures or practices are made. This power must be in place to stop repeating adverse events and to insure prompt improvements are made.
Clearly the current ability of the physician’s liability insurance to block public investigation must be dealt with. No individual doctor’s professional insurance can be allowed to prevent an investigation into a serious adverse event and in turn, blocking the ability of the system to learn and improve. This form of self-centred individualism has no place in a high performing, team-based system and certainly no place in a health system which should be dedicated to the best care possible for its patients. It should not perpetuate practices which have caused harm. Clearly the investigation needs to be done in a careful and just manner very differently than is the case today.
We believe Alberta’s health system can “lead in continuously improving, high performing, team-based, patient partnered, health care”. It will take strong government and public action on the system’s basic culture, the electronic medical record system and communications and to have in place the disciplined system to learn from mistakes to insure that they do not continue to be repeated. These three priorities will only be addressed if Alberta’s “healthy public”, along with Albertans who are patients and family members, become engaged enough to cause major changes in the political priorities of the past. If we work together with the great people inside the system who have been trying to make the right changes a much safer and better health care system will be available for all.
We plan to post on Health Arrows fairly soon, a review the “lessons” we listed as part of Greg’s Journey and provide our perspective on what has and has not changed over the last 4 years.