Today's guest is my friend John Ervin and we were able to sit down together here in San Antonio to record this episode. John has about 20 years of healthcare leadership experience, including in military medicine and the civilian sector. He's been a manager and director of operating rooms in many types of hospital and surgical center settings.
2022 update: John is now a part of the team and is my colleague with the firm Value Capture and we were able to collaborate on an engagement with a Philadelphia health system.
We share a passion for Lean and, more importantly, patient safety. We believe strongly that you need the right type of culture and leadership to encourage and support a culture of safety and that's what we'll talk about today.
For a link to this episode, refer people to www.leanblog.org/215.
Not guaranteed to be 100% defect free.
Welcome to the Lean Blog Podcast. Visit our website www.leanblog.org. Now here's your host Mark Graban.
Mark Graban (13s):
Hi, this is Mark Graban. Welcome to episode 215 of the podcast for, oh gosh, it is Friday the 13th. It is February 13th, 2015, and hope it's not a scary day for you, but you know, thinking seriously now, I guess about things that are scary, I'm gonna be talking about patient safety and culture and lean in the operating room setting today with my good friend, John Ervin, John lives here in San Antonio. We moved here right about the same time in 2012. And he was actually one of the first people that I met here in San Antonio. Thanks to our shared interest and lean and continuous improvement. I've learned a lot from John over these couple years and, you know, comparing notes and talking about how to try to better transform healthcare.
Mark Graban (1m 0s):
John has about 20 years of experience in healthcare management, operating room management, including in military medicine and here in the civilian sector in different types of healthcare organizations. So I was happy to sit down with John and to let him share some thoughts and stories about his time in healthcare, hopefully that inspires you to, you know, further your work to improve healthcare cultures and make a better healthcare system. So as, as always, thanks for listening. If you'd like more information about the podcast series, you can go to lean cast.org. Well, Hey John, thanks for being a guest on the podcast today.
John Ervin (1m 38s):
Morning, Mark. Thanks for having me. I appreciate it.
Mark Graban (1m 41s):
We're gonna be talking today about lean and, and patient safety and leadership and operations from, from your experiences. And I'm glad we can talk about that. Can you start off and introduce yourself and, and your professional background a little bit about yourself for the listeners?
John Ervin (1m 57s):
Sure. My name is John Ervin. I'm a registered nurse. I have a bachelor's of science and nursing, a master of business administration. I started my career early as a surgical technologist and my whole career, I was really into health and wellness ended up with a, almost a biology degree early in my career, and I decided I would join the military. And after becoming a surgical technologist, I then became a registered nurse. I worked at a small community hospital in the Maryland area and also a Walter Reed Army Medical center in Washington, DC. From there, I left the military after almost 10 years and then worked in several civilian hospitals.
John Ervin (2m 38s):
And my specialty over the years has been basically running operating rooms in different hospitals and also combined with a mix of medical device sales with some large companies in the medical device sales industry.
Mark Graban (2m 54s):
So through that experience in both military and civilian medicine, when did you first get introduced to lean principles and methodologies?
John Ervin (3m 2s):
The first time that I was introduced to lean significantly was in 2010, and I was working at a, a large academic hospital in Philadelphia, and I was lucky enough to be involved in multiple lean projects related to patient safety leadership operations. And I eventually became lean certified through the university.
Mark Graban (3m 28s):
And, you know, we both share, you know, a passion and interest in the important issue of patient safety. And it's interesting, I think that you mentioned right away that you were doing some lean projects focus on patient safety. I think yes. One, one thing that that can be frustrating is to see people when they're they're new with lean. I think they're sometimes dabbling around the edges of the organization. You hear stories of, you know, focusing on the, the number of pencils and the nurses station. And, and sometimes I think, boy, those are, those are trivial issues compared to the amount of, of harm and, and death that occurs in hospitals. Do the preventable medical error.
Mark Graban (4m 8s):
What, what are, what were some of those initial projects? What types of things were you addressing? Well,
John Ervin (4m 13s):
When I was first exposed, I think the interesting thing that I learned early in my lean journey as we call it, as you know, is that, you know, six Sigma and lean are two different things to different animals. And we've found that lean in health systems is really more applicable for a lot of things that we work on. And it's interesting because one of the first projects I worked on was a specimen lean project. And we were trying to increase the efficiency and safety in which we collect a surgical specimen after a procedure and how that specimen then makes it down to pathology.
