May / June 2005
Consumers as Partners
Standards, Audits, and Saying I'm Sorry:
An Engineer's Family Proposes Solutions
I dreamed of being an engineer when I was growing up, but algebra and calculus were not my cup of tea, so I pursued a career in politics and public relations. I was a press secretary and policy analyst for the Illinois House Republicans, and then I became the executive director of Illinois Lawsuit Abuse Watch (I-LAW), a tort reform group, in 2000. Like all tort reform groups, we advocated caps on damages and other legal reforms. Working for I-LAW was my first exposure to the politics of medical malpractice, but I was no stranger to the issue on a personal level.
Two years earlier, I had lost my oldest brother, Jim, to medical errors. While the circumstances of his death are unique, the events surrounding his passing are not: A series of medical errors and misdiagnoses compounded until his body quit. Also typical was the hospital and doctors' response to my brother's bad outcome: They refused to talk with my parents, and medical records were not forthcoming. The stonewalling and silence did not sit well with my parents, especially my father, who is an engineer.
My dad holds a PhD in structural and civil engineering and has been involved in the development, design, manufacturing, and service of nuclear power plants for the United States Navy and aircraft engines for military and commercial customers. I can say without bragging that Dad is a great engineer, and his highly specialized training and mindset instinctually kicked in after my brother's death.
My dad wanted to know from the doctors and hospital administrators how Jim died, what system breakdowns contributed to his death, and how the system would be fixed so another person doesn't suffer the same fate. Dad's questions were greeted with a stony silence and a canned response: "We're sorry, but we can't discuss these issues with you." Maddening.
Here sat my father who made a career out of designing, implementing, and fixing processes so that nuclear ships and aircraft engines would be safe, and he was impolitely told to butt out of the death of his own son. Absolutely maddening.
My family turned to the courts for redress and received a monetary settlement, but the hospital and doctors never admitted fault. Our attorney said the doctors would have a "black mark" on their record; however, we still have lingering questions: Has the hospital truly learned from Jim's death? Have they improved their processes? Have other families suffered our fate?
These lingering questions continue to haunt our family, especially during the current tort reform debate over capping damages and attorneys' fees and insurance reform. Whenever I speak with Dad about the tort reform battle, he poses the same frustrated, rhetorical question: "Why aren't the politicians and the media talking about fixing medical processes to reduce all these errors?"
He also makes another interesting point: "When engineers make a mistake, the plane crashes or the ship sinks, hundreds if not thousands die, and there is an outcry from the media, legislators, and the public for heightened safety standards. Furthermore, there is no talk of limiting lawsuits. However, the Institute of Medicine says medical errors kill between 44,000 and 98,000 Americans annually, and all we're talking about is capping damages and making it tougher for people to file a lawsuit. There is no serious public discussion about increasing safety standards and reducing medical errors."
Engineering: A Culture of Safety Driven by Accountability
To be fair, engineers and doctors work under much different conditions.
I've pointed out to my father that he could pick and choose the time and place he worked on a nuclear reactor or aircraft engine, whereas a doctor doesn't know who or what is coming through the emergency room doors in the next 10 minutes. Dad agreed with this point, but he was quick to retort that he believes the stakes for engineers and their companies are much higher. When a plane crashes, it's front-page news, massive lawsuits will be filed that could bankrupt the company, and engineers will lose their jobs; whereas when a doctor makes a mistake it usually affects only a single patient, most often it's not newsworthy, a lawsuit might be initiated, and strong disciplinary measures are rare.
My father believes these heightened stakes have created an unparalleled culture of safety within the engineering profession. The safety culture begins with engineers being trained to work in teams and being able to coordinate complex projects with top to bottom communication from the team leaders to the most junior engineers. A major part of this communication system involves creating written records of all events and producing reams of data to show compliance with procedures and that can be studied to fix processes if something goes wrong. Furthermore, as my father says, "cowboys, gamblers, and risk takers" are generally frowned upon in engineering. If engineers are not sure about something, they run the numbers and do the tests again and again until they are sure. Risks are minimized. "We just don't think something is OK, we prove it's OK with data," says my dad.
Doctors, on the other hand, tend to work independent of each other and other medical providers, which can lead to miscoordination of patient care, and are generally not religious about writing down information and producing data that can be reviewed. Also, due to their independence, doctors can become the risk takers and gamblers scorned by Dad and his engineering colleagues.
