Imagine sitting in the front row of a National Transportation Safety Board inquiry following an airline crash where you have lost several loved ones. A reporter asks the chairman of the airline, "What was the cause of the crash?" The chairman begins to rattle off all of the causes for the disaster.

First, he says that his airline is understaffed. They are short of maintenance personnel to do the proper upkeep and they do not have adequate parts. The turnover rate of the staff makes it difficult to maintain the level of training they need. He also explains that with gasoline costs so high and revenue from ticket sales so low, the airline just cannot provide the level of quality that they would like.

He assures everyone that all of the airline's employees are dedicated, nice people and they are doing the best they can. He promises that they will try to do better, but we have to understand that this is the real world.

Excuses, Excuses

By now you probably know where this is leading: The excuses espoused by our fictitious airline chairman sound suspiciously like the ones we give when a patient develops a pressure ulcer.

The number of patients who develop pressure ulcers each year is still at a shameful level. I suspect that hundreds more people die each year from pressure ulcers than in airline crashes. Yet, which draws more attention?

The question, then, is what is the standard of care and who is making sure that it is maintained? Unfortunately, I do not think there is an answer.

Making a List

Because the present system clearly does not work, I propose a new approach to the standard of care for pressure ulcers. I would like everyone interested in pressure ulcer management-hospital and nursing home personnel, attorneys, legislators, and health care facility inspectors-to make a list of the excuses that would be deemed acceptable when a patient develops a Stage III or a Stage IV pressure ulcer. Make sure you think about your loved ones when you decide which excuses are legitimate.

Once we have all the possible excuses, we can create a National Pressure Ulcer Excuse List. This list would relieve anyone of any responsibility if a patient develops a pressure ulcer. Of course, if a health care provider offers an excuse that does not appear on the List, sanctions would be appropriate.

No Joking Matter

You may think that my tongue is planted firmly in my cheek, but I can assure you that like airline tragedies, pressure ulcers are nothing to joke about. Think about the quality and safety issues facing the airline industry for a moment. Then consider the health care industry. Are the issues any different? I would say not, yet the level of accountability in the 2 industries is miles apart.

What is the problem? Why do we accept less from our hospitals and nursing homes than we do from the airline industry? Why do we accept the large number of pressure ulcers that occur each year, even though we know that most pressure ulcers are preventable?

I would say that we get what we deserve, but the problem is that our patients are the real victims of our complacency. What will shake us out of it? Malpractice and litigation are not working. Education helps, but only for short periods of time.

A Carrot and a Stick

I have thought long and hard about this issue, and I think a carrot-and-stick approach is the answer. The "carrot" would be to eliminate all Certificate of Need applications and let a free market economy rule. Consumers would have the power to shop around and choose the facility where they and their loved ones would receive care. The best facilities-the ones with the lowest pressure ulcer rates-will survive. The worst-the ones that accept escalating pressure ulcer rates-will falter.

So what is the "stick" in this scenario? It has to be enforcement of the standard of care-with the full force of the penalties available-by the Centers for Medicare & Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations, and other regulatory bodies charged with this task.

We should expect that every licensed hospital and nursing home will meet the standard of care-which means we must place the same expectations on the health care industry as we do on the airlines. After all, it is the right thing to do.