John Ervin (4m 56s):
So that was my first introduction to lean, which was really an amazing experience.
Mark Graban (5m 2s):
That's things like biopsies, right?
John Ervin (5m 4s):
Correct. Yeah. Correct biopsies. So when a piece of skin or piece of tissue is taken from a patient, the process of that individual patient biopsy leaving the operating room during a procedure, and then having someone either pick it up or having it being transported in some manner down to the pathology lab was a process that we decided to work on at the hospital. Yeah.
Mark Graban (5m 30s):
And what, what, what was the pressing need that, that led to that? Was it a matter of timeliness or mistakes being made in that process?
John Ervin (5m 39s):
It was a matter of timeliness, also the process of the specimen getting to the correct location at the correct time. And the focus was really around safety. And how do we get the staff involved in that safety process? Because what we found, looking at the process from step one to step 20 is that there was a lot of opportunity for improvement in increasing communication and collaboration. And also most importantly, adding some structure to the process that everybody would follow in a similar manner.
Mark Graban (6m 19s):
And, and so then what were some of the, the results or, or the benefits? What, what types of things were changed in that, in that process? You
John Ervin (6m 26s):
Recall? That's, that's a great question. So the first thing we did was really get really all staff involved, you know, frontline staff, physicians, administrators, and what we found was everybody was obviously really interested in the safety feature of this. And what we did is we standardized a lot of the processes. So we standardized where we would place a specimen in the operating room, what table in every operating room. We also picked a certain color container that we would use for the specimen. And in some situations, specimens were transported by various modalities. So we, the, the, the container that we used, we actually made it all red.
John Ervin (7m 6s):
So everybody would know when they saw this specific container, that that container was for specimen transport down the pathology. And that was through a series of several months of meetings and interactions with the group and the physicians. And really the big thing that we've learned about lean is sometimes you just gotta do it. And, you know, you can spend months, sometimes years planning, but sometimes you need to come up with a process and just do it and implement it. And then you learn, I always say, lessons learned the lessons learned. We learned from that process. Then we modify and we improve
Mark Graban (7m 43s):
Now to set context or some of these procedures situations where the, the biopsy is sent to pathology. The patient is still in the, or still open, or yes, that's one reason why that timeliness is so critical. Correct.
John Ervin (7m 57s):
So, perfect example, we're doing a, a type of procedure and we called a, sometimes a frozen specimen. And as soon as the specimen is removed from the patient, the biopsy, then we literally have to have that biopsy sent down to pathology. It has to be reviewed under a microscope. And then the pathologist actually calls the physician on the telephone, why the patient is still in the operating room to report on the diagnosis or the findings. So that's a critical, critical component, as you can imagine, the safety is so important in that and any delay in time or any delay in that specimen reaching it's, you know, correct location could be a critical factor in that procedure.
Mark Graban (8m 41s):
Yeah. Cause, and it's true. In any surgical setting, you wanna try to minimize the amount of time the patients under anesthesia that reduces risk, it improves recovery, right? Correct.
John Ervin (8m 51s):
Mark Graban (8m 51s):
And I guess it's also good for, for or flow. Yes. I mean, that's maybe a secondary factor compared to the safety and, and quality component, right?
John Ervin (8m 59s):
That is absolutely correct. So the factors that we look at, obviously we try, always try to put safety first, but the efficiency and the process of again, avoiding delays, avoiding, avoiding bottlenecks as we call them is crucial. Because again, we have other patients that are coming into the, or, and the more efficient and the more effective that we can make a process like specimen collection, then the better we can provide care for other patients. So, yeah.
Mark Graban (9m 27s):
Good point. Do, do you remember how much of a turnaround time reduction or how much of a time savings there was in, in that process?
