What Joe Paterno Could Have Learned About Disclosure from Health Care

Submitted by Steven Lewis on November 11, 2011 - 13:44

Steven Lewis, President
Access Consulting Ltd., Saskatoon SK Canada

Happy Valley it ain't. 

Penn State University is aflame, its President, two senior officials, and sainted football coach Joe Paterno out the door after 46 years. A former assistant coach, Jerry Sandusky, is under indictment for multiple sexual assaults against young boys over a 15 year period. Each new piece of evidence confirms that any number of people could have stepped in years ago. On being told an eyewitness account of the  sodomization of a ten year old boy in the showers of a Penn State facility - where Sandusky maintained an office long after retiring - Paterno notified his campus superiors (absent the gruesome details) and did nothing more. No going to the police; no search for corroborating evidence; no updates; no making Sandusky look him in the eye and deny.

He was told in 2002. Now, he tells us, he is devastated, and grieves for the victims. Two university officials are charged with perjury. There will be civil suits and millions paid out in damages. The Nittany Lions football program takes in $50 million a year. No wonder the damage control operation is at full throttle.

Irony doesn't begin to describe it. Paterno championed a culture that (so far as we know) tolerated none of the tawdry ethical violations that dog big-time NCAA football programs. It’s not like they were choir boys: between 2002 and 2008, 27 players garnered 45 criminal convictions. But on the playing field, Penn State won often and won clean. Other programs produce glamorous quarterbacks; Penn State is Linebacker U. It was a badge of honour – a sacred trust – to adhere to the NCAA rules: don't you dare give my players free concert tickets. Ex-coaches raping little boys? Not our territory - you deal with it.

Here we have a series of adverse events, to put it mildly. They are criminal acts, which makes them different from 99.999% of adverse events in health care. But the adverse events of interest here are not the crimes themselves, but the shared failure to respond. Not wanting to know, not wanting to tell, not wanting to call to account - that's the Penn State story. Too often it has been the story in health care. Are things different now?

What happened at Penn State sounds a lot like what happened to the children under the care of the Bristol Infirmary or the Winnipeg pediatric cardiology program. People knew that substandard health care was killing and maiming kids. There were lapses in judgment and in communication. Hierarchies resisted challenge and there was too much unearned deference to authority. Systems were ill-designed to detect early signs of trouble. Good people who could have acted earlier felt disempowered. Organizational peace trumped concern for the victims. The worst of all possible sins was a false-positive allegation.

Thanks to enlightened leaders, crusading patient advocates, and the insights of the quality improvement movement, there are a lot fewer Penn States in health care than there used to be. Health care has belatedly recognized that the way to earn public trust is to tell the truth, admit mistakes, apologize, and make things right. It's the same on the inside. If your employees and staff trust their leaders and each other, they will embrace a culture of disclosure, report near misses, and value errors as learning opportunities.  No name, no blame, no shame. Just improve. That's the deal.

But it's a hard deal to live up to. There is an irreducible tension between withholding the lash in service of quality improvement and the very human desire to call individuals to account. It sounds Orwellian to be told that your loved one died because of "system error" - even if it's true. The best-designed systems try to take human variability out of the picture almost entirely. That's why aviation is so safe and why OR teams that use a surgical checklist outperform the most conscientious teams that don't.

You shouldn't have to create protocols for decency, but there's nothing like the advice of lawyers to scramble the signals of an active conscience. Insurers instructed doctors not to apologize to patients they had harmed because apology implies guilt which creates liability. Patients and their families faced a wall of maddening obfuscation. It took decades to pass legislation - legislation! - that allowed people to say they were sorry. Only a few wise organizations had already understood that telling patients the truth reduced the likelihood of being sued.

I suspect something more elemental explains much of the tragic delay in coming to terms with hard realities. Our moral compass can spin wildly out of control in unfamiliar terrain. The usual defence mechanisms take over: denial of the unthinkable, the instinct to flee, the hope that others will fix it. The longer the silence, the harder it is to come forward because of the added guilt imposed by the rising number of avoidable victims. Finally, inevitably, the evidence overwhelms the protective psychological levee. The reckoning is long, hard, and costly for all involved.

There are moral failings to be sure in these cases, but humans fail morally all the time. More vexing is the failure of curiosity. Why didn't Paterno want to get to the bottom of the allegations about someone he had trusted for decades? Why didn’t the graduate assistant who told Paterno what he’d seen – now the receivers coach – follow up on what had become of his revelation? And on purely self-interested grounds, how could senior Penn State officials calculate that a cover-up was a sound risk management strategy?

I’d like to think the CEOs of big-time health care organizations would do better than Paterno if faced with a similar situation. And I’d like to think Paterno would have done the right thing had he ventured outside the adulatory bubble to hear from people whose harm was compounded by powerful people who chose to do nothing.




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