Movies from 1939 are engrained in American culture. They share narrative, characters and quotes that people are aware of even if they, alas, haven’t seen the films. The list of films produced in what some consider the finest year in Hollywood history speaks for itself; it includes Stagecoach, Ninotchka, Destry Rides Again, Mr Smith Goes to Washington, The Wizard of Oz and both my and the Academy’s favourite, capping the impressive output with a December 1939 release, Gone with the Wind.
While recognising that certain characterisations in these movies haven’t aged well, the films have made an indelible mark on Hollywood history. The films of 1939 laid the groundwork for great things to come. They launched the careers of artists that have made a cultural mark worldwide: need I say more than John Wayne or Judy Garland? Another capstone to a productive year is the end of the 20th year post the publication of To Err in Human. The widely influential 1999 US publication showed us how to fight for patient safety – our Tara. It outlined approaches to address the seemingly reoccurring tornadoes in healthcare built to instead point toward home – a safe health system.
Scarlett’s tenacity, her force of personal will and sustained belief in Tara is what pulled her through the maelstroms of civil war Georgia. Clinicians, however, cannot rely on grit and willpower alone to address clinical and organisational threats to safety. The lack of control to minimise systemic pressures on their moral imperative to do a job well in non-supportive situations reduces a clinician’s ability to practice safely. Building on the To Err is Human legacy, The US National Academy of Medicine (NAM) is committed to understanding factors that contribute to unsafe care. A NAM recent report on burnout lays out a system-focus strategy for organisations to reduce conditions that degrade physician health and, thus, safe practice.
Dorothy’s quest to return home energised her instead to engage a multidisciplinary team. The skills of Scarecrow, Tin Man, Cowardly Lion and, yes, even Toto got them through the forest to safety. Without their individual commitment to the mission, humanness and competence the team would have never gotten to Oz. The American Association of Medical Colleges (AMMC) recently released a set of competencies expected in physicians to support quality practice. By suggesting what educators embed in their training efforts, the AAMC helps ensure learning opportunities that build competencies are embedded in programmes on the yellow brick road to safe care provision.
Transparency helps us to see situations as they really are. Peaking behind the curtain enables exploration that, if used appropriately, can drive improvement. Toto pulled back the curtain to expose a threat that, once clarified, launched a collaboration that got Dorothy back to Kansas. The US-based Leapfrog Group has also forged a partnership to look behind the curtain. The latest release of the Hospital Safety Score data has focused attention on what isn’t working to support safety while celebrating hospitals that demonstrate sustained safety and quality. The scores track weaknesses in hand hygiene, infection control, and patient falls as elements of whether a hospital is safe.
There have been challenges: wicked witches, budget constraints, refusal to accept change and conflicts. It has not been an easy road to Tara since Err is Human was released. Experts in the field have shared their dismay in the lack of progress. Yet stories of resilience, partnership and teamwork continue to motivate the resolve of Dorothy and Scarlett to keep going.
Goal-focused efforts can backfire and not live up to their expected purpose. The South didn’t win the Civil war though they believed it was their destiny to do so. Scarlett never won back Ashely no matter how hard she tried. A recent article published in Health Affairs highlights the lack of correlation between the US Medicare and Medicaid programme reimbursement initiative and direct impact on patient safety in the state of Michigan. Its impact is questionable—which for a large-scale solution embedded throughout the system—is humbling.
Questionable actions can be a human reaction to stress that needs to be called out and managed to reduce their presence and impact. While centering her as a force for action, Scarlett’s spoiled and selfish behaviour also destroyed her most meaningful relationship. Such destructive behaviours degrade relationships needed for the safety of care. A large US study published in NEJM found that harassment and inappropriate behaviours effect one-third of general surgery residents surveyed, particularly women. The mistreatment and bias generated by both patients/families and medical team members were identified as a key factor in burnout and physician suicide.
The stories from great films of 1939 illustrate the power of grit, resolve, focus and leadership as elements of achievement. They share with us memorable characters that live with us long after the movie theatre lights come up. Through the embodiment of the tenacity of Scarlett and the team-focus of Dorothy we can and will work through the known barriers to reduce patient harm due to medical care. We have not yet arrived at Tara, but we continue to work tomorrow toward getting over the rainbow.