Hospital policies and procedures don't automatically improve patient safety

Hospital leaders, including administrators, physicians, and nurses, spend a lot of time writing policies and procedures that are designed to guide health care provided in the facility. As a former hospital administrator with accreditation compliance responsibilities, I remember spending countless hours in committee meetings pouring over policies and procedures.

Although I can’t imagine any hospital or its personnel having anything other but wishes for good outcomes for their patients, the reality is a lot of the policy and procedure work is triggered by requirements of accrediting agencies such as The Joint Commission.

One of The Joint Commission’s mandates is that hospitals perform a root cause analysis any time there’s a sentinel event.

A sentinel event is a patient safety event that’s not primarily related to the natural course of the patient’s illness or underlying condition, leading to the patient’s death, permanent harm, or severe temporary harm where intervention is necessary to save the patient’s life.

Sentinel events are also called never events and include occurrences such as a patient fall, suicide, unanticipated death of a full-term baby, discharge of an infant to the wrong family, leaving an unintended foreign object in a patient after surgery, or performing surgery on the wrong patient or incorrect site.

A root cause analysis is basically an exercise where the hospital investigates an event that should have never happened to determine why it did and how to prevent it from occurring again. These reports are confidential, but it shared with The Joint Commission, which uses this information to create new requirements for policies, procedures, and staff training.

From my perspective and experience as a Houston, Texas medical malpractice lawyer, many hospitals have excellent policies and procedures. Unfortunately, many of those same policies and procedures have no practical impact other than helping the hospital pass an accreditation inspection.

How does this happen?

Fundamentally, it’s a failure of hospital leadership. It’s not enough for hospital committees to convene and draft beautifully worded policies and procedures that will impress accreditation surveyors visiting the facility.

Additional hard work is necessary, in the form of making sure that supervisors and front-line nurses and health care providers are aware of what’s expected of them and why following prescribed policies and procedures promotes patient safety.

In every case that we investigate here at Painter Law Firm involving hospital care, one of the first requests for production will serve on the hospital is for the table of contents or index for policies and procedures. This provides us with an overview of how comprehensive the policies and procedures are, and also allows us to request specific ones that are relevant to the lawsuit at hand.

Armed with the proper policies and procedures, our next step is to review the personnel files of the health care providers involved with the care at issue. For registered nurses, for example, we look for evidence of orientation and training on the relevant hospital policies and procedures.

Finally, when taking the deposition—out of court sworn testimony preserved by a court reporter—of nurses or other health care providers, we ask specific questions to determine their knowledge of policies and procedures and why they didn’t follow them in our client’s case. I’ve seen countless nurses squirm under this line of questioning. Sometimes I feel sorry for them that the hospital nursing leadership and administration let them down by not providing proper training and competency assessments to ensure that there nursing care was safe for patients.

Policies and procedures can also provide useful information on the hospital’s perspective on expected service times. For example, we are currently working on a case where a man was involved in a high-speed motor vehicle accident. He had a number of injuries but had no neurological impairments. He was able to walk, wiggle his legs, and move his arms and hands.

After the emergency and trauma surgery teams got his acute injuries under control, this patient began to have negative changes in his neurological status over the first post-operative day.

Eventually, a doctor ordered an MRI scan. By then, the patient couldn’t move his lower extremities and had lost sensation from the nipple line down. It took over five hours for the MRI scan to be performed, interpreted by a radiologist, and reported back to the clinical team. The clinicians had decided to wait on the MRI findings before calling a spine surgeon. Meanwhile, hours passed by in the patient got worse and worse.

Our medical experts can’t conceive of a hospital taking five hours for an MRI scan in a hospitalized patient with clear signs of a spinal cord injury. As this case gets underway, we will certainly study the policies and procedures to see what this Dallas area hospital had in writing concerning performance times for stat (as soon as possible) and routine MRI and CT scans.

The long and short of it is that hospitals enact policies and procedures for one reason, patient safety. When they don’t follow through and train their staff about these policies and procedures, or nurses and other providers ignore them, it poses a danger to patient safety.

Robert Painter
Article by

Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.