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


Ebola-592x460Today's post a link to my article written for the LinkedIn “Influencers” series:

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

Part of my article:

“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?”

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.

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  1. Elizabeth Davis says


    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!

    1. Mark Graban says

      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. Mark Graban says

    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. Mark Graban says

    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. Mark Graban says

    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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