Why Every Patient Deserves the Care & Caution that Surrounds the American Ebola Patients


Today's post is a link to my article written for the LinkedIn “Influencers” series:

Why Every Patient Deserves the Care & Caution that Surrounds the American Ebola Patients

Please post a comment here or on LinkedIn (there's likely to be more discussion here about processes and culture and more on LinkedIn about politics and blame).

I'm curious to hear what you think as a Lean thinker.

Full Article:

There's been a ton of discussion and many questions raised in the news and social media about the two Americans, Dr. Kent Brantly and Nancy Writebol, who contracted the ebola virus while selflessly serving others in west Africa and were then brought back to the U.S. for treatment at Emory University Hospital in Atlanta.

This has become a very politicized story and I'd like to avoid or ignore that the best we can here and in the comments.

I'm interested in story from the perspectives of risk, protocols, and “standardized work” as we'd refer to procedures and best practices in the “Lean” methodology and management system. What do they need to do at Emory and how do they ensure it's done?

How were the Americans infected?

I've read references to medical standards and equipment in Liberia not being up to American standards. But, I would hope and presume that Westerners who are volunteering there would, at the very least, have been able to bring the proper protective suits and equipment with them.

Since ebola can be deadly for up to 90% of people who contract the virus, Dr. Brantly and Writebol, and all of their colleagues, would have every bit of self interest and motivation to follow the standardized work when treating ebola patients.

The one thing that I have not been able to find in any news article is any sense of detail about HOW they contracted ebola. Was it a needle stick? A hole in a glove? Some other contact with bodily fluids? How did that happen? And how did it happen to the two of them? Bad luck or some sort of procedural breakdown?

The Daily Mail reports:

“Brantly, who had meticulously adhered to protocols when treating patients, immediately isolated himself when he recognized the symptoms and notified team members, Strickland said.”

This article says:

“He knew the CDC and WHO protocols for safety inside and out,” Samaritan's Purse spokeswoman Melissa Strickland said. “He was very meticulous in following that and making sure the entire staff was following that. That was one of the reasons he was given that responsibility….

Before he was infected, Strickland confirmed that Brantly sometimes spent three hours treating patients in the clinic. It's a feat few doctors can manage since the medical gear they have to wear ends up becoming almost unbearably hot.”

So how did he get infected then?

Did Brantly really adhere to protocols 100% of the time? People sometimes THINK they are following a protocol (such as handwashing) but, in reality, do not. Sometimes our own awareness of what we're really doing isn't 100% accurate.

The Wall St. Journal reports that 15% of the Liberians who have died of ebola were healthcare workers.

Michael Stulman, information officer for Catholic Relief Services, said:

Even with protective gear and precautionary measures, the stress of coping with so many gravely ill Ebola patients opens room for mistakes that allow the virus to spread, he added. “The doctors and nurses who are working on the front lines are working in a particularly high-risk environment. It's possible for someone to slip up and become infected. That's been a major challenge.”

This is important to understand how the healthcare workers are getting infected, even with protective gear like this — not to point fingers, but to better understand the problem and how to prevent other healthcare professionals (in Africa or elsewhere) from contracting ebola.

Washington Post report about the death of Sierra Leone's top doctor has an ominous warning:

Even with the full protective clothing you put on, you are at risk.”

Let's hope the protective clothing at Emory is better.

If anybody has details (from reputable sources) about HOW the healthcare professionals, American or otherwise, contracted ebola, please post a comment below.

Emory is taking every precaution…

Emory University Hospital is a world-class hospital with well-trained, extremely caring healthcare professionals with the best education and the best equipment.

Many hospitals have all of these advantages… yet a few hundred thousand Americans die each year as the result of preventable medical errors and many times more are harmed. They're not harmed due to people who get referred as “bad apples.” In most cases, it's not a matter of asking “who screwed up?” but, instead, we need to ask “where did the processes break down?”

