“Help, I Need a Bureaucrat!” A Healthcare Comedy.

“Oh my, are you bleeding?” The nurse stood with her hands on her hips, assessing the situation.

“Well, yes. I think so,” the patient replied. “I tried pressing the call button, but I didn’t know which bureaucrat could help with this.”

“What’s going on in here?” It was the doctor.

“Well, sir, the patient does not know how to use his bureaucracy call buttons,” the nurse explained.

“Is it a billing issue? Lots of people have billing issues.”

“Oh, I know. But I think this might be a diagnostic question.”

“Really?” The doctor‘s eyebrows raised. “Well, I’d like to help with that. Go ahead and call the diagnostic coding bureaucrats and let me know what they say.”

“Excuse me, Doctor?” The patient raised his hand. “I’m not feeling quite right. Look, I’m bleeding.”

“I see what you mean.” The doctor nodded seriously. “Nurse, go ahead and loop in the supply-side bureaucrats with a request for bandages.”

The nurse sighed. “Yes, but you can see the blood there, and he’s quite pale, so maybe this once we could just treat the patient?”

“And put both our licenses on the line? That reminds me, we’ll need to get a pre-authorization from the insurance bureaucrat for treatment approval.”

“Well, I’ve tried pushing all the buttons you mentioned, but no one seems to be answering,” the patient whispered weakly. “Maybe they’re not working the way they should?”

“Nurse,” the doctor said resolutely. “Please call the equipment and technical bureaucrat to check into this matter. We need to get these buttons fixed!”

“Ah, which button is that?” The nurse looked at the tangled mess of buttons, confused.

“I’m feeling … quite … dizzy …” The patient swooned.

“Not again!” The doctor threw up his hands. “Get a legal bureaucrat in here to check for DNRs and power of attorney paperwork. STAT!”

How often does your job feel like this comedy sketch? I don’t know about you, but there are times when I felt like the weight of bureaucracy stuck to me like cement boots. Nurses spend hours on the phone and computer instead of with patients. Physicians are frustrated because they feel like telephone operators, forced to refer questions to various bureaucratic agencies before doing anything for the patient sitting in front of them: They trained in medical school to assess patients and make autonomous decisions, but their hands are tied by financial and regulatory chains. Patients are so confused by the regulations and fine print they often opt to avoid medical care than face the dark, endless tunnel of bureaucracy.

But laws, regulations, and facility policies are for the best, right? They’re just trying to help us do our jobs and keep patients safe.

But do they work?

Author and patient safety advocate Michael Millenson points out in Forbes that several decades of effort to reduce harm to patients and improve patient safety has not improved our harm and risk rates.[1] With lofty goals of eradicating errors, the rate of harm is virtually the same, maybe even worse (2022 was a record year for patient harm).[2]

Another article, Who killed patient safety? asserts that issues in equity, urgency, and commitment are lacking in U.S. healthcare.[3] To some extent, this is true, simply because other demands are louder and more costly. But the various bureaucracies also issue repeated and urgent commitments to zero harm for every patient with a published deadline, so can we really say that ignoring these issues is the root cause of patient harm? However, the article also points out that patient engagement is largely absent. And how could it not be when the patient is lost in obscure regulatory language, distant bureaucratic decision-makers, and political oversight of clinical decisions?

Why do healthcare bureaucracies keep failing to help patients?  

One reason is that each time we fail to produce the desired results, an action plan is needed to show that we are actively working to achieve perfection. But the answer often proves too complex, so we’re forced to study the problem and open a new position for another bureaucrat to monitor the situation and provide recommendations. Then when their action plan is due the next year because the problem proved too complicated, they recommend hiring someone else. And so, the list of bureaucratic bloat expands with each unrealistic goal, and the patient is still left out in the cold.

If you’re not sure whether that’s true, please review the latest statement from your favorite safety or quality organization. How many of the recommended interventions revolve around councils, new officers, and other policy-based bureaucracies? In contrast, how many provide practical tools to measurably improve patient care?

This is my point.

In the quality cycle, when the outcome does not improve despite our interventions, we begin asking whether the problem statement was ever right in the first place. Surely, there is some other cause that we have not yet discovered and addressed. When will we use our own quality standards and admit that we missed the root cause of patient harm?

Patient safety doesn’t need another bureaucrat; patient safety needs a philosophical overhaul.

Otherwise, we are sitting in a surgical theater of bureaucracy, watching our patients bleed out on the table while we discuss who to pull from patient care to chase the paper trails, repeat the same mistakes, and perhaps make things worse.

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[1] Millenson, M.L. (Nov. 17, 2022). Address ‘Plane-Crash Level’ Patient Harm, HHS Tells Hospitals, As Political Currents Swirl. Forbes. Retrieved Aug. 28, 2022, from https://www.forbes.com/sites/michaelmillenson/2022/11/17/address-plane-crash-level-patient-harm-hhs-tells-hospitals-as-political-current-swirl/.

[2] Devereaux, M. (April 4, 2023). Reports of serious adverse events rose in 2022: Joint Commission. Modern Healthcare. Retrieved Aug. 28, 2022, from https://www.modernhealthcare.com/safety-quality/joint-commission-data-hosital-falls-2022-surgeries.

[3] Hemmelgarn, C.; Hatlie, M.; Sheridan, S.; Daley Ullem, B. (May 5, 2022). Who killed patient safety? Journal of Patient Safety and Risk Management, 27(2): 56-58. Retrieved Aug. 28, 2022, from https://journals.sagepub.com/doi/full/10.1177/25160435221077778.