An Astronaut’s Viewpoints on Systems & Patient Safety
Today, I'm sharing a brilliant Slate.com interview : “Risky Business: James Bagianâ€”NASA astronaut turned patient safety expertâ€”on Being Wrong.” He's actually also an engineer and an anesthesiologist. An impressive background and impressive thinking.
I will share a few highlights and some core themes, encouraging you to go and read the whole article (with comments and discussion welcome back here on this post).
Here are some core themes that would be familiar to Lean thinkers or quality and patient safety professionals, as well as a few provocative statements that are worth thinking deeply about.
- It's about systems, not individuals. Blaming and punishing really doesn't help
- We need to ask “why?” instead of just blaming
- Traditional medical culture can interfere with quality and safety improvement
- Healthcare needs to use “near misses” as an opportunity to improve
- The risk of embarrassment or humiliation gets in the way of reporting errors (more so than the risk of punishment, even)
- Early on, the number of reported errors will go UP as people are being more honest and open
- Punishing people for not reporting errors is as harmful as punishing people for committing errors
- When we pay organizations based on quality metrics, we should expect that people will game the numbers
- Airlines are legally prohibited from advertising based on their safety record – the same should apply to healthcare?
- It's tempting for people to say “There's no standard, so we didn't violate anything.” – “Well, there should be a standard.”
I hope my bullet points tempt you into reading the entire article.
Other stuff I've been reading recently (and might blog about in the future):
- A plan to save lives lost in surgery: 61 S.C. hospitals will take part in pioneer program aimed at curbing errors (referencing Dr. Atul Gawande)
- A Problem Solution: Standardized Work
- I've Never Actually Been to Toyota
- BMW chooses flexibility over lean manufacturing