In a Lean culture, the mindset is that “problems are treasure” or “problems are gold.” By honestly identifying problems, we can solve problems and prevent them from occurring in the future. Problems in healthcare can include medication errors, laboratory specimen mixups, and other problems that can harm or kill patients. The stakes are high.
Traditional organizations pressure people into hiding or covering up problems. When people cover up “near misses,” that's particularly tragic because yesterday's near miss might become tomorrow's patient harm if we don't understand and solve the problem.
Yesterday, I got two different emails from people at different systems complaining about how the culture drives people to hide problems — there is direct fear of being fired… so people cover things up to protect themselves, putting patients in jeopardy.
Lean thinkers realize that most problems are caused by the system, not so-called “bad apples.”
If only it were so easy as to fire all of the “bad apples.” If we fired all of the bad apples, safety would improve and patients wouldn't be harmed, right? Let's just figure out a way to predict WHO will cause an error… and proactively fire them. But, that doesn't work, because in a bad system, any good person might be involved in an error (which is not the same as saying it's “their fault.”)
We can't proactively fire people to improve safety, but we can try to improve the hiring, training, and supervision processes. If there are truly “bad apples” in the organization, isn't that the organization's fault for hiring them, or not training them properly, or not supervising them?
See this article that was in the news recently: “Hershey Medical Center addresses flawed lab procedure.”
The headline isn't “Hershey Medical Center fires lab technician” but that's what happened.
The problem is probably the procedure, the process, or the system… but a person got fired. Will that really solve anything or prevent future problems?
From the article:
A lab technician at Penn State Hershey Medical Center failed to follow proper procedures when conducting a genetic test used to help physicians decide on cancer treatments, affecting the test results of 124 patients, the organization said this week in response to an Intelligencer Journal/Lancaster New Era inquiry.
Penn State Hershey determined the flawed procedure was used from March 2013 to March 2014.
Read that again. The “flawed procedure” was followed for A YEAR.
The technician (just one of them?) “failed to follow proper procedures.”
If that's true, whose responsibility is that? That's management's responsibility to make sure people are trained properly, that they have the right supplies and equipment, and that they are indeed following procedures.
This is a point I made in my book Lean Hospitals, that “standardized work” is not just about writing procedures… it's about proper training and supervision. Supervisors and managers have a responsibility to check and see that procedures are being followed. They can't just sit back and blame and punish somebody after the fact. The wrong procedure being used for an entire year is a management failure, plain and simple.
What other procedures are not being followed in that hospital? Managers must take responsibility, whether it's a taco restaurant or a hospital.
As I wrote about in that LinkedIn article:
We often see similar things in healthcare, where the stakes can also be a matter of life or death (with outcomes worse than food poisoning). If you recall the case of the actor Dennis Quaid's twins being harmed by a preventable medication error at the famed Cedars-Sinai Medical Center, leaders blamed employees for systemic problems.
The Chief Medical Officer said:
“This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai.”
You can't just beat your chest after the fact when you've discovered that people weren't following policies and procedures. It's your job as a manager (or a CMO) to be proactive and make sure people are following procedures.
Back to the Hershey Medical Center story:
“The technician in question is no longer working there, Penn State Hershey said.”
We can only assume they were fired.
Looking back to this pathology specimen mixup, the case involving the patient Darrie Eason, we saw similar reactions:
“[The CEO] said the technician responsible for the mixup also no longer works there.”
In that case, the supervisor admitted they KNEW the technician wasn't following standard protocols… but the technician got fired when when it all hit the fan. Was the supervisor fired? Was the CEO?
The beatings will continue until morale improves… and the firings will continue until safety improves?
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