I love student speeches. Not all of them… but enough to matter. In the last week, I’ve heard some pretty good speeches on the Ku Klux Klan, the Vietnam War, Watergate. (It’s really fun to hear a speech from a student who knows nothing about her subject except from her own research. Watergate is ancient history to the current crop of college students).
But one speech seemed almost prescient. It was delivered just a few days before the account of Thomas Duncan and his death from Ebola became known. His speech was on medical errors. His thesis was clear, and well stated:
The American healthcare system must eliminate medical errors.
And in his speech, he included this:
These errors are usually due to negligence, forgetfulness, miscommunication. We need to change: these errors can be prevented through the standardization of protocol, procedures, and communication. “The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”
The quote came from a book entitled Crossing the Quality Chasm: A New Health System for the 21st Century, put out by the Institute for Medicine. I borrowed his copy, and found more. Consider these brief excerpts;
The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering.
Why is the problem so staggering? There is a reason:
Health care is characterized by more to know, more to manage, more to watch, more to do, and more people involved in doing it that at any time in the nation’s history.
So, this is a book about the quality chasm in health care. But it reveals an increasingly universal challenge. There is a quality chasm in just about any and every arena.
We’ve all heard about the VUCA world: we face volatility, uncertainty, complexity, and ambiguity in multiple arenas. And it seems to be increasing, in all four factors, by the month/year — more volatile, more uncertain, more complex, more ambiguous…
It is the complexity factor that is such a threat to quality. So many people involved; so many things to get right; such a heavy price to pay when there is a slip up anywhere within the process/system.
My student’s short speech did not give the definitive solution to this problem. But I think he stated the problem pretty well. Just read about the story of Mr. Duncan, the Dallas Ebola patient, and I think you’ll agree that this quality chasm is one that needs our best and prolonged attention.