John Ervin (9m 36s):
You know, I don't remember offhand. I can tell you that we utilized some transport modalities that were kind of not in the box that you would originally think that you would use a perfect example is, you know, when we collect a lab specimen, we have vacuum transport systems throughout hospitals,
Mark Graban (9m 58s):
John Ervin (9m 59s):
Tube systems, correct? Yeah. So we actually did some extensive research and we started in certain situations using the tube system and we found that people would say, well, what happened if the tube ended up in a different department? Well, through extensive research, extensive data validation, we could track it wherever it went. And we actually ended up putting an alarm system on the other end where pathology lab was. So that way, when the specimen came in, a bell would ring and the tech on the other end would know that that was a, an operating room specimen. So, but those little touch points that we put in were really important. And those were the, that was the key to implementing the lean system because yes, we had processes of systems prior to that, right?
John Ervin (10m 46s):
Yes. We had good team ideas, but we never had a formal process. And that's where lean really came in and kind of solidified it and provided that structure that everybody could follow.
Mark Graban (10m 58s):
Yeah. What you said about the tube system, remind it just seems like one of the situations where, you know, people say, well, somebody might suggest why don't we use the tube system? Well, we've never done it that way. We've always done it the way we do it before you can't use the tube system. Well, correct. And a lot of times people will then back off and without going and doing the research, obviously you want to be, you know, look looking at things the, the right way and you know, but to, to do that research and, and see what are the capabilities, what are the regulations to, to try experimenting with something new,
John Ervin (11m 30s):
Right. Yeah. I think that's a great point. When I, when I had come into the hospital, they had already started working on the project. So I was, I came in at the beginning and that was the first question I asked, one of the administrators who was on the project previous is, you know, has this been validated? Can we use this transport system for specimens? And, you know, he was a formal Naval adminis officer in the, in the Navy. And he absolutely said, yes, John, we've done our validation. And we've verified that this system is very good. Can what you compared that to is we would sometimes have an individual go to the actual operating room, you know, so they would walk to the operating room.
John Ervin (12m 11s):
They would collect the specimen, there'd be a process for a handoff. And then they would then transport that physically down to a pathology lab. So as you can imagine, that takes time, that takes staffing availability. And as we spoke about earlier, it's a critical period that that specimen needs to get to a certain point, a certain location in order to get the results back as soon as possible. Right. So, you know, you don't have to wait for the elevator. You don't have to wait for a, a nurse or nursing assistant to be available for transport. So I think in the end, the specimen process really ended up focusing number one on safety. And as you mentioned, also on productivity process and building in the infrastructure, I think to really standardize the process, which was important.
Mark Graban (12m 58s):
Yeah. So let, let's move on and, and talk about some of the aspects of culture and, and leadership. I know we're in agreement that that plays a big role in improving patient safety, or it's a big cause for why we have risks or, or problems in healthcare. So kind of moving beyond projects, which are great. Can, can you talk a little bit about maybe the existing operating room culture? What are some of the challenges and things that, that you try to work on as a leader, things that you try to get physician leaders in involved into improve the safety culture in, in that setting.
John Ervin (13m 35s):
Okay. And I've been lucky over my career. I served almost 10 years in the United States military, and I was stationed at a smaller community hospital, large academic medical center in the military. And then in the civilian world, same thing, some large health systems, some smaller health systems. So it got to really a unique perspective of the different styles of leadership that I've noticed over the years. And I think in the military, as most people would assume is, you know, everybody thinks that it's top down leadership and you have a drill Sergeant type person talking to you and trying to, you know, get you to do things well, that was exactly the opposite of my experience in the military, which I think was very surprising as a young soldier, but the ability to communicate and collaborate that I experienced in the military was really a great learning experience for me, especially early in my career and the challenges that I have seen in the civilian world.
John Ervin (14m 38s):
We don't have rank and file. We don't have colonels, we don't have captains. So we have to rely more on team dynamics and teamwork and collaboration. And I think that the challenges that we've faced over the years is really how do we coach and mentor a team of individuals to all work together collaboratively for the same mission. And you can of course equate that to the military, but in the operating room, we have a mission of patient safety and patient care. So those are some of the things that we focused on over the years. And the physicians, obviously, you know, when you're talking about an or the physicians are the leaders of the operating room and they are the ones, a lot of times you can say the CEO or the captain of the ship.
