“Jaded Julie, if you were going technical mountain or rock climbing out in the Rockies or down at Devil’s Lake, this is the advice that I would give you: ‘Climb on good rock, with good equipment, and with good people.’”
“That sounds like excellent advice, Curmudge, but why are you giving it and what does it have to do with health care?”
“If you are climbing, I want you to be protected against misfortunes that might befall you (no pun intended) that are no fault of your own. The same should hold true for health care. If I am experiencing anything from a simple injection to major surgery, I want it done according to an evidence-based protocol, and by a person who is well trained, has done the procedure hundreds of times, and is not distracted by the hospital surroundings or problems at home.”
“I’ve got it, Curmudge. It’s our job to protect our patients against errors just like it’s the climbing guide’s job to protect his clients against falls. In health care we’ve got to do it right the first time every time; in climbing the first false step may be a long way down.”
“We’ve already laid the foundation for our discussion and talked about the importance of having a culture that allows one to report errors safely. It’s time now to consider some specific threats to patient safety.”
“This ought to be old stuff to most everyone working in patient care. Is there really any value in our taking time to talk about this?”
“Consider this, Julie. Would you prefer to be cared for by someone who is completely up to date on safe practices or one who reads this blog and says, ‘I didn’t know about that.’? We want to get inside the head of anybody who is even the slightest bit uninformed.”
“Okay, Curmudge, let’s do it. Where do we start?”
“Let’s begin with AHRQ’s 20 Tips to Help Prevent Medical Errors (1). A medical error is when something planned as a part of medical care doesn’t work out, or when the wrong plan was used in the first place. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports. Sometimes errors can occur when doctors and their patients have problems communicating. LucidMED (2) is an example of new technology that can reduce communication problems. The 20 tips cover such things as medicines, hospital stays, surgery, and other topics. AHRQ (Agency for Healthcare Research and Quality) says that the single best way a patient can help to prevent errors is to be an active member of his/her health care team.”
“That sounds like something that everyone should read. All that is required is a computer connected to the Web.”
“Here are some other topics that patients as well as caregivers should have in mind:
· Accurate patient identification
· Labeling and administration of medications
· Reconciled medications across the continuum of care
· Effective communication among caregivers
· Reduced health care-associated infections
· Reduced risks of patient injury from falls.”
“I presume that we’ll talk more about some of these in the coming weeks. But Curmudge, how can you, a retired chemist, hope to tell anyone in health care about patient safety?”
“It’s pretty simple, Julie. I read, write, and tell other people where to find the information. As long as I have your help, it’s an easy job even for a curmudgeon.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ahrq.gov/consumer/20tips.htm
(2)http://www.lucidmed.com
Tuesday, December 30, 2008
Thursday, December 18, 2008
Holiday Greetings from Curmudge and Jaded Julie
“Julie, last year you really dumped on me when I wished our readers a Merry Christmas. I thought it was safe to use that greeting in any hospital with a name like St. Elizabeth, St. Mary’s, or St. Whatever.”
“Nope, Curmudge. These days one must be politically correct everywhere. So how are we going to handle our greetings in a way that is, as you would say it, innocuous?”
“Let’s try this. Major holidays, as celebrated by most religions, heritages, and ethnic groups, have several elements in common. Things like religious observances, festive meals, days off work, and family gatherings. Let’s consider family gatherings and focus our concerns and best wishes on those people who can’t attend. For those folks, any holiday must be a real bummer.”
“Great idea, Curmudge. People like nurses in the patient care units, physicians in the ED, and flight crews on airplanes.”
“My presumption is that the nurses and others will simply defer their family celebration until their shift is over. That may be an inconvenience, but the problem shouldn’t be insurmountable. Things will be much sadder for those who can’t just wait a few hours until their schedule allows them to be home.”
“Of course. Hospital inpatients and members of the military who are deployed in far-away lands. At least the patients will probably have family visits, and the service people will call home. It is certainly worse for the people on the streets who are homeless or whose home doesn’t want them. Also among the homeless are the survivors of earthquakes and civil wars. Then there are those whose physical or emotional state prevents their even remembering what home was, but it is unlikely that they will even be aware that a holiday is occurring.”
“That’s quite a list, Julie. What is celebratory to most people ranges from an inconvenience to abject misery for others.”
“What can we do, Curmudge? You initiated this topic; I hope you have some ideas.”
“Your mission Julie, if you choose to accept it, is to bring a bit of light to the dark side of the human condition. It’s hard to make much of an impact as an individual, although the Good Samaritan gained quite a reputation for his efforts. There are lots of charities—religious or secular and from local to international—who would love to have your financial support or service as a volunteer. Political correctness prevents my making a specific recommendation.”
