Why Do Hospitals Have to Rely on Vigilant Patients and Families?


Bedside Manner: Advocating for a Relative in the Hospital (WSJ)

WSJ Health Blog (free): Five Tips for Helping a Family Member in the Hospital

Hospital Selfie StevenI've written before about my questions of why so many hospitals abdicate their leadership responsibility for quality and patient safety, or at least offload much of it onto the patients. I think it's wrong to put patients of the position of asking the providers if they've washed their hands. The hospital, the providers, the physician leaders, and the administrators need to take on this challenge. They need to fix processes and put better management systems in place. That's getting closer to fixing the real root cause of these problems instead of asking families to play the role of “quality inspector.”

The article and blog linked to at the top of the post give these recommendations:

Here are a few tips for taking care of a loved one in the hospital:

  • Ask everyone if they've washed their hands.
  • Ask nurses to read drug orders out loud and confirm that they match the patient's ID bracelet. If it's a new medication, ask what it's for and what to expect.
  • During long stays, be alert for bedsores. Make sure the patient is moved often, and lifted rather than slid.
  • Don't try and help the patient into or out of bed by yourself.
  • Don't give the patient medications on your own.

I can understand asking families to not give medications or help move patients… but you want families to be the ones responsible for making sure the wrong drug isn't given? Seriously?

You don't see articles about “How to Be a Vigilant Airline Passenger” with tips such as

  • “ask the pilot if they have done pre-flight maintenance checks” and
  • “be sure to sit over a wing so you can see for yourself if the flaps have been properly set for takeoff.”

People wouldn't accept that when flying or when buying a car (“Be sure to check that the lugnuts have been tightened before driving away!!”). So why do patients and families accept this in hospitals? At best, it's a short-term stop-gap fix — a necessary intervention to make up for a bad system. But I'd feel better if hospitals also explained to patients how the system is being fixed (through Lean methods or otherwise).

In the WSJ article, Melinda Beck writes about a typical “vigilance required” tale:

Don't go to the hospital alone, if you can possibly avoid it.

A friend of mine slipped on the sidewalk recently and broke her hip. She had surgery in one of the best hospitals in the country.

But it was my friend's grown daughter who noticed that she was having an adverse reaction to a pain medication. And that her IV drip had pulled out of a vein and was pumping her arm full of fluid. And that the hot compresses to reduce the swelling in her arm had left blisters on her skin. And that the blood-sugar test she was about to be given was meant for her roommate instead.

Hospitals need to ask why these errors or oversights occur and how they can be prevented. Are nurses too overburdened with unnecessary administrative functions and are they dealing with “waste” and problems that keep them being being as attentive to patients as they could be?

Many hospitals are under financial pressures to keep nursing staffs lean.

As you might guess, I really dislike this colloquial use of the word “lean.” In this use, it might mean “less staff than we had before” or “less staff than we'd really like to do the work the right way.”

To me, “Lean staffing” (in the Toyota Production System sense) is about having the RIGHT number of employees. This is a topic I'm going to explore more in a future post — how DO we determine the right number of employees? If it's based on budgets or financial targets, that might not give the right answer. The answer should be based on a real operational analysis of the work that's required, not arbitrary targets or benchmarks.

When does short-term financial pressure to keep staffing low actually lead to higher costs? These costs might include poor morale (which leads to expensive turnover and hiring) or poor quality (the impact of which might be a lawsuit or incalculable loss).

While I'm leery of relying on families as “partners in quality and safety” (they're really customers), I do like the idea of including families (and the patient) in communication and handoffs, as some hospitals are doing:

“This is a huge cultural change,” says Mary Chatman, Chief Nursing Officer of Pitt County Memorial Hospital in Greenville, N.C., which is giving family and patient advisory groups a voice in designing new facilities and interviewing physicians.

Initially, some staffers worried that family involvement would take up valuable time, but in the long run, it saves time because doctors have more information, says Ms. Chatman. After MCG Health's neuroscience unit became more family-centered, average length of stay dropped 50% because discharge planning went faster. Patient satisfaction rose, and nursing turnover dropped.

Here's an example of a short-term cost (time and staffing) that pays off through lower costs and better service down the road. That's the type of systems thinking that the Lean approach encourages. Don't just micromanage your budget column, improve the whole system.