John Ervin (15m 27s):
And, you know, it's always been really interesting to learn and work with a lot of the physicians over the years, because in the end they just wanna take care of patients and they provide good patient care. And I always tell my staff, you know, we always have to remember everything that happens in an operating setting. There's lots of multifactorial factors that come into play and the more communication, the better teamwork, the better collaboration that we have, the better outcome for the patient in the end.
Mark Graban (15m 59s):
Yeah. And you know, it's interesting, you know, you talk about your time in the military. I have no personal experience, time serving in the military, but I worked very closely with a lab director at a children's hospital who had retired for military medicine, 25, maybe 30 years, and then was in, in the civilian healthcare world. And, you know, he really taught me a lot about how this, I guess, stereotypical command and control yeah. Approach is not the daily norm in military medicine that yeah. And the heat of battle, there's a time and a place where you do what I say, where people are going to die. Correct. But he described, you know, military medicine like you did I, instead of command and control, I like what you say, communicate and collaborate.
Mark Graban (16m 43s):
Yeah. It's a different CNC. Correct. Of, of that being the style and, and that being something that leads, like you said, the teamwork and quality and to safety, but in civilian medicine, we have hierarchy though. Yes. You mentioned that, I'm curious, you talk more about, you know, we don't have the formal rank of, you know, generals and kernels and, and down the chain, but in healthcare, there is a pretty strong, if you will, a pecking order and hierarchy within an operating room. Right. Can you talk about that in some of the challenges or some of your observations about that?
John Ervin (17m 15s):
Sure. As you mentioned, it's, it's a different model. And traditionally, you know, the, the captain of the ship has always been the surgeon. So in a typical operating room, you have a registered nurse who we call the circulating nurse. We have a, usually a nurse or a surgical technologist. Who's highly skilled individual that is basically the surgeon's assistant. And we have an anesthesiologist who puts the patient to sleep and monitors vital signs, and does a lot of other things. So the challenges of, again, getting each individual on the same page every day for every patient, as you can imagine, if you don't have the right systems and processes in place, that can be very challenging.
John Ervin (18m 1s):
And that's some of the struggles that we've always faced in the operating room over the years. A good example is years ago, we had a thing called crew resource management. And that was really about getting individuals on a team to work more collaboratively, more effective together. And we've worked on that many, many times in the operating room over the years. And some hospitals I've worked in, we've been very successful at it. And some we haven't, but what we've found over the years is the less successful that we're, we are in increasing team dynamics, collaboration, and communication that can impact outcomes positively or negatively.
John Ervin (18m 45s):
And that's really the core of, you know, when you're working with a surgical team and getting everyone on the same page, I'll give you a good example. Over the years, you know, I've been doing this for 20 years, there was, you know, medical errors. We talked about medical errors. As you know, we talked about the Institute of medicine several years ago, coming out with an amazing report on, you know, patient deaths related to medical errors.
Mark Graban (19m 10s):
It's been 15, 16 years now, correct? Since that report came out, correct?
John Ervin (19m 13s):
Yeah. And it's a widely known report and every healthcare organization has done, you know, a lot of things to improve, you know, or decreased medical errors. Some of the things that we've been challenged with over the years is number one in any organization as you and I talk about all the time, you know, is systems and processes, of course. But number one is the leadership that you have in place and you can have great systems and processes or sometimes not so great. But the most important thing is really the leadership and, and having a professional development, a professional leadership program in place. And luckily in the military, you know, that's one of the things that they really Excel in, but we've found that the focus on team dynamics and really decreasing medical errors on a surgical team, it really comes down to communication and getting people to talk and understand each other's point of view.
John Ervin (20m 9s):
And then of course it always helps to have a coach or a mentor facilitate things. And I know you as a, you know, an expert in a consultant in healthcare have worked with a lot of different groups over the years. And I've had several individuals work with me over the years in hospitals and my surgical teams. And we've had, you know, there's instances, I'll give you a good example where we've had medical errors, we call it in the operating room, a retained sponge. So that's when you're doing a surgical procedure and you have a, a sponge, and they're really, there are very white sponges and they have a little blue tag on them that is detectable by the x-ray machine if you lose it. And hopefully you never do, but we've had incidences where unfortunately the sponges may be left behind in a patient and we call that technically a retained sponge.
