Learning from the Oakland whistleblower
There are shining stars in our profession who work hard to promote quality, and strive for performance improvement while minimizing the blame game
By Art Hsieh
Last week, an Oakland, California Fire Department employee embroiled in a long dispute with the agency filed a lawsuit claiming that his colleagues provided inadequate treatment to a man after he was fatally shot by a transit police officer.
This case bears watching, not only because it is literally in my neighborhood, but also for what the lawsuit alleges.
For the record, I don't know the plaintiff, nor do I have any inside knowledge of what happened during and after the event itself. The court system exists to tease out the details, to slowly separate fact from heresay and innuendo. However, there are several points about quality management that can be teased out.
Chaotic scenes are just that — messy, stressful and entirely difficult to manage. Training helps us prepare for these events. Experience plays its part. At the end of the day though, these are difficult cases to be on.
In the culture of medicine, we are often willing to accept that nontextbook situations will often be run in a non-textbook way — and that we often make judgments that in hindsight, might not have been the best one. That's why quality improvement exists, why we should do case reviews and and why we have to learn from those providers who were in these rare occasions.
If it is assumed that we can learn from poor judgment, the process of discovery and learning becomes easily transparent. Being clear about finding out what happened promotes even greater understanding and trust among all involved.
That philosophy runs counter to the philosophy of punishment, where it's much easier to assign blame rather than spend the energy to unearth what really happened and what could be done to prevent its reoccurrence. Unfortunately, many of our organizations resort to the latter, since systems that support the former cost money and take effort to maintain.
There are shining stars in our profession that work hard to promote quality, and strive for performance improvement while minimizing the blame game. There's a lot to learn from them; it takes that first step in attitude adjustment to start the process.
As for this case, we'll be following it carefully as it progresses. There will be more lessons to learn.