Lean Thinking: We Don’t Blame Individuals for Systemic Errors
I saw this video last night on Paul Levy's blog and it's important enough that I want to share it here with a few additional thoughts.
In the Lean methodology, our mindset is that we respect people as individuals, respecting their human nature, and this means we appreciate that we are fallible and make mistakes. Therefore, we don't blame and punish individuals for things that are systemic problems. There is a high degree of overlap here with “Just Culture” and the modern patient safety movement.
What happened? One nurse misread a patient's glucometer, thinking it was high, when it was really low.
It would have been really easy for the hospital to “name, blame, and shame” the nurse and punish her. That's the common reaction before Lean thinking (or systems thinking) principles are introduced.
But, then a second nurse made the same error.
The initial reaction was still to want to suspend the nurse, pending an investigation.
The nurse said, “I was talked to like I was a five year old. I wasn't talked to like I'm an adult.”
There's that “respect for people” notion again… or lack thereof. We can do better. We can (and must) treat adults like adults.
A nursing director pushed back on suspension and called in the “human factors” department to look at the process. There was a design issue that contributed to the process, they said.
Not surprisingly, the video references the “Just Culture” approach. “You can't fault any one individual… that's a process problem that needed to be addressed.” They took away the threat of discipline and it helped the nurse regain her confidence (since she felt horribly about the error).
We show respect for future patients… by ensuring their safety… and that means treating nurses and professionals with respect. People are then more likely to come forward about near misses and other safety risks… so we can work together to get things fixed.
We need to make sure this is part of our “Lean transformation efforts.” Medstar is an organization that uses “Lean Six Sigma” as a methodology. Thanks for their leadership on this front.
This shift in thinking is just one reason why nurses (and their unions) should support and embrace Lean healthcare.
Two of my favorite quotes:
“Human error is inevitable. We can never eliminate it.” We can eliminate problems in the system that make it more likely to happen.”
– Sir Liam Donaldson
WHO World Health Alliance for Patient safety
“You respect people, you listen to them, you work together. You don't blame them. Maybe the process was not set up well, so it was easy to make a mistake.”
– Gary Convis, Toyota
It's good thinking and it's the right thinking for nurses, patients, and safety.