John Ervin (20m 58s):
Right. And it's amazing as you do your after action review, as we used to call it in the military and really look at, Hey, how did a, a sponge end up in a patient? You know, how did we, how did we miss it? And it's amazingly, each time you go through the process and we do after action reviews, that the majority of the time we find that we need to improve our systems and process is the infrastructure of you really? How do we, how do we count the sponges? Where do we count the sponges? What individuals on that surgical team are involved in that count. And then how did we record and document, right? Those
Mark Graban (21m 36s):
Sponges now in, in an operating room setting, how common is an after action review after each case? Is that done only if there's a problem, is that done routinely? Is that done more in a crew resource management, CRM driven environment?
John Ervin (21m 51s):
Great question. It's very dependent on the organization. I think now, and many organizations becoming a lot more prominent and there's an organization which is called we call who, but it stands for the world health organization. And several years ago, this organization developed a surgical safety checklist, which is more comprehensive than a surgical checklist that we've done, you know, before the, who came out with their checklists. And it was a big change, I think, for a lot of organizations, because through this process, we've learned that it's not just about the point of actually counting sponges.
John Ervin (22m 38s):
It's also about what do you do to plan before, during, and after the counting of sponges. And that's where the, who safety checklists has really, really done some great things, but it's amazing some organizations where they're not using the who checklist and, and, you know, a lot of organizations are trying to use that as a standard method, as a benchmark. And I've been involved with some of those organizations, but it's been amazing over the years to see organizations that still want to do it their own way or how they feel is the best way or what has worked for them over the years. Yeah. And that's where a system like lean process improvement, I think really helps to provide discovery, understanding for teams, for organizations to realize that, you know, we're not just trying to shove a system or process down your throat all the time.
John Ervin (23m 29s):
Mark Graban (23m 29s):
Well, and I think there's parallels with lean and for what I've managed to learn about CRM. I have a friend of mine, who's an airline pilot, former Navy pilot, who does work in hospitals, that, that there's strong parallels of having good processes, but maybe more importantly, creating an environment where people are free to speak up. Correct. You know, a retained sponge is in that never event category. It's supposed to be a never event. We know it happens a lot and, you know, trying to help, I'm curious if you, any stories, examples of this, of how to work with people to speak up, you know, I'm, I'm a big nerd and I was watching a show last night on airline safety on the weather channel.
John Ervin (24m 11s):
Well, you were tweeting
Mark Graban (24m 11s):
In the middle of that called yeah, well called why planes crash? And, you know, none of the stories in that episode were about bad technology. It was about dynamics in the crew, among the crew, within the cockpit. And, you know, one example was a flight that was circling for an hour and a half or so over Portland, back in the, in the seventies, I think it was 78 and everyone was focused on whether the landing gear had come down properly. The captain wasn't paying attention to fuel levels if the, the engineer and the first officer had concerns, but they really didn't speak up very prominently. They didn't speak up forcefully enough. And the plane crashed short of the runway because it ran out of fuel.
Mark Graban (24m 51s):
And, you know, Toyota has this system called an andon cord where, you know, people are encouraged to speak up. Not only when they know there's a problem, but when they suspect there's a problem. So I assume in an operating room, someone might say, no, I'm not sure, but I'm, I'm afraid we might not have all of the sponges out of the patient. Hopefully that's speaking up. Even if that person turns out to be wrong, they have a concern that hopefully, you know, that, that, that concern whether it's validated or not is welcomed and, and rewarded. So I'm, I'm curious, you know, some of your thoughts, your experiences about trying to make that a better dynamic or more likely to happen.
John Ervin (25m 29s):
Yeah. You know, I guess I've been lucky and unlucky in that area. I've personally experienced that. And of course, with team members that I I've managed over the years, we've also had, you know, again, what we call is retained sponge. So let's talk about my first introduction to that. When I was in the military, we were doing a, a heart procedure. And at the end of the procedure, we count the sponges and that's like our checkoff to make sure, Hey, we started this procedure with 10 sponges. We finished the procedure with 10 sponges. Right. Seems pretty simple, pretty basic process.
