Please mess with Texas

When I was a Labor & Delivery nurse, and long before I had a better conceptual framework for understanding quality in healthcare, I learned two words that summed up what families valued during their childbirth experiences: "safe" and "satisfying." While these weren't all-inclusive quality markers, they're foundational elements that signaled quality. They still do.

"Satisfying" is a concept that belongs to individuals. The way pain is relieved, how much restoration of function is enough, what a good birth, or a peaceful death look like are outcomes subject to interpretation, outcomes rightly defined by individuals. So long as they're competent to make decisions and their choices don't interfere with others, consumers should own "satisfying."

On the other hand, "safe" can't venture far in territory that's defined by the perception of individuals. Here's one reason why: Each of us is a statistical sample of one. A good outcome may arise because the people and processes effecting the experience are fit, robust, and reliable. In a word, safe. It's also plausible that one good outcome represents a lucky spin of a very damaged wheel. When comparative processes are absent, one outcome tells little about safety. This is why licensing, professional standards, regulatory oversight, benchmarking, quality metrics, error analysis, and peer-review processes are deeply rooted in industries that post excellent safety records. Measures like these unearth information from a variety of sources, revealing data not readily apparent to individual consumers.

Quality assurance processes are far less perfect in healthcare than they are in other high-stakes, high-consequence industries. In the US, over 100,000 people die each year as a result of medical error and healthcare acquired infections, adverse events that cost billions and rob citizens of peace when they are most vulnerable. In healthcare, we're struggling to align individual competency, personal accountability, and good design in a way that's more reliable, better able to deliver the predicted outcome, and, well, safer than it currently is.

Which is why a case in Texas, in which two registered nurses face felony charges for good-faith actions aimed at protecting patients, should concern you. The nurses, both employed at a county hospital, reported concerns about a physician's practice to the Texas Medical Board. Their report included numbers (but not names of patients) that medical board officials would need to identify medical records for review. As a result, both nurses:

• were charged with "misusing official information" (criminal charges arising from the act of disclosing medical record numbers to the Texas Medical Board)
• were fired from their jobs
• face $10,000 fines and up to ten years imprisonment, if convicted

Let me be clear here: A nurse's report of concern about a physician's practice does not constitute a professional sanction. Reports of concern are pieces of data, not judgments. In a healthy system, reports of concern about licensed professionals result in peer-review. In a sick system, reports of concern result in acts that punish those who raise them (and intimidate those who might consider raising similar concerns in the future).

One of the biggest challenges to healthcare safety and quality is under-appreciation and under-reporting of things that have the potential to cause harm. Healthcare is a "no harm, no foul" game, and playing by these rules means we often miss the chance to fix a known problem before actual harm occurs.

In a culture where safety is valued, people who report things that are outside of perceived norms are highly valuable players. But in Winkler County, Texas, they could be criminals.

You can read more about this case, the charges, and contribute to the nurses' legal defense fund, set up by the Texas Nurses' Association, by clicking here.