Case Studies

Why Rules Strengthen the System

Virginia Mason Hospital is an award winning healthcare system located in Seattle, Washington. They have been recognized as one of the safest hospitals in America for 12 consecutive years.

One of the legendary stories that has help build this culture is recounted by Charles Kenny, in his book, Transforming Health Care Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience.

A nurse was ready to begin chemotherapy for a cancer patient. However, she noticed that two required tests had not yet been done but was over ridden by the physician who directed her to proceed. She could have done as instructed OR what she thought was in the best interest of the patient. Electing to go with the patient, she called the Chief of Cancer Services who in turn called the physician and told him the nurse was correct. Furious, the physician let loose on the nurse, verbally abusing her. She again called the Chief of Cancer Services who pulled a Patient Safety Alert (PSA). It is the equivalent of a worker in a Toyota automotive plant pulling a cord to stop the entire production line so an error does not get passed on. The Chief of Cancer Services again called the physician, told him his conduct was unprofessional, abusive to the nurse & violating the value of respect and that he would be taken off line until there was a formal investigation. Behaviors are important at Virginia Mason. This was a lesson to anyone verbally abusing a worker for doing the right thing, disrespect will not be tolerated.