Comments on: A Pharmacist’s Jail Cell Interview – What Good Does Blame Do? http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/ Mark Graban's leanblog.org - Lean Healthcare, Lean Thinking, Lean Manufacturing, Toyota Production System Fri, 10 Feb 2012 10:01:31 +0000 hourly 1 http://wordpress.org/?v=3.3.1 By: Questions about and Lessons from a Steering Wheel Falling Off — Lean Blog http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-20151 Questions about and Lessons from a Steering Wheel Falling Off — Lean Blog Wed, 13 Apr 2011 02:46:53 +0000 http://www.leanblog.org/?p=5117#comment-20151 [...] in healthcare, there’s still a tendency to wrongly look for “the idiot.” We often throw people in jail or ruin their careers. This approach probably does little to improve quality. In fact, the punitive [...] [...] in healthcare, there’s still a tendency to wrongly look for “the idiot.” We often throw people in jail or ruin their careers. This approach probably does little to improve quality. In fact, the punitive [...]

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]]> By: Richard Chapman http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-14289 Richard Chapman Mon, 29 Nov 2010 22:27:24 +0000 http://www.leanblog.org/?p=5117#comment-14289 In Australia we have too much medico- and pharmaco-fraud so there certainly are doctors and pharmacists who should be in jail. But certainly agree they should not be there for making mistakes of process. Having fee-for-service payments from government direct to providers is putting temptation in the way of too many people. We hear cases of gamblers stealing from the government because they've lost too much, doctors and pharmacists self-administering drugs of addiction or habit, buying holiday houses and yachts, and let's not start on the dubious 'conferences' and other lurks and perks. I'd sooner see government payments made direct to the beneficiary, with vouchers or other mechanisms from the beneficiary to the practitioner. In Australia we have too much medico- and pharmaco-fraud so there certainly are doctors and pharmacists who should be in jail. But certainly agree they should not be there for making mistakes of process.

Having fee-for-service payments from government direct to providers is putting temptation in the way of too many people.

We hear cases of gamblers stealing from the government because they’ve lost too much, doctors and pharmacists self-administering drugs of addiction or habit, buying holiday houses and yachts, and let’s not start on the dubious ‘conferences’ and other lurks and perks.

I’d sooner see government payments made direct to the beneficiary, with vouchers or other mechanisms from the beneficiary to the practitioner.

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]]> By: Mark Graban http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-14277 Mark Graban Mon, 29 Nov 2010 02:19:56 +0000 http://www.leanblog.org/?p=5117#comment-14277 Mina - thanks for your comment. I'm really sorry to hear that you're in such a stressful situation at your hospital. It does sound scary... I've read horror stories about retail pharmacies have techs doing (or even have untrained stockpeople doing when it's too busy)... that sort of bad management has to stop. http://www.leanblog.org/2007/04/say-no-to-bad-drug-stores/ Mina – thanks for your comment. I’m really sorry to hear that you’re in such a stressful situation at your hospital. It does sound scary… I’ve read horror stories about retail pharmacies have techs doing (or even have untrained stockpeople doing when it’s too busy)… that sort of bad management has to stop.