The engineering safety culture is further enhanced by the customers, the government, and management.
Customers of engineering products like a major airline are highly educated, sophisticated consumers that know how to demand and receive a quality product. These customers have audit power, and if they are not satisfied with their audits they know how to complain to the government and get their auditors involved in the review. Furthermore, there are only so many airlines, and if they cancel a project it can destroy a company's bottom line. Indeed, engineering customers have the ability to inflict consequences.
This stands in stark contrast to patients and families who are usually unsophisticated consumers literally at the mercy of their medical providers. Patients don't have audit power, most don't know how to complain to the government, and if they leave the hospital they'll quickly be replaced by another sick person looking for care. Indeed, patients and families generally don't have the ability to inflict consequences, with the exception of the occasional lawsuit.
The federal government also plays a major role in engineering safety. In addition to actively listening to customer complaints, the federal government has tough oversight and audit powers with engineering companies as well as their customers. The government's job is to make sure engineers, their companies, and their customers are meeting safety standards and codes so the boat doesn't sink or the plane doesn't fall out of the sky. Government's auditors have teeth and are respected and feared by engineers. They have the ability to delay or cancel projects, as well as put people in jail.
The medical profession has a much different view and perception of bureaucratic state medical boards and JCAHO. One hospital administrator remarked to me that JCAHO is a "joke." Indeed, JCAHO audits only every three years, while the government audits some military engineering projects on a monthly basis, and corporate projects are reviewed several times a year.
Company managers want to keep the government at bay and customers happy, so they closely manage and monitor their engineering teams and demand quality and constant improvements. Companies institute their own internal audits to make sure their people understand and meet the required specifications and standards. Since many doctors are independent contractors, many hospital administrators generally don't have the same oversight powers.
Finally, when engineering companies and their customers discover problems or deficiencies in processes or products, they are likely to share their findings with the federal government in an effort to develop new industry-wide standards and practices. As my dad says, "Engineers make a real effort to share information and learning, especially after bad outcomes and near misses."
Compare this culture to the medical profession and medical malpractice insurers that require sealed records to be part of most settlement agreements. "How much learning is lost by sealing medical malpractice settlements?" my father wonders.
Indeed, if medical professionals truly wish to improve their processes and reduce errors, they should welcome the establishment of similar outside pressures experienced by engineers. This means better-educated patients who know how to complain to the government and get results, strengthened government oversight and regulatory pressures, and hospital management that is more involved in the day-to-day activities of their doctors.
Much like engineering, these external pressures will produce better team work and communication among doctors and medical providers. Furthermore, it will cause standards to be elevated and audited frequently, and when those standards are not met, meaningful reviews will occur that will produce the necessary system improvements.
Finally, the medical profession must reform by allowing better sharing of information after bad outcomes so doctors can learn from the mistakes of other doctors.
Over the past year I continued my education in the politics of medical malpractice, this time working for the plaintiffs' bar. I advocate the typical anti-tort reform messages of enhanced insurance regulation and stronger doctor discipline. However, I have also had the opportunity to promote a unique solution called "Sorry Works!" that encourages apologies and upfront compensation for medical errors. I learned quickly that the Sorry Works! full-disclosure idea appeals not only to plaintiffs, but it also has crossover appeal to doctors, risk managers, and some insurers.
In an effort to gain greater exposure for Sorry Works, I helped start a new group aptly named "The Sorry Works! Coalition" (www.sorryworks.net). We believe that apologies and upfront compensation dissipate anger after bad outcomes, and, thus, lower the number of lawsuits and related liability costs. We also say that full disclosure provides swift, fair justice for victims of medical errors. Finally, we believe full disclosure creates a culture that will lead to a reduction of medical errors, especially repeat medical errors.
Indeed, living in a culture of honesty is the only way doctors can learn from errors and implement changes to reduce the chances of repeat errors. Furthermore, adopting honesty is the first step required to implement the changes recommended in this article.
I penned this article, but most of its insight and substance belongs to my father. Losing Jim was a devastating blow to our family, and the pain of his passing has never left. However, we hope good will come out of our tragedy. Specifically, we want the medical profession to make continuous process improvements so other families will not know our pain. Would you expect anything less from an engineer's family?
Doug Wojcieszak is a public relations and public affairs consultant living in Glen Carbon, Illinois. He may be contacted at email@example.com or 618-559-8168.