[See my last LinkedIn piece about the VA scandal as a case study of bad systems, not bad apples.]

Even world-class hospitals in the top 10 or top 100 rankings from whatever publication still manage to harm and kill patients. That's not hyperbole, it's a sad truth. I don't mean to offend those who work in healthcare and I don't mean to overly alarm those of you who don't. But, our current health system is riskier than it needs to be, by far. This can be fixed.

Thankfully, many health systems are using Lean and other methods to dramatically reduce harm. This happens because of better management, better processes, and better communication – not as the result of having better people or better technology. It's certainly not the result of firing all of those so-called “bad apples.”

The hospital and medical professionals are downplaying concerns the public might have about ebola being brought into the country for the first time.

The hospital has a special containment unit that was set up in collaboration with the CDC. Emory says:

Emory University Hospital physicians, nurses and staff are highly trained in the specific and unique protocols and procedures necessary to treat and care for this type of patient. The standard, rigorous infection control procedures used at Emory protect the patient, Emory health care workers, and the general public. As the Centers for Disease Control and Prevention says, Ebola does not pose a significant risk to the U.S. public.

As an engineer trained in risk analysis, I'd note that “no significant risk” is not the same as “zero risk.” There are local news media reports in El Paso, Texas about the CDC prepping “quarantine camps,” that would be used in the event of an ebola outbreak.

I'm glad there's a specific team at Emory that's been highly trained, with regular practice. That's a huge positive in their quest to safely treat these patients while protecting caregivers and the public. One of the common systemic problems in healthcare is poor training on specific protocols and processes – and many patients are harmed as a result.

The people at Emory are being protected by strict protocols… yet Dr. Brantly was infected while working under strict protocols. This is puzzling, right?

Maybe I've become a bit of a cynic, working in hospitals for the past nine years. I've seen countless instances of physicians and nurses cutting corners and not properly “gowning up” to enter an isolation patient's room. Granted, none of these were ebola patients. But, policies and protocols are ignored for a number of reasons (lack of time, supplies not always being available, “I won't be in there that long”), but the everyday isolation precautions are generally there to protect the patient from germs, not the healthcare provider.

In the case of the ebola patients, the healthcare professionals have more at stake and are more likely to follow protocols and procedures. I read about a two-person “buddy system” that's used with one person constantly inspecting and looking out for risks to the other care provider. That doubles the cost of care, but the cost of an infection is enormous – whether it's ebola or c. diff in everyday hospital life. Everyday hospital infections are costly and deadly, so why aren't we doing more (even if that means spending more) to prevent them?

Why aren't hospitals always as cautious with every patient?

I'm not going to be as cynical as to assume that there will be a process problem in the containment unit at Emory. If there was ever a situation where people were under scrutiny to constantly do the right thing, it would be now. There's not as much scrutiny at 2 pm in a average hospital cardiac care unit on a normal Wednesday afternoon.

But, it makes me think… if hospitals CAN be extra cautious and make sure people are following protocols in situations like this, why aren't they doing a better job of protecting patients from the everyday infections that kill so many each year, even in the “best” hospitals? Why does the media generally ignore the deaths from post-surgical infectionscentral line associated bloodstream infections, and the like? How do we ensure that everybody protocols are actually followed 100% of the time? How do we make sure that checklists are in place and always followed?

Arguably, the normal everyday risks that Americans face when going under the knife or being admitted to the hospital are far more risky than exotic threats like ebola… yet these everyday risks are rarely in the news. We should pay more attention to the common everyday risks (and work to prevent them) and not just worry about the sensational.


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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. Mark,

    Thank you for pointing out that we should be as vigorous in following protocols for “everyday” hospital infections. I have worked in healthcare performance improvement for 15 years (and yes, I’m even been guilty of L.A.M.E). I am also the wife of a double-lung transplant recipient; infection control has become an important consideration in everday life. My husband was hospitalized for almost 4 months following his transplant. During that time, he had several hospital-acquired infections, none of which proved to be overly detrimental to his recovery, but did require additional treatment. There were at least 3 CAUTI infections, and two infections from skin breakdown where his ID bands chafed his arm. In my mind, the worst was a rhinovirus!

