It seemed like such an easy task that day on rounds.  I was a first-year surgical resident asked to remove a central venous catheter that was no longer necessary for monitoring.  No one asked whether I had slept the previous night on call (I hadn’t); this was a task that could be performed at a “spinal” rather than cerebral level, so I thought.

Taking off the dressing and cutting one of the sutures that held the catheter in place were easy tasks that I had done hundreds of times before.  Unfortunately, as I maneuvered my scissors around the knot where it entered this 82 year-old patient’s neck, he suddenly twisted, and I was left holding the short end.  The remaining piece lodged in the right side of his heart.

I felt terrible as I called for help and apologized to the patient’s attending surgeon, chief resident, family, nurses, and anyone else who would listen.  They tried to console me by telling me about errors that they had made.  It did not help.  My self-confidence plummeted.

I jumped in the air with glee when told that a cardiologist had successfully removed the catheter from the right atrium with a wire snare.  I was convinced that if the patient did not survive, I should resign from the program and worked tirelessly to help him recover.  To this day, I remain grateful for the collaboration from all the healthcare professionals who helped him recover.

Decades later, I learned that I was on the “sharp” end of a systems error.  Sure, I was the one who cut the catheter, but the resident who placed the line sewed it to the neck without leaving a loop into which I could easily insert my scissors; furthermore, he used an internal jugular (neck) rather than a subclavian approach.  In retrospect, I could have asked a nurse to stabilize the patient’s head and used a sharply pointed scalpel blade rather than scissors.  This was truly an example of painful learning.

In their chapter,“Quality in Healthcare: Concepts and Practice”, (Cohn KH and Hough D. The Business of Healthcare. Westport:Praeger, 2007, Greenwood Publishing Group, Inc.), Buttell, Hendler, and Daley define quality as the degree to which health services increase the likelihood of desired health outcomes, are consistent with current practitioner knowledge, and meet the expectations of healthcare users.

According to the chapter authors, the 5 principles of quality are:

• Leadership: the ability to influence behavior to improve outcomes
• Measurement of outcomes and care processes
• Reliability: including shared goals, mitigation of risk, rewards for achieving goals, and actions to correct suboptimal performance
• Practitioner skills: to avoid overuse, underuse, and misuse of patient services
• The marketplace: the perception of quality drives word-of-mouth feedback about organizations and practitioners and decision-making about where to go for diagnosis and treatment; the cost of treating certain complications, like hospital-acquired infection, contributes significantly to rising healthcare costs

The old paradigm of physicians and nurses taking care of clinical dimensions of care and hospital administrators taking care of finance and operations does not work any more.  Quality and safety must become and remain a collaborative effort in which board members, hospital leaders, physicians, nurses,allied healthcare professionals, and patients and families reflect on and discuss openly how to come to a common vision on optimizing care for their community.  Moreover, they need to set timely deadlines for implementation and monitor their progress at regular intervals.

What do you think?

• What do we need to do to move beyond paying lip service to the business and humanitarian rationale for quality? 
• Where have we succeeded to date?