http://www.leanblog.org/2007/04/say-no-to-bad-drug-stores/

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]]> By: mina http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-11592 mina Tue, 20 Jul 2010 19:49:22 +0000 http://www.leanblog.org/?p=5117#comment-11592 We are all missing the most important issue here. WHY ARE WE ALLOW A TECHNICIAN INSTEAD OF A PHARMACIST TO COMPOUND DRUG??!!!! IT SHOULD BE AGAINST THE LAW FOR ANY NON LICENSED PHARMACIST TO COMPOUND DRUG..ESPECIALLY IV..FOR PATIENTS. I am a 15 years licensed pharmacist working in the hospital. I always felt very angry whenever they rotate me to go work in the IV room instead of outpatient clinic. They hired one pharmacist and 3 technicians and that one pharmacist are responsible in checking the work of the technicians. How am I going to check??? The technicians can put 2 banana juice into the iv bag and I wouldn't be able to check. I can only check the bag visually and rely on the technician being competent enough to inject the right thing and right amount...which he claimed...into the bag. IT IS SO SCARY!!!!! The technician is not responsible..only I am responsible because I supposed to be CHECKING..a licensed pharmacist. And I am as a pharmacist are not suppose to compound any drug because THERE IS NO TIME!!! IT IS SO BUSY IN THE PHARMACY...SIX HUNDRED ORDERS..AND NON STOP PHONE CALLS FROM THREE PHONES INQUIRING PHARMACIST FOR DRUG INFORMATIONS...THAT IS WHY THE HOSPITAL HIRED 3 TECHS TO HELP ME. I AM SUPPOSE TO CHECK THEIR WORK. I think the US government and management of the health care should be sued for running our healtcare system like this. They want to spend less money cutting cost on hiring staff. Replacing pharmacist with non licensed people called technicians. A licensed technician is not equal to a licensed pharmacist. This is what our government is doing. We are all missing the most important issue here. WHY ARE WE ALLOW A TECHNICIAN INSTEAD OF A PHARMACIST TO COMPOUND DRUG??!!!! IT SHOULD BE AGAINST THE LAW FOR ANY NON LICENSED PHARMACIST TO COMPOUND DRUG..ESPECIALLY IV..FOR PATIENTS. I am a 15 years licensed pharmacist working in the hospital. I always felt very angry whenever they rotate me to go work in the IV room instead of outpatient clinic. They hired one pharmacist and 3 technicians and that one pharmacist are responsible in checking the work of the technicians. How am I going to check??? The technicians can put 2 banana juice into the iv bag and I wouldn’t be able to check. I can only check the bag visually and rely on the technician being competent enough to inject the right thing and right amount…which he claimed…into the bag. IT IS SO SCARY!!!!! The technician is not responsible..only I am responsible because I supposed to be CHECKING..a licensed pharmacist. And I am as a pharmacist are not suppose to compound any drug because THERE IS NO TIME!!! IT IS SO BUSY IN THE PHARMACY…SIX HUNDRED ORDERS..AND NON STOP PHONE CALLS FROM THREE PHONES INQUIRING PHARMACIST FOR DRUG INFORMATIONS…THAT IS WHY THE HOSPITAL HIRED 3 TECHS TO HELP ME. I AM SUPPOSE TO CHECK THEIR WORK.

I think the US government and management of the health care should be sued for running our healtcare system like this. They want to spend less money cutting cost on hiring staff. Replacing pharmacist with non licensed people called technicians. A licensed technician is not equal to a licensed pharmacist.
This is what our government is doing.

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]]> By: Liveblogging the Quaid Patient Safety Documentary — Lean Blog http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-9579 Liveblogging the Quaid Patient Safety Documentary — Lean Blog Sat, 24 Apr 2010 14:13:33 +0000 http://www.leanblog.org/?p=5117#comment-9579 [...] Quaid says “medical error should not be criminalized. All it’s going to do is alienate the very people we’re trying to bring in to help.” I AGREE! [...] [...] Quaid says “medical error should not be criminalized. All it’s going to do is alienate the very people we’re trying to bring in to help.” I AGREE! [...]

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]]> By: Matt C http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-9188 Matt C Mon, 22 Mar 2010 19:23:31 +0000 http://www.leanblog.org/?p=5117#comment-9188 Whether we are talking CEO's or workers on a line or Pharmacists and Technicians - how does blame prevent future issues. LEAN is about continuous improvement and respect for people. Just placing blame goes against both of these ideals. Is it horrible that someone died because of a process issue/human error?? Very much so. Is punishment necessary?? Maybe. I'm no judge. I am more concerned about preventing it in the future. We can play the blame game as much as we want but in the end the real questions/discussions need to surround process improvements - driven from the top AND the bottom. How can the CEO's and management help prevent this from happening AGAIN? What ideas thoughts do the process experts (in this case the technicians and the pharmacists) have to improve the process? @Jefferson Martin - It is sad to hear that you don't believe your workers can become empowered. I know it is difficult to do, but I have worked to implement LEAN thinking in manufacturing and once colleagues realized that their ideas/thoughts were going to be taken seriously and action items were created to make THEIR jobs easier, many people were "empowered" to look for Continuous Improvement ideas on a regular basis. The key is (in my opinion) management coaching, support, and follow-up. It is that respect for people principle that makes the difference in really achieving improvment. "We need to work together." - Couldn't agree more... Whether we are talking CEO’s or workers on a line or Pharmacists and Technicians – how does blame prevent future issues. LEAN is about continuous improvement and respect for people. Just placing blame goes against both of these ideals. Is it horrible that someone died because of a process issue/human error?? Very much so. Is punishment necessary?? Maybe. I’m no judge. I am more concerned about preventing it in the future.

