What I’m Reading: Good News and Bad News on Patient Safety & Government Processes


Here's the latest in my “What I'm Reading” series, where I clear out some of the inventory of articles I've read, but haven't blogged about.

NY crime lab improves efficiency with ‘Lean Six Sigma' process

It's great to see Lean used to help improve government operations – productivity AND quality.

If someone said you could increase the efficiency of your jurisdiction's crime lab by 200 percent, you'd probably initiate an investigation into possible illegal use of controlled substances.

Veterans' wait time for benefits is ‘too long,' VA official concedes

I  blogged about this before. But, sadly, it's not any better. We need to improve flow in this approval process to take better care of our vets.

…the number of veterans waiting more than a year for their benefits has skyrocketed, from 11,000 in 2009 to 245,000 in December 2012, a jump of more than 2,000%.  The VA states the average wait time after a veteran files a claim is 273 days.

Hospital infections kill 30,000 a year

This isn't just an American problem (100,000 a year killed) — it's also a problem in Germany. Read more statistics I've compiled on patient safety problems in the U.S. and around the world.

A “Wrong Patient” Surgery in France

Translated from French via Google. it appears a hospital needed to rush a man into surgery after a CT scan… except the wrong patient ended up on the O.R. table, somehow.

Ottawa Hospital C. difficile outbreak blamed on clutter, poor cleaning

Is this really so hard to fix?

Problems that encouraged the disease's spread included cluttered rooms, cluttered nursing carts, improper handwashing stations in some of the units, and a lack of training among cleaning crews…  The report also found that there was “no process to distinguish if equipment was clean or dirty” and that cleaning of equipment shared among patients was only being done when an outbreak was declared.

Brigham and Women's airing medical mistakes

Brigham and Women's is published stories about mistakes in an employee newsletter in an attempt to encourage people to speak up and work on preventing future problems.

“Open-faced transparency is really valuable to staff at an institution because it causes them to know themselves better,” said Paul O'Neill (my podcast with him), a member of the Lucian Leape Institute at the National Patient Safety Foundation, a nonprofit research organization based in Boston. But few, if any, other hospitals are doing anything like what the Brigham does, he said: “Unfortunately, I would say it's highly unusual.”

Hospital workplace safety means better patient care

“To the extent that people are unhappy in their work, or feel unappreciated or disrespected, they are less likely to be focusing entirely on patients and on making sure they do everything correctly, following the safe procedures and not cutting corners,” Lucian L. Leape, M.D., patient safety researcher and adjunct professor at the Harvard School of Public Health,  told  American Medical News.

Feel free to comment on any of the articles below…

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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. As long as it took, I’m glad I got my VA claim submitted in 2009 when the waiting time was so “short”. Working with the VA is awful, they want you to do everything on a very non-intuitive website, and it takes forever to get an answer to a simple question. It took a whole year for them to analyze the results of my sleep study and get me back in for the second appointment. They and many other government agencies need a complete Lean overhaul.

    • Here is a case of a county government using Lean to reduce time in a process. The VA should learn from this:

      County saves with lean projects

      “The adult mental health assistance application process in Winona County used to have application forms – and clients – bouncing between social workers and support staff. After transforming the system using “Lean Management” techniques, the turn-around time for mental health applications was reduced by 87 percent, county dollars and staff time have been saved, and the project is just one example of how Winona County government workers are changing the way they do business.”


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