“Good thought, Curmudge. I’ll put serving as a volunteer in my New Years resolutions. Maybe my efforts will help someone get home for his or her special holiday. If they can’t get home, perhaps they can feel more at home wherever they are.”
“You’ve got it, Julie. You’ve got the real Christmas…oops, holiday spirit.”
“Happy Holidays, Curmudge.”
“Merry Christmas, Julie.”
Affinity’s Kaizen Curmudgeon
“Nope, Curmudge. These days one must be politically correct everywhere. So how are we going to handle our greetings in a way that is, as you would say it, innocuous?”
“Let’s try this. Major holidays, as celebrated by most religions, heritages, and ethnic groups, have several elements in common. Things like religious observances, festive meals, days off work, and family gatherings. Let’s consider family gatherings and focus our concerns and best wishes on those people who can’t attend. For those folks, any holiday must be a real bummer.”
“Great idea, Curmudge. People like nurses in the patient care units, physicians in the ED, and flight crews on airplanes.”
“My presumption is that the nurses and others will simply defer their family celebration until their shift is over. That may be an inconvenience, but the problem shouldn’t be insurmountable. Things will be much sadder for those who can’t just wait a few hours until their schedule allows them to be home.”
“Of course. Hospital inpatients and members of the military who are deployed in far-away lands. At least the patients will probably have family visits, and the service people will call home. It is certainly worse for the people on the streets who are homeless or whose home doesn’t want them. Also among the homeless are the survivors of earthquakes and civil wars. Then there are those whose physical or emotional state prevents their even remembering what home was, but it is unlikely that they will even be aware that a holiday is occurring.”
“That’s quite a list, Julie. What is celebratory to most people ranges from an inconvenience to abject misery for others.”
“What can we do, Curmudge? You initiated this topic; I hope you have some ideas.”
“Your mission Julie, if you choose to accept it, is to bring a bit of light to the dark side of the human condition. It’s hard to make much of an impact as an individual, although the Good Samaritan gained quite a reputation for his efforts. There are lots of charities—religious or secular and from local to international—who would love to have your financial support or service as a volunteer. Political correctness prevents my making a specific recommendation.”
“Good thought, Curmudge. I’ll put serving as a volunteer in my New Years resolutions. Maybe my efforts will help someone get home for his or her special holiday. If they can’t get home, perhaps they can feel more at home wherever they are.”
“You’ve got it, Julie. You’ve got the real Christmas…oops, holiday spirit.”
“Happy Holidays, Curmudge.”
“Merry Christmas, Julie.”
Affinity’s Kaizen Curmudgeon
Thursday, December 11, 2008
Patient Safety Requires a Reporting Culture
“Let’s see, Curmudge, there’s a Lean Culture, a Safety Culture, a Just Culture, a Learning Culture, and even a culture we don’t want, a Punitive Culture. We’ve got more cultures than a microbiology lab.”
“Think of the Learning Culture as supporting the other cultures, Jaded Julie. All of the other ‘good’ cultures require us to learn continually how to make our activities safer and more effective and efficient. We must ‘routinely capture data on processes to discover how work really happens.’ This practice forms the basis of a ‘learning infrastructure that makes continual learning part of business as usual.’ (1) Without a Reporting Culture, the Learning Culture can’t function, and the other cultures are in jeopardy.”
“And in a hospital we need blame-free reporting so we can find and correct systemic problems—if that’s what they are—before they turn into something more serious.”
“Good point, Julie, and it’s well known in industry. Heinrich’s Law on Safety says that for every 330 industrial accidents, one may be serious. (2) Heinrich said that to avoid that one serious event, the minor and no-damage accidents should be reduced. Mark Graban teaches the same lesson using the Alcoa safety pyramid, in which there are 30,000 unsafe behaviors per 3,000 first-aid accidents or near misses for each fatality. (3) One cannot obtain these data or conduct an effective safety program without the organization’s having a reporting culture.”
“Golly, Curmudge, is this another instance—like Lean—where health care is lagging industry in finding better ways to do what needs to be done?”
“Regrettably true, Julie, but I think we are finally getting our act together. The University of Nebraska Medical Center has collected a lot of information, all on the same website, about engineering a reporting culture, a just culture, a flexible culture, and a learning culture. (4) Their PowerPoint presentation on Reporting Systems as the Foundation of Patient Safety Programs is especially informative. In it they quote Dr. Lucian Leape’s list of characteristics of successful reporting systems:
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive”
“Those headings look valuable. I’ll bet there’s good information behind them.”
