by Suzanne Gordon
Anyone interested in transparency in healthcare should check out the Sugar Bowl website
under chairlift safety program, under inspiration
. So right on the website of this famous ski area in California is the story of an accident that killed seven-year-old John Marco Henderson.
As the article explains, “Last December our community suffered a great loss. John Marco Henderson, age 7, died after falling from the Mt. Lincoln chairlift while skiing with the Sugar Bowl Ski Team. Over the past 10 months, Sugar Bowl Corporation and Sugar Bowl Ski Team have worked with John’s parents to investigate how this accident occurred and determine what steps could be taken to prevent a similar tragedy. At Sugar Bowl, safety remains our highest priority.”
The article then goes on to detail what could be pieced together about what happened to the boy and, in great detail, discusses what the ski area is doing in response. The website acknowledges that there were problems with the lifts and the ski area does not in any way try to shirk its responsibility — both in the accident and in fixing the problems that may have caused it. “Ultimately our safety practices were insufficient to prevent this tragedy,” the article reads. Although the article acknowledges problems, it does so without apportioning blame or scapegoating anyone.
“As a result of this tragedy,” the resort explains, “we reviewed existing policies, procedures and best practices relating to the loading, riding and unloading of the chairlifts at Sugar Bowl. We have implemented a comprehensive Safety Program
that includes the following changes: restraining bars will be lowered for all minors under 51 inches in height (including equipment); increased adult supervision of children in the ski school and on ski team; and installation of cameras to continuously monitor and improve chairlift loading practices. The Safety Program
will be distributed widely and is available on the Sugar Bowl website.”
Imagine seeing something like this on a hospital website. How remarkable would that be?
Reading this people might think, Suzanne has lost it. Does she really imagine that any hospital or health care professional would actually publicly post an acknowledgment of safety problems and how they are being remedied? But no, I have not lost my mind. This kind of behavior is common in high reliability organizations (HROs)
. In our book Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork
, we describe the kinds of reporting programs and information sharing that have made flying safer than it has ever been. These kinds of programs can be adapted to healthcare. Patients know healthcare isn’t safe. They know hospitals are dangerous places. What they cannot do is protect themselves if they don’t know what to do and don’t have guidance and assistance from professionals as they try to protect themselves.
Right now, too much of patient safety is being outsourced on to patients themselves. We are asked to check our meds, to make sure no one gives us the wrong dose, a more — rather than less — invasive operation. We are asked to ask professionals if they have washed their hands. And everyone expects us to do this — even when we’re unconscious — and some actually blame us if experience a medical error or injury because, according to the outsourcing logic, we have not been vigilant enough. It was our own fault. It’s kind of like asking an airplane passenger not only to listen in to the air traffic control channel but to make sure the captain has, in fact, descended to 25,000 feet.
Patients — like child skiers — can only do so much to protect themselves. Yes, we should do what we can. We should be vigilant. But when we are most vulnerable, we also the most unable to act to protect ourselves, and if we’re lucky enough to have family and friends nearby, they too may be unable to effectively advocate for us. One has only to read the last two Narrative Matters selections in the journal Health Affairs by Beth Swan
and Jonathan R. Welch
to discover how difficult it is for even seasoned professionals to protect their loved-ones.
Although I will write more on these two stories later, the take home message is, without the kind of high level committment exhibited by those who lead (the kind of high-level commitment exhibited by Sugar Bowl) institutions as well as efforts to involve staff at every level, patients will never be safe.
Cross-posted from SuzanneGordon.com