I can understand “partnering” with families in things like discharge planning, as shown above. But I still think it's ridiculous to think of the family as a “partner” instead of a customer. Any service provider has the duty to make sure their customer is taken care of and that quality is maintained. Don't offload that onto the family — they have enough to worry about.


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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Frightening stuff. Is the industry really that incapable of managing people and processes, as portrayed in these articles?

    Inexcusable. Thanks for shining some light on this. Come on healthcare, get it together…

  2. Well said, Mark.

    Look forward to reading your thoughts on how to determine the right number of employees. Seeing the question here reminded me of Peter Scholtes’ challenging Questions for Downsizers in the Leader’s Handbook, which you can read on Google books here


  3. Thanks, David.

    I’m going to develop this further, into a blog post and an article for publication somewhere about staffing levels.

    Long story short — staffing levels should be based on data and a knowledge of the work that’s taking place, not just on benchmarks or arbitrary targets.

    With whatever staffing level, “the work gets done” (meaning we get through the day), but at what cost of


    work that’s NOT getting done

    staff stress


    When people don’t have enough time, they cut corners. Often, the wrong ones. So being understaffed can end up costing you more money (if you can measure it).

    You also have to look at reducing waste, not just throwing people at the problem.

  4. I am a nurse and I am angered by this article. By asking you to help in your families care isn’t because we can’t. It is because we want you to take part in their healing process. It is only meant to make sure your family member is safe and getting the best care possible. This country is, has been, and probobly always will be in a nursing shortage. We can’t be at the bedside 24/7 with patients. It is unreasonable and unecessary. we are very busy taking care of very sick patients. In contrast asking the family to help in the patients care shouldn’t make up for poor quality nursing care.

  5. To the nurse:

    I’m not attacking nurses. Why does hand hygiene not occur 100 pct of the time? This is a management problem, at the root cause level.

    Participating in care is one thing, but hospitals shouldn’t make families lecture the staff about washing their hands. That’s what I take issue with. The hospital needs to manage that themselves.

  6. I am a nurse too. The difference between pilots and nurses is a simple one.

    a pilot has ONE plane to fly. An Rn may with another team member have responsibility for 8 – 10 patients. The only place you get one on one patient nurse ratio is ICU.

    We just don’t have time. Errors are terrible and inexcusable. They shouldn’t happen….but even planes can fall down from the sky.

    I’ve been nursing for many years I’ve NEVER asked a family to care for patient. I do tell them what we are doing and why.

    I’ve never worked in a hospital where families lecture staff about washing their hands!!

  7. To the last nurse from 4:03 AM… first off, I'm not blaming you as an individual. I'm empathetic to the stress and situations you work in.

    But I have to ask some questions in return.

    "I am a nurse too. The difference between pilots and nurses is a simple one.

    a pilot has ONE plane to fly. An Rn may with another team member have responsibility for 8 – 10 patients. The only place you get one on one patient nurse ratio is ICU."

    —> So I'd say, OK, so if a pilot makes an error, the pilot likely goes down with the plane and might die too. A nurse with 8 to 10 patients has more complexity but you also have the responsibility to make sure you aren't possibly infecting 8 to 10 patients each day (which could go on forever without harming you physically). The pilot has "skin in the game" while a nurse might just have c-diff on their skin or scrubs.

    "We just don't have time. Errors are terrible and inexcusable. They shouldn't happen….but even planes can fall down from the sky."

    —> Yes, errors are inexcusable. Not washing hands properly is an error, I'm sure you'd agree. But you're making EXCUSES (we don't have time). Do you and the other nurses (and management) just tolerate the "we don't have time" condition or do you make improvements to free up time so you CAN wash your hands properly? Reduce the amount of time you spend searching for IV poles and linens and meds and you might just have more time now for proper hand hygiene. If you're flying, would you want your pilot to say "well I don't have time to do the pre-flight checklist today" and then scream "errors are inexcusable!!!" as the plan is crashing on take off because flaps are set wrong?

    "I've never worked in a hospital where families lecture staff about washing their hands!! "

    —> Do you mean the families have never asked or they've never lectured in a mean way? Maybe they should if you don't have time to follow proper infection control processes. Again, it probably feels like I'm blaming you individually, but I'm not. It's a system problem and it needs to be fixed at a system level.

    Thanks for the work you do.


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