    I clearly recall an incident where a nurse who occasionally cared for my husband came in to work (in the transplant ICU) with a cold. She said hi from the doorway and said she couldn’t come in because of her cold. Just because she didn’t come into the room, she was still shedding virus where the nurse who had my husband that day could have come into contact with it. I asked her why she hadn’t stayed home (she looked miserable), and she said she didn’t want to incur an incidence in her PTO, because they were only allowed three incidences of illness a year before they were brought up for review with their manager. It continues to blow my mind that healthcare still follows policies that punish people for doing the right thing (staying home).

    All throughout my husband’s hospitalization, I couldn’t silence the lean practitioner in me; it was frustrating to see all of the communication breakdowns, lack of process, poor layout for optimal care, and all of the resulting waste. I don’t blame his caregivers – they were phenomenal people doing the best they could given the resources they had. The experience was extremely valuable in that I was at the gemba day in and day out, and gained a new appreciation for the insane conditions we ask healthcare workers to perform in. I now work for the hospital where he received his transplant, and it continues to be a frustrating daily struggle to “speak the gospel” to influence a leadership that still believes margin comes before mission. Thank you, Mark, for providing a daily dose of clarity!

    • Thanks for sharing your story, Elizabeth.

      Yes, it’s crazy that there would be incentives/penalties that encourage people to come to work at a hospital when they are sick. Talk about losing sight of the “true north” of the organization. Dr. Deming talked about the dysfunctions that come from artificial targets and limits (like the # of sick days). If management thinks people are “abusing” sick days, then there is a root cause to people’s dissatisfaction that needs to be investigated and addressed.

      If “margin comes before mission,” then those leaders should really re-think which industry they’ve chosen to work in. It’s always sad to hear about (or meet) leaders who feel that way or think that way (and act that way).

      You’re right that this is a problem of “bad systems,” not “bad people.” I’ll say that here every day if I have to… :-)


  2. This NYT story explains some of the circumstances in which Sierra Leone doctors and nurses might have gotten infected with Ebola, even with precautions. The initial precautions might not have been good enough.

    With the first cases, the nurses simply used their Lassa goggles. Ebola demands a far more protective face shield. They also used “light gloves,” Ms. Sellu said. Now, she puts on two layers of heavy-duty rubber gloves. The inadequate initial precautions had fatal consequences, even for the revered young doctor who headed the Lassa unit, Dr. Sheik Umar Khan.

    “Such a careful man, always saying, ‘Don’t do this, don’t do that,’ ” Ms. Sellu said. “That is the mystery.” Dr. Khan died on July 29, a huge blow to the nation.

    They had to improve the standardized work, it seems. It’s a shame that the Kaizen process included identifying the problem through the deaths of those who were working to save others.

    Was Dr. Khan careful within the context of a bad process?

  3. New article, interviewing the American nurse who recovered – in this article:

    About 250 staffers at the hospital use thousands of disposable protective suits each week, but that’s not enough to fully protect the doctors and nurses who must screen people entering the emergency room or treat patients outside the 50-bed Ebola isolation unit, they said.

    “We don’t have enough personal protective safety equipment to adequately be able to safely diagnose if a patient has Ebola. So they are putting themselves at risk,” David Writebol said.

    More in the article about workers striking due to not having enough protective equipment. Sad.

  4. I heard an interview with Dr. Brantly earlier and he seems convinced, right or wrong, that he contracted Ebola when in the emergency department, seeing new patients there (without the same protective gear). He is convinced that he didn’t contract it in the isolation unit and that it wasn’t an issue of protocol breaches or not taking off equipment properly.

    He was described as the most “meticulous” about following protocols.


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