Too Many Patients Harmed, Too Few Leaders Committed to Real Change?
I recently received two emails that are worth sharing, in anonymous form here. One was from somebody I know who just quit a Lean role at a major academic medical center after a few years there, as he’s looking to join an organization that has a “deeper commitment to profound change” (spoken like a reader of W. Edwards Deming’s work).
The second email reads as follows (again, edited and anonymized):
I’m an industrial engineering graduate with a few years of experience in the field. I’ve been following your blog, podcast, and tweets for a little over a year now. Your content has helped me stay connected to the larger Lean community. For example, I picked up The Essential Deming after seeing your post about the book.
I’ve had trouble drawing personally relevant useful ideas out of your stories on Lean in healthcare. However, this past week, I spent a day in a hospital to support my mother.
Upon reflecting upon the processes I was seeing, I was shocked. This was a reputable teaching hospital and, in the nine hours we were there, I observed two errors that caused my mother physical pain, two that could have led to serious harm, and a good half-dozen clerical and communication issues.
I was even more surprised when I heard staff members make comments that suggested that these were common errors.
Coming from a manufacturing environment, I’ve seen plenty of poor processes, but to see a system actively abuse the customer was heartbreaking. This experience has caused me to start thinking of Lean as a sort of humanitarianism, rather than pragmatism.
As I watched the post-op nurse remove an IV and inadvertently put pressure on a botched IV needle in my mother’s arm that she didn’t know was there, I couldn’t help but feel pity for the nurses who made the mistake. They felt bad for harming the patient, not realizing that culpability was really with management for designing a bad system.
I’ve never considered a career in healthcare, but now that I’ve seen the need for good Lean thinking firsthand, I might have to reconsider.
Thank you for the opportunity to share my story.
As the I.E. writes, these are definitely not situations in which we should blame individuals. I appreciate that he recognizes that (he’s clearly absorbing Dr. Deming’s ideas). I recommended that, if he’s interested in helping improve healthcare, that he check out the Society for Health Systems (part of the Institute of Industrial Engineers) and their annual conference (where I will be presenting again in February — this time on Statistical Process Control as a way to manage better).
I haven’t written about it because it affects me so personally, but my grandfather was in the hospital earlier this year and I heard similar reports from my dad and my aunt about the ongoing parade of mistakes and process problems (including a prescription error upon discharge that could have killed him, said the sharp-eyed retail pharmacist who questioned the medication and the dosage).
My grandfather is an incredibly kind and patient man, yet he was driven to comment, after a few days in a long-term care facility that, “it seems like they haven’t done anything right so far.” This included being given the “new admission welcome packet” on Day 3 of his stay and numerous other errors that caused pain, discomfort, or annoyance.
There are so many problems in healthcare, we need “all hands on deck” to come help fix things. I just hope things can get fixed quickly enough. One thing that will help is not alienating and chasing away those who are trying to help, like the guy from the first email.
I recently gave a lecture at a hospital that had hired two engineers from Toyota. The engineers were very sharp and they seemed to be effectively making the transition into healthcare. But, two engineers, no matter how good they are and what their backgrounds are, can’t save an organization of 5,000 people if the leaders aren’t on board.
In the class I taught, there were about 20 nurses and front-line staff, including a few charge nurses. The higher-level managers who had been invited all had a reason to skip out and not attend – apparently, there was some fire to fight (isn’t there always?) and their attendance was apparently mandatory.
So, I had been asked to talk about “leading in a Lean culture” and I had to re-craft my talk to be more about “here’s what it would be like to work in a Lean culture” – and I’m not sure the people in the audience will ever experience this. My talk was meant to helpful and inspiring, but it might have been discouraging and demoralizing. I talked about the need to look at systems and processes instead of blaming people… and they might very well get blamed for some error that’s not their fault while they are “working on a Lean project.”
It makes you wonder what the point is. Why are we teaching front-line staff about Lean when their leaders are not participating in the learning? At least the front-line staff might be able to parlay their Lean education and experience, as minimal as it might be, into a job in a different health system where leaders are on board with Lean thinking and Lean practice?