Health care today operates with QA (quality assurance)
equivalent to that of American and Japanese manufacturing in the
1950's, before formal QA techniques and analysis were introduced.
Yes, our system is incredibly improved
over the past 60 years, it is now better.
'Better' is not necessarily even
'poor.' (If I cut smoking from 2 packs a day to 1 ½ packs per day, I
am now 'better' but the prognosis is still 'bad.')
As a systems analyst and a patient,
reviewing my personal experiences with the health care industry I
find myself appalled at the level of QA which the
industry finds acceptable.
No major manufacturer could stay in
business with QA at this level.
Policy is irrelevant if not followed
and properly executed, and there appears to be little effective QA
information gathering, verification or analysis.
I realize that my experience isn’t
scientific evidence, but as it covers 35 years and several clinics &
hospitals located around the country, I do believe it is indicative
(if only because only a single error elicited any real response from
the physician who discovered it.)
I’m not a Dr. (though I was an EMT
for a time,) I’m an analyst. For two decades my work has been to
examine operations of companies and locate extraneous, faulty,
duplicative, obsolete and other costly interruptions of the work
which exist in the work flow. I then make recommendations based upon
my findings. My intent is always the same: reduce error, reduce cost,
increase safety, increase processing speed, and generally improve the
overall efficiency, effectiveness and profitability of the entire
organization.
In my experience with health care I
have had; diagnostics performed multiple times when even I as a
layman knew that previous procedures would render the results
useless, improper IV treatment, deadly medications prescribed,
unnecessary surgery, symptoms ignored, expected organ failure go
unnoticed, over-prescription of drugs, been consulted on my treatment
by a Dr. while I was under the influence of narcotics he had just
prescribed, instructions given w/o followup and other systems
failures. I’ve been given complex instructions w/o verification
that I truly understood them--with no followup.
I’ve been asked questions which
weren’t properly designed to elicit necessary information, given
vaguely worded information, been mis-heard, misunderstood and had
these errors entered into my record.
Thankfully, none of these killed me,
but I have lost years of my life to some of these simple errors--of
which no action or recognition of the error seemed to be taken where
other than to revise treatment.
The single, simplest, cheapest option
to improve health care is to bring QA out of the dark ages and
provide a system with transparency, system failure identification and
correction, and solid metrics by which success can be determined.
I know that there are problems, I know
the type of problems I've personally encountered in my limited
contact with various parts of the system.
Obviously, I have had contact with only
the tiniest bit of the system, but the number of errors convinces me
that my case is not unique.
A full-scale analysis will reveal
numerous places in which the system fails both the patient and the
caregivers at unthinkable expense. Many of these will be easy and
inexpensive to repair.
Perhaps the industry is awaiting a huge
class-action suit charging thousands of facilities and individuals
with incompetency. Win or lose, such a suit would waste billions
which could be used not only to repair the system faults, but provide
better facilities and infinitely better levels of care.
