An Astronaut’s Viewpoints on Systems & Patient Safety


Today, I'm sharing a brilliant interview:

Risky Business: James Bagian “NASA astronaut turned patient safety expert” 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 worth thinking deeply about.

  • It's about systems, not individuals. Blaming and punishing really don'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 – should the same 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):

  1. 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)
  2. A Problem Solution: Standardized Work
  3. I've Never Actually Been to Toyota
  4. BMW chooses flexibility over lean manufacturing

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  1. Bryan says

    Hi Mark,

    Vermont House passed a law yesterday increasing the tax on cigarettes and healthcare services. One of those services is a tax on insurance companies for each claim filed. I’m assuming it is intended to force insurance companies to sharpen their pencils and reduce costs. Another way to look at it is that it forces indirect rationing and actually requires administrative overhead to manage this new dynamic factor in claims processing, thereby not reducing health insurance costs one penny, but likely increasing them or forcing a pass through to the insured. One of the items in your astronaut post that caught my eye and made me wonder about this new law is:

    “When we pay organizations based on quality metrics, we should expect that people will game the numbers.”

    Your thoughts on what the results will be with this new tax if we consider the astronaut’s insight as stated above?

    1. Mark Graban says

      Bryan – that’s disturbing to hear. My prediction would be that the tax will increase costs, not lower them. It sounds like a simplistic “solution” to a complex problem.

      Are you hopeful of much “PDCA” involved with this, or with the Vermont politicians just assume that the change is an improvement without awful side effects?

      News story on that tax being passed yesterday.

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