Building a Blameless Culture in an Integrated Clinic

By William Morgan, DC

One of the hindrances of doctors working together in a collegial team is the strong individual
sense of competition that the educational process imbeds in physicians. Physicians can be
strongly opinionated, competitive and domineering in relationships. So it is not uncommon for
practitioners to point the finger at someone else when negative outcomes occur. In such a
culture, workers tend to hide mistakes rather than bring them forward for analysis and
correction.

For example, a nurse working for a doctor who yells and blames his staff for mistakes may hide
the fact that she gave a patient the wrong injection to protect herself from scrutiny. This is a
recipe for disaster. A health center should recognize that individuals make mistakes, and that it
is good policy to encourage people to reveal their mistakes and near misses.

Here’s another example: a physical therapist mistakenly uses electrical muscle stimulation on a
patient with an internal defibulator (an implant with strong contra-indications for the use of
electrical stimulation) but later identifies the error, though no injury occurred. What should he
do? Keep the incident a secret and make a mental note to avoid the same mistake in the future?
Obviously, the right thing would be for the therapist to alert the rest of the staff and work
toward a systemic solution that will prevent he and others from making the same mistake
again.

Building a blameless culture in an integrated clinic will only succeed if the providers cultivate
trusting, safe relationships with each other. Trust does not occur overnight, and it may take
years to develop. The ultimate goal in a blameless culture is increased patient safety and better
healthcare delivery.

There is No “I” in Team

If you recognize a condition overlooked by another provider and find it necessary to tell the
patient and others that you--the great diagnostician--found what others missed, you may have
un-addressed issues with your own self-esteem. The correct way to address a missed diagnosis
by another physician is to respectfully contact the other provider. You may send a note to the
radiologist (“Beth, could you take another look at the sacrum on Mr. Grant’s MRI? Something
doesn’t look right.”) or to the orthopedist (“Bob, the patient that you referred turned out to have
a positive HLA-B27. With your consent, I would like to refer him to Rheumatology.”).

We are all human, and we can overlook important findings from time to time. That’s why it is
important to have people on your team who you trust to help uncover relevant findings that
you may have overlooked, and who you can also trust to help preserve the patient’s confidence
in you.

As an integrated group matures, the individual specialties blur and the focus turns toward
supporting the team. For instance, when a surgery has a negative outcome, instead of gossiping
about the orthopedist, remind yourself that you and the orthopedist are on the same team,
with the same goal. Apply yourself to healing of the patient, whether you believed the surgery
was appropriate or not. Likewise, if a patient has a reaction to a chiropractic adjustment, the
other providers on your team can provide care to minimize the reaction’s effects … while
protecting your reputation.

A blameless integrated culture maximizes honest communication between the healthcare

staff. This results in greater patient safety and more appropriate treatment plans.