Normalization Deviations (2): What are Shuttle and Corporate Healthcare

Part 2: Normalizing Deviations in the Organization of Medical Care for a Sample (HMO)

Based in Rockville Maryland, the HMO is an example of an organization that has received many awards for its integrative approach to healthcare and excellent feedback from patients. However, there is another form of NoD that seems to work in the HMO, which is contrary to its public image. Instead of a gradual transition to bad practice, contrary to the normalization of organizational standards, decisions are made by the management of the HMO, which is not consistent with acceptable standards of patient care and risk management in the medical profession, and these decisions become both normalized and institutionalized as policies within the organization.

After talking with several doctors in the HMO, there are four important decisions that have come to the conclusion that these are deviations from regulatory medical practice. First, it is the impetus that surgeons also cope with sedation surgery. Secondly, the promotion of more complex operations in clinics owned by HMO, with extraordinary capabilities. The third - with a colonoscopy. Finally, the latter deviation is associated with additional burdens on patients for doctors.

First, I discuss the impetus for a sedation operation without the presence of a trained anesthetist or nurse anesthesiologist. As a rule, sedative surgery is a safer alternative to general anesthesia, although even here the risks are very low. However, the safe use of sedative surgery suggests that well-trained anesthesiologists or anesthesiologists nurses are directly involved in administering and treating sedative pharmaceuticals or providing surgeon supervision and accessibility in the event of a problem or emergency. The HMO differs from this standard in that the attending surgeon manages both anesthesia, in which they have minimal training (PowerPoint slide deck and open book test), as well as anesthesiology-free operation. The first time it was tested, the surgeons could not properly anesthetize the patient, because they were improperly trained and did not have available expert reserve.

The second deviation of the HMO in the regulatory state is more complex surgical procedures in their outpatient clinics, in which there are no hospitals to deal with emergency situations. When the operating room nurse asked about this risk, the head doctor said that this risk is only the cost of doing business.

The third deviation from regulatory medical practice is a colonoscopy. Patients scheduled for colonoscopy are required to prepare in advance for the 24-hour period using the “bowel preparation” for cleaning up all wastes from the colon. This allows the gastroenterologist to examine the inside of the colon to find abnormalities that may be cancerous or lead to cancer. Used laxatives are extremely powerful, which makes it unusable, so there are patients who do not perform bowel preparation. Regulatory clinical practice is to cancel the procedure, reschedule and send the patient home with instructions for completing the preparation or without the procedure. HMO management and marketing specialists have determined that no one can be rejected for planned procedures in order to maintain high patient satisfaction scores, so that all patients who planned to undergo a colonoscopy receive a procedure regardless of whether they have performed a bowel preparation or not. This means consuming the supplies needed for the procedure, tying the treatment room, the doctor, and one or more nurses. Most importantly, the patient is anesthetized, and the chick is inserted into the colon to begin the procedure. Invariably, the process stops as soon as the colongcope strikes, since the doctor cannot see the intestinal wall. This puts the patient at two risks: unnecessary anesthesia and the risk of perforated colon, which becomes even higher when the doctor cannot see where the colonoscope is located relative to the intestinal wall. It also increases costs, which are extremely covered by patients at the expense of higher premiums.

Unfortunately, patients are strictly unaware of these risks and unnecessary costs. The chief medical officer, who is guided by savings and patient satisfaction, and hides these risks and costs that they take, has promoted a concierge drug delivery model for HMO members, suggesting to staff that doctors do not waste time on surgical sutures and staples, and that patients can be taught how to do it at home.

The fourth deviation from the historical practice of this HMO dramatically increases the doctors' hours without additional compensation. Doctors usually pay depending on their contract hours per week, so the doctor, who works 1.0 or full time, has a 40-hour week. In primary health care, the actual hours worked are close to 80 hours per week. One primary care physician, who has a schedule of 0.8 or 32 hours per week, is at least 60 hours a week, about half of whom are at home. By specialty, watches are also increasing, with the addition of Saturday hours for neurology and urology. The understanding is that additional services will be required to provide Saturday services over time. In addition, doctors are expected to see more patients at the same time every day, forcing doctors to either spend less time on patients or dramatically increase the waiting time for patients. The goal is to increase patient access (and, therefore, the burden on the patient) and to assess satisfaction.

This pressure, in order to increase the burden on the patient, is identical to NASA’s desire to increase the number of Shuttle flights, to show that missions are routine and safe events, and not real actions at the highest level. Encouraging the Shuttle contractor’s team to increasingly launch Shuttles for launch, it was unacceptable to spend significant resources on problems that were not at risk of “safety”, that is, if the problem could lead to the loss of a car. This created obstacles for engineers to identify the source of the problems, although many of them were not part of the Shuttle design and, if they were enlarged, could be flight safety. risks. Often the flight was cleared on the basis of previously successful battles that completed their missions, but still demonstrated the problem. This reasoning led to the fact that physicist Richard Feynman commented: “When playing Russian roulette, the fact that the first shot came out safely doesn’t comfort for the next one.” (Hall, 2003)

If we apply this observation to the HMO in my research, we can make phrasal substitutions:

it is an unacceptable in order to spend significant funds? Unable to use resources that are located not "Health risks" that is, if the problem can cause death or disability of the patient. This provides obstacles for doctors to identify the source of the problems, although many of them were not part of health regulatory practice , if increased, can pose patient safety risks. Often, procedure has been cleared based on previously successful procedures which was completed ... but still demonstrated the problem. When playing Russian roulette, the fact that the first procedure was completed safely is a bit of comfort for the next one.

Link cited:

Hall, JL (2003). Colombia and Challenger: organizational failure at NASA. Space policy , 19 (4), 239-247.