We can play the blame game as much as we want but in the end the real questions/discussions need to surround process improvements – driven from the top AND the bottom. How can the CEO’s and management help prevent this from happening AGAIN? What ideas thoughts do the process experts (in this case the technicians and the pharmacists) have to improve the process?

@Jefferson Martin – It is sad to hear that you don’t believe your workers can become empowered. I know it is difficult to do, but I have worked to implement LEAN thinking in manufacturing and once colleagues realized that their ideas/thoughts were going to be taken seriously and action items were created to make THEIR jobs easier, many people were “empowered” to look for Continuous Improvement ideas on a regular basis. The key is (in my opinion) management coaching, support, and follow-up. It is that respect for people principle that makes the difference in really achieving improvment.

“We need to work together.” – Couldn’t agree more…

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]]> By: How the Gold Medal Puck Was Almost Lost — Lean Blog http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-9145 How the Gold Medal Puck Was Almost Lost — Lean Blog Fri, 19 Mar 2010 08:04:05 +0000 http://www.leanblog.org/?p=5117#comment-9145 [...] A Pharmacist’s Jail Cell Interview – What Good Does Blame Do? [...] [...] A Pharmacist’s Jail Cell Interview – What Good Does Blame Do? [...]

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]]> By: Detroit Firefighter Not Thinking, Parks on Train Tracks — Lean Blog http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-9033 Detroit Firefighter Not Thinking, Parks on Train Tracks — Lean Blog Sun, 14 Mar 2010 16:23:23 +0000 http://www.leanblog.org/?p=5117#comment-9033 [...] by Mark Graban on March 14, 2010 · 0 comments tweetcount_url='http://www.leanblog.org/2010/03/detroit-firefighter-not-thinking-parks-on-train-tracks/';tweetcount_title='Detroit Firefighter Not Thinking, Parks on Train Tracks';tweetcount_cnt=0;tweetcount_src='RT @LeanBlog';tweetcount_via=false;tweetcount_background='cc6600';tweetcount_border='DAE2F0';tweetcount_text='DAE2F0';tweetcount_api_key='d8f2363c00a05734d2ba0ea87b17c416c523acd1af22ead7f9ed47018ff2bfb7';We had a lot of spirited debate last week around the case of the pharmacist who was jailed after the tragic medical-mistake death of a two-year old girl (“A Pharmacist’s Jail Cell Interview – What Good Does Blame Do?“). [...] [...] by Mark Graban on March 14, 2010 · 0 comments tweetcount_url='http://www.leanblog.org/2010/03/detroit-firefighter-not-thinking-parks-on-train-tracks/';tweetcount_title='Detroit Firefighter Not Thinking, Parks on Train Tracks';tweetcount_cnt=0;tweetcount_src='RT @LeanBlog';tweetcount_via=false;tweetcount_background='cc6600';tweetcount_border='DAE2F0';tweetcount_text='DAE2F0';tweetcount_api_key='d8f2363c00a05734d2ba0ea87b17c416c523acd1af22ead7f9ed47018ff2bfb7';We had a lot of spirited debate last week around the case of the pharmacist who was jailed after the tragic medical-mistake death of a two-year old girl (“A Pharmacist’s Jail Cell Interview – What Good Does Blame Do?“). [...]