Mark Graban (26m 8s):
Right. Don't sew up the patient until you've confirmed.
John Ervin (26m 10s):
Correct. Correct. And that's pretty much standard, you know, in all surgical settings. So in this situation, and I was with a very experienced nurse who was mentoring me at the time and we found out that we had an incorrect surgical sponge
Mark Graban (26m 26s):
John Ervin (26m 27s):
Count. Oh, incorrect count. Yeah. Correct. So let's just say, for example, we started with 20 sponges. We had 19 towards the end of the procedure. Now, luckily we were following pro the correct processes and systems, and we notified the surgeon who was doing the procedure. And the surgeon had said basically, well, I think we have all the sponges. I don't think we have a
Mark Graban (26m 52s):
Miscarriage, I think, or we know,
John Ervin (26m 54s):
Mark Graban (26m 54s):
John Ervin (26m 55s):
So what happened was the surgeon ended up completing the procedure and actually suturing up or sewing up the patient's chest. And me and my colleague continued to, you know, kinda speak up as we say, in the healthcare world and say, listen, we don't have all the sponges and we need to confirm or validate right. Our sponge
Mark Graban (27m 22s):
Count. And that's possible the sponges on the floor, correct. Or in the middle of some linens or inside the patient. Correct.
John Ervin (27m 28s):
I mean, that's absolutely correct. So we basically look through every trashcan. We crawl on the floor, we look in every corner of the operating room setting to see if we could find this sponge and this situation, unfortunately we could not. So after the procedure, when the patient unfortunately was already sewed up, we called x-ray and they came and they bring in a, a x-ray machine that was on wheels into the operating room. And I'll never forget it. We, we took a picture, we took an x-ray and low and behold, we had a sponge in the patient's chest. So of course, you know, the surgeon was there and he was obviously notified. And we had to go back in, open up that patient's chest, which is obviously risky, right.
John Ervin (28m 13s):
Especially if they're a long open heart procedure and then go back in and retrieve that sponge. And as I mentioned before, again, it's communication and processes, and usually it comes down to team dynamics. You know, what kind of team dynamics exist? What kind of culture exists in that team? And do you feel comfortable speaking up because if myself or my colleague did not speak up and some people might say, well, you should have got the x-ray before you should have got it before you closed the patient's chest. But, you know, we followed our process and, you know, luckily we did get the sponge and pulled out
Mark Graban (28m 50s):
Was, was the surgeon in this case, not following the process though. Did, did the surgeon kind of plow ahead and say, correct? No, I think it's fine. And, and, and the patient was sutured up, correct.
John Ervin (28m 59s):
Which you hit on a really good point, you know, in an operating setting, you know, there's a lot going on, you know, there's usually multiple procedures, one following another, and there's a lot of pressure on everybody, again, to do the best job you can provide the best care you can. But to, again, you know, you have several cases during the day, so that really hits to the culture. Right. You know, the culture in that room, the culture of the organization and how a surgeon or an individual nurse or surgical technologist, how they feel communicating to each other
Mark Graban (29m 30s):
Right now. And, and I'm sure, you know, it sounds so simple. How does a never event ever happen? It it's what you described. It's human dynamics. It's whatever blind spots or arrogance or whatever you might attribute it to that lead to someone saying, well, no, I, I didn't screw up or checklists are fine for other surgeons, but no, we never make mistakes. And correct. You know, there, there was one thing they talked about in that aviation show last night when they were rolling out crew resource management, when they realized in the airline industry, in the seventies, all these air disasters were occurring because of these, these crew dynamics, people not speaking up, not challenging the captain, the captain not welcoming being challenged.
Mark Graban (30m 12s):
And, and somebody made a comment that the captains of the, of, of the planes that needed CRM the most were the ones that were most resistant
John Ervin (30m 20s):
To. That's amazing. Isn't
Mark Graban (30m 22s):
It? Yeah. So, I mean, I'm just curious what reflections you had about different surgeons and their receptiveness or resistance, or even in that case with a retained sponge, what, what's the feedback loop or the reflection do you think on, on the, the part of that surgeon, how do they react to a situation like that? How do you create kind of better dynamics of convincing the surgeons that this stuff does matter if, if they didn't already believe it?
