Something's always wrong

I had an idea for an absurd indie comic strip about Corrective Action Plans - those in-depth multi-departmental administrative remedies that are developed in response to bad outcomes, dropped balls, missed communications. Over time we've taken to calling them CAPs.

The comic would follow the adventures of CAP'n America. He'd never arrive in time to save the day (in fact, he only worked business hours) but he would be sure to show up after a traffic accident or crime scene investigation and make sweeping pronouncements about how workflows will have to change.

Wouldn't that make for funny reading?

I still consider myself relatively new to medicine, but I think I've been around long enough to see the culture morph from closed-door, M&M-style reviews of cases... to CAPs. Maybe this is progress - certainly, it's change - but it's a far cry from the data-driven, common-sense laden discussions we don't seem to be having often enough.

CAPs seem like an outgrowth of Six Sigma mindset - getting to a defect rate of under 3 per million. Of course, when your ED sees half a million patients over five years, and a particular bad outcome happens once during that time, administrators don't like to be reminded that the failure rate is actually well in line with six sigma. They want a CAP, so that it never happens again.

Never is a powerful word in medicine. And "never" always comes with a cost, though sometimes it's not easy to measure that cost.

So what if the corrective action plan - to prevent that one really rare foulup - makes routine care a little bit worse? Length-of-stays and time-to-dispositions become a bit longer as doctors and nurses implement a new workflow. The delay is ok because it's all for a good cause, right?

But whenever we agree to a CAP - agree to revise our rules in response to a rare, awful event, rather than to address a routine awful events like extended boarding times or delays in prompt care, the process is stacked against us from the beginning. It's stacked against practitioners and against the vast majority of patients, too. And it becomes impossible to truly improve care.

How can we correct this process?