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]]> By: Jefferson Martin/synfluent http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-8967 Jefferson Martin/synfluent Thu, 11 Mar 2010 19:47:32 +0000 http://www.leanblog.org/?p=5117#comment-8967 As an owner of a few businesses, I can state with certitude that employees in my organizations are not going to be empowered to do anything over and above their job descriptions. It is upon me solely as the owner to insure that the roles and responsibilities within those job descriptions are quite explicit and that we have designed, documented and trained the employee in those particular Use Cases and processes to achieve our goals. I am confused as to how 'Lean' is neither top down nor bottom up. I have an affinity to the top down style. I own the business; it's my money; it's my vision; it's my goal, and try to excite others with the scenario that they, too, could rise up, be creative and spin-off a company that comes back to eat my lunch at what we do. That sounds a lot like the Silicon Valley business model and it seems to work. Polarization is what supplies the energy to the system. A little bit goes a long way. .-= Jefferson Martin/synfluent´s last blog ..Midvale Steel: Early Silicon Valley? =-. As an owner of a few businesses, I can state with certitude that employees in my organizations are not going to be empowered to do anything over and above their job descriptions.

It is upon me solely as the owner to insure that the roles and responsibilities within those job descriptions are quite explicit and that we have designed, documented and trained the employee in those particular Use Cases and processes to achieve our goals.

I am confused as to how ‘Lean’ is neither top down nor bottom up.

I have an affinity to the top down style. I own the business; it’s my money; it’s my vision; it’s my goal, and try to excite others with the scenario that they, too, could rise up, be creative and spin-off a company that comes back to eat my lunch at what we do.

That sounds a lot like the Silicon Valley business model and it seems to work.

Polarization is what supplies the energy to the system. A little bit goes a long way.
.-= Jefferson Martin/synfluent´s last blog ..Midvale Steel: Early Silicon Valley? =-.

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]]> By: Mark Graban http://www.leanblog.org/2010/03/pharmacist-jail-interview-what-good-does-blame-do/#comment-8965 Mark Graban Thu, 11 Mar 2010 18:12:04 +0000 http://www.leanblog.org/?p=5117#comment-8965 Fred - Sorry about the comment being hidden. That's literally the first time that's happened in the 3 months that I've been this blog platform. My intent isn't to have a club of people who all agree with each other. I'm trying to figure out how to change that. I don't think I'm "CEO bashing." If you read what I wrote again, I asked a question -- does the CEO ever get held accountable? I'm not saying anyone should be jailed in this example. <blockquote>Do you see the contradictory logic of: 1. CEOs should empower employees and let them fix things. 2. CEOs should be 100% responsible if the people they empowered do not fix things.</blockquote> I don't think the CEO is "100% responsible," but we disagree. In a lean management system, it's not contradictory that employees are empowered yet management is still responsible. Lean isn't a traditional "top down" model nor is it completely "bottom up" where the top leaders abdicate responsibility. Thanks for your opinion. I have no idea why you would bring up Hitler and Nazi Germany. Apple and Microsoft are not followers of the lean management system. Jobs and Ballmer can act however they like. Also, I can't be blamed for creating management/employee polarization. It's been around a very long time. In lean environments, we bridge that gap. I don't want things to be combative. We need to work together. Fred – Sorry about the comment being hidden. That’s literally the first time that’s happened in the 3 months that I’ve been this blog platform. My intent isn’t to have a club of people who all agree with each other. I’m trying to figure out how to change that.

I don’t think I’m “CEO bashing.” If you read what I wrote again, I asked a question — does the CEO ever get held accountable? I’m not saying anyone should be jailed in this example.

Do you see the contradictory logic of:

1. CEOs should empower employees and let them fix things.
2. CEOs should be 100% responsible if the people they empowered do not fix things.

I don’t think the CEO is “100% responsible,” but we disagree. In a lean management system, it’s not contradictory that employees are empowered yet management is still responsible. Lean isn’t a traditional “top down” model nor is it completely “bottom up” where the top leaders abdicate responsibility.

Thanks for your opinion. I have no idea why you would bring up Hitler and Nazi Germany.

Apple and Microsoft are not followers of the lean management system. Jobs and Ballmer can act however they like.

Also, I can’t be blamed for creating management/employee polarization. It’s been around a very long time. In lean environments, we bridge that gap. I don’t want things to be combative. We need to work together.

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