John Ervin (30m 46s):
That's a great question. And I remember, you know, I'm, I still keep in touch with the surgeon to this day. I remember at the procedure and the surgeon came up to me afterwards and, and he thanked us, you know, for following the process for following the system. And he said, you know, and he wasn't, and it wasn't one of those crazy surgeons that you sometimes hear about, you know, he was a good person, a, a good hardworking man. And, you know, he just felt strongly cuz he never had an error before he never had a retained sponge before. So again, he felt like, you know, we did it the right way. There was no question in his mind that we had left a sponge in that patient's chest, you know, but again, that's why the airlines over the years has really focused on implementing checklists, you know, a tool Gandi, you know, from Harvard, I saw him on, I think CNN the other day again.
John Ervin (31m 45s):
And he again has always focused on checklists because if we continue to rely on individuals, right. And not systems and processes, then we always err on the side of, well, this is how we do it or this is how we feel it should work better. Right. That's why the airlines over the years, it's funny that you mentioned the airlines. I actually visited the airway airlines a couple years ago to benchmark lessons learned from them and how they have implemented safety as the center. A lot of things they do compared to the hospitals. And it's absolutely amazing how similar the two systems are between the airlines and the hospital. Yeah.
John Ervin (32m 26s):
And as you mentioned, the thing that we found was if you look at an airline and you say, okay, the surgeon is the pilot, the operating instruments, look at them as the food going onto the plane and on the plane, you have your, your, your team, you know, you have your flight attendant, right. Which is working directly with your, with your pilot. So we have nurses in the hospital right. In the operating room and the co-pilot for a plane is exactly like the anesthesiologist in an operating room. So we looked at those systems and processes and over the years, I think they've done an amazing job of really adding checklists and people, most importantly have learned that they follow the checklists and, but they review before and after the incidences they have, and they continue to refine that over the years.
John Ervin (33m 20s):
Right. So that's a good point.
Mark Graban (33m 21s):
Yeah. And, and I'm a big fan of Dr. Gawande's books, including The Checklist Manifesto and his earlier books. He has a new book out now on the mortality and dying. But the, the only thing I could find to, to be critical of was Dr. Gawande own admission. When I saw him on his book tour for checklist manifesto, admitting that even when he was traveling the world with the world health organization, promoting checklist, he was not using them in his own operating room really. And he admitted to that, which I think is a I, that was troubling to hear that it was good. He would admit that. And you know, he finally came around to realizing that these checklists are good for everybody.
Mark Graban (34m 3s):
Yes. Regardless of where you're trained and where you're working. And he, he, he said at least once a week that, you know, cuz he still does quite a few surgical cases, at least once a week, they catch something that would have been a problem or potentially cause harm to a patient that they catch it because of the checklist once a week.
John Ervin (34m 21s):
Mark Graban (34m 21s):
That's amazing. Right. And you know, we, we could step back and say, well, he should have been doing this from the beginning. You know, I guess better, late than never. But I guess it just goes to show where sometimes it's easy for people to convince themselves well, you know, well, I, I don't make mistakes. I'm different when we're all human and we all do.
John Ervin (34m 37s):
Yes. And it's interesting, you mentioned, I had a discussion with a very good close friend yesterday and you know, he's been doing little personal coaching with me and, and he said, you know, he said, John, I know the things, the checklist that we have in place for you. I know you're going to kind of veer off path a little bit, but I'm gonna make sure I get you back on track. Right. And in the, you know, in the manufacturing world, you can call that upper control limit, lower control limit, you know, whatever limits we set for ourselves or organization, you know, nothing, there
Mark Graban (35m 10s):
Might be a statistic geek, sorry to interrupt. It would be more the specification limit than the specific, the control limit. Sorry. Okay.
John Ervin (35m 16s):
That's alright. Good point.
Mark Graban (35m 18s):
There's a there's boundaries. Exactly.
John Ervin (35m 