The Executive Suite: Broken windows: A metaphor for fixing problems

Neil Baum, MD

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I recall how New York City adopted a "broken windows theory" to reduce crime in New York City." The theory argues that neighborhood disorder creates fear and gives out crime-promoting signals. According to the idea, targeting minor problems, such as vandalism on walls, litter on sidewalks, or broken windows in abandoned buildings, will prevent more serious crimes from occurring. Consider a building with a few broken windows. If the windows are not repaired, the tendency is for vandals to break a few more windows. Eventually, they may even break into the building, and if it's unoccupied, this may invite squatters or light fires inside.

Fixing the broken windows coincided with a significant decrease in crime in New York City. The New York City Police Department implemented a "zero-tolerance" policy for policing petty crimes based on this concept. (Gau, J. M. (2010). Wilson, James Q., and George L. Kelling: Broken Windows Theory. In F. T. Cullen & P. Wilcox (Eds.), Encyclopedia of Criminological Theory (Vol. 2, pp. 1018-1022). Thousand Oaks, CA: SAGE Reference.)

The question that deserves discussion is, "What does that possibly have to do with healthcare?"

What does a patient think when they enter a restroom in your office that has paper towels overflowing the wastebasket, urine specimen cups scattered in the sink or the back of the toilet, and no toilet paper? You can assume that they won't have a favorable impression of the practice when they see the condition of your sloppy restroom. On one occasion in the late afternoon of a clinic day, I walked by the bathroom and saw the situation as I described, and I gathered the staff asked them, "How many of you would avoid using this restroom?" The staff was unanimous that they wouldn't avail themselves of the restroom in that condition. I told them that the cleanliness of the bathroom would be the first topic at the next staff meeting. We talked about the situation at the staff meeting and agreed that the restroom is checked multiple times during the day. First, before patient arrival at 8:45. Then checked again at 12:45 before the afternoon patients and finally mid-afternoon. That routine makes sure that the restroom is always clean and tidy throughout the day. The afternoon patients deserved a clean restroom just like the first patient of the day. That was a "broken window" in our office that needed repair.

How many of our offices were painted or wall-papered 10-15+ years ago and have paint peeling off the wall or are scuffed when the chair backs rub against the walls in the reception area or the exam rooms? I suggest you take a careful look at the condition of the walls in these areas and take action if they need painting or papering. Your wall coverings also reflect the hygiene you practice with your patients.

The carpeting in your reception area and the hallways frequently needs replacing. (You might consider a no eating policy in the reception area and the exam rooms to avoid food, wrappers, and paper bags left in these areas.) Stains on your carpeting should be cleaned or replaced if necessary.

Have you taken the time to look at the wall coverings in your reception area or exam room? These areas are barren or have photos and posters that are not interesting or don't pertain to your practice. You need to look at these areas from the patient's point of view and decide if what is on your walls would be of interest to your patients. If you have an exciting hobby, you might consider placing photos, posters, or paintings on the wall to discuss with your patients. Some SERMOans will state that with only 10-15 minutes for each patient, they don't have time to chat about stamp collecting or photographs from their travels. However, you will find patients interested in their doctors beyond their medical degrees. Even if these paintings don't generate conversation, placing examples on the wall is a plus for connecting you and your patients.

Next, check out the equipment in the exam rooms. Are the exam tables antiquated or have torn coverings, and do the sides need painting? Even if the table has disposable paper, you want to have working, clean, and repaired exam tables.

An overlooked broken window is the doctor's desk. On one occasion, I brought a patient into my office for a discussion, and the desk was full of papers. I had to search for several minutes to find the report related to the patient. I was embarrassed and recognized that this situation had to be remedied. I have frequently left papers, reports, and correspondence on my desk. These papers have overflowed the in- and out-boxes and made my desk look unkempt.

I am always impressed when I visit a doctor and see a clean desk with only one or two papers on the desk. Perhaps a clean desk represents a clean mind. As a result, I have made every effort to make my desk tidy with a minimum of clutter.

Decades ago, before the electronic prescribing of prescriptions from the EMR to the pharmacy, doctors wrote prescriptions and gave them to the patient to present to the pharmacist. Often, there was illegibility of the signature and handwriting.

Sometimes the doctor's signature is more like the signature of Salvador Dali or Pablo Picasso. I imagine that few of us have the fame of these artists and would do well to make their writing more legible. If this isn't reason enough to improve your handwriting, consider several examples of poor handwriting that led to giving patients the wrong medication, leading to complications. (Zhang, Y., Zerafa, N. M., & Attard Montalto, S. (2020). Student and doctors' handwriting and transcription skills: how great is the potential for medical error?.)

Bottom line: The concept of repairing broken windows helps avoid decay and solves problems in the office when they are small. When a window is broken or a problem is identified in our practices, then fix it immediately.

For more reading on broken windows, I suggest "Fixing Broken Windows: Restoring Order and Reducing Crime In Our Communities" by James Wilson and George Kelling