“There is, Julie, but you’ll have to go to the web to read it. Remember that this is a blog and not a textbook.”
“Curmudge, I don’t want to wreck your day by bailing out now, so I’d better ask if there is any more info about a reporting culture that we need to mention.”
“One very import thing, and it’s from our friends at IHI. It’s an example of a non-punitive reporting policy from Wentworth-Douglass Hospital in Dover, New Hampshire (5) The document looks like an excellent model that captures much of what we have discussed about a just culture.”
“I can’t wait to read it. See you soon.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ncbi.nlm.nih.gov/pubmed/18681298
(2) Imai, M. Gemba Kaizen. p. 274, McGraw-Hill 1997.
(3) Graban, M. Lean Hospitals. p. 133, CRC Press 2008.
(4)http://www.unmc.edu/rural/patient-safety/tools/Inventory.htm
(5)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Non-Punitive+Reporting+Policy+Wentworth+Douglass.htm
“Think of the Learning Culture as supporting the other cultures, Jaded Julie. All of the other ‘good’ cultures require us to learn continually how to make our activities safer and more effective and efficient. We must ‘routinely capture data on processes to discover how work really happens.’ This practice forms the basis of a ‘learning infrastructure that makes continual learning part of business as usual.’ (1) Without a Reporting Culture, the Learning Culture can’t function, and the other cultures are in jeopardy.”
“And in a hospital we need blame-free reporting so we can find and correct systemic problems—if that’s what they are—before they turn into something more serious.”
“Good point, Julie, and it’s well known in industry. Heinrich’s Law on Safety says that for every 330 industrial accidents, one may be serious. (2) Heinrich said that to avoid that one serious event, the minor and no-damage accidents should be reduced. Mark Graban teaches the same lesson using the Alcoa safety pyramid, in which there are 30,000 unsafe behaviors per 3,000 first-aid accidents or near misses for each fatality. (3) One cannot obtain these data or conduct an effective safety program without the organization’s having a reporting culture.”
“Golly, Curmudge, is this another instance—like Lean—where health care is lagging industry in finding better ways to do what needs to be done?”
“Regrettably true, Julie, but I think we are finally getting our act together. The University of Nebraska Medical Center has collected a lot of information, all on the same website, about engineering a reporting culture, a just culture, a flexible culture, and a learning culture. (4) Their PowerPoint presentation on Reporting Systems as the Foundation of Patient Safety Programs is especially informative. In it they quote Dr. Lucian Leape’s list of characteristics of successful reporting systems:
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive”
“Those headings look valuable. I’ll bet there’s good information behind them.”
“There is, Julie, but you’ll have to go to the web to read it. Remember that this is a blog and not a textbook.”
“Curmudge, I don’t want to wreck your day by bailing out now, so I’d better ask if there is any more info about a reporting culture that we need to mention.”
“One very import thing, and it’s from our friends at IHI. It’s an example of a non-punitive reporting policy from Wentworth-Douglass Hospital in Dover, New Hampshire (5) The document looks like an excellent model that captures much of what we have discussed about a just culture.”
“I can’t wait to read it. See you soon.”
Affinity’s Kaizen Curmudgeon
(1)http://www.ncbi.nlm.nih.gov/pubmed/18681298
(2) Imai, M. Gemba Kaizen. p. 274, McGraw-Hill 1997.
(3) Graban, M. Lean Hospitals. p. 133, CRC Press 2008.
(4)http://www.unmc.edu/rural/patient-safety/tools/Inventory.htm
(5)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Non-Punitive+Reporting+Policy+Wentworth+Douglass.htm
Thursday, December 4, 2008
Implementing a Culture of Safety
“Curmudge, I have the feeling that we’ve been here before.”
“We have, Jaded Julie. Same church but a different pew. We spent much of April and May of 2008 talking about change leadership. Our goal then was changing from an existing culture to a Lean culture. Now we want to change from a punitive culture to a just culture. Each type of change requires many of the same tools, starting with the dedicated and active support of the organization’s top management. As we said back in April, he or she should follow the guidance provided in John Kotter’s book, Change Leadership. Although one element of Kotter’s ‘Eight-Stage Process of Creating Major Change’ is to establish a sense of urgency, one shouldn’t wait for a sentinel event to initiate the change.”
“I just read Leanne Huminski’s ‘Eight Steps to Creating a Culture of Safety.’(1) Let’s list them and see how similar they are to Kotter’s. Note that the order of Huminski’s list has been changed to fit Kotter’s order.”
Huminski, 2008
· Develop a sense of urgency
· Involve leaders in the process
· Develop a vision
· Communicate the change vision
· Engage and empower the staff
· Realize it can’t happen overnight
· Test new ideas before full rollout
· Be alert for sabotage and workarounds
Kotter, 1996
· Establish a sense of urgency
· Create a guiding coalition
· Develop a vision and strategy
· Communicate the change vision
· Empower broad-based action
· Generate short-term wins
· Consolidate gains and produce more change
· Anchor new approaches in the culture
“It’s pretty clear, Julie, that Kotter’s recommendations apply to implementing all
sorts of changes, including a culture of safety. However, one must realize that if
an organization doesn’t develop a reporting culture, their culture of safety will never get off the ground.”
“Curmudge, two weeks ago you said that the ‘blame game,’ or hiding one’s errors, is the natural thing to do. I guess that means that reporting errors is unnatural. It should be evident to any mom that instilling a reporting culture is not too different from toilet training. People have to learn that doing the right thing often requires doing something that is not natural, just like when they were little kids. Remember? We discussed this back on May 8, 2008.”
“Of course I do. Error reporting is intimidating to employees just like the big porcelain toilet may be scary to a child. In both cases, they are fearful of being flushed.”
“I’ve got the solution, Curmudge. It’s trust. If the child trusts her mommy when she says that everything is okay, the problem should go away. And when employees trust their employer and their colleagues, error reporting should become less unnatural. Of course, mothers have a better reputation for trustworthiness than organizations.”
“That’s right, Julie. A reporting culture requires that trust exist among and between the organization’s people from the very top all the way to gemba. People must be able to trust that they will be treated fairly if they report an error. We’ll talk more about this next time. I trust you’ll be here.”
“I might bring the kids. They’ll learn how they help Mom teach about change.”
Affinity’s Kaizen Curmudgeon
(1)http://blog.hin.com/?p=391
“We have, Jaded Julie. Same church but a different pew. We spent much of April and May of 2008 talking about change leadership. Our goal then was changing from an existing culture to a Lean culture. Now we want to change from a punitive culture to a just culture. Each type of change requires many of the same tools, starting with the dedicated and active support of the organization’s top management. As we said back in April, he or she should follow the guidance provided in John Kotter’s book, Change Leadership. Although one element of Kotter’s ‘Eight-Stage Process of Creating Major Change’ is to establish a sense of urgency, one shouldn’t wait for a sentinel event to initiate the change.”
“I just read Leanne Huminski’s ‘Eight Steps to Creating a Culture of Safety.’(1) Let’s list them and see how similar they are to Kotter’s. Note that the order of Huminski’s list has been changed to fit Kotter’s order.”
Huminski, 2008
· Develop a sense of urgency
· Involve leaders in the process
· Develop a vision
· Communicate the change vision
· Engage and empower the staff
· Realize it can’t happen overnight
· Test new ideas before full rollout
· Be alert for sabotage and workarounds
Kotter, 1996
· Establish a sense of urgency
· Create a guiding coalition
· Develop a vision and strategy
· Communicate the change vision
· Empower broad-based action
· Generate short-term wins
· Consolidate gains and produce more change
· Anchor new approaches in the culture
“It’s pretty clear, Julie, that Kotter’s recommendations apply to implementing all
sorts of changes, including a culture of safety. However, one must realize that if
an organization doesn’t develop a reporting culture, their culture of safety will never get off the ground.”
“Curmudge, two weeks ago you said that the ‘blame game,’ or hiding one’s errors, is the natural thing to do. I guess that means that reporting errors is unnatural. It should be evident to any mom that instilling a reporting culture is not too different from toilet training. People have to learn that doing the right thing often requires doing something that is not natural, just like when they were little kids. Remember? We discussed this back on May 8, 2008.”
“Of course I do. Error reporting is intimidating to employees just like the big porcelain toilet may be scary to a child. In both cases, they are fearful of being flushed.”
“I’ve got the solution, Curmudge. It’s trust. If the child trusts her mommy when she says that everything is okay, the problem should go away. And when employees trust their employer and their colleagues, error reporting should become less unnatural. Of course, mothers have a better reputation for trustworthiness than organizations.”
“That’s right, Julie. A reporting culture requires that trust exist among and between the organization’s people from the very top all the way to gemba. People must be able to trust that they will be treated fairly if they report an error. We’ll talk more about this next time. I trust you’ll be here.”
“I might bring the kids. They’ll learn how they help Mom teach about change.”
Affinity’s Kaizen Curmudgeon
(1)http://blog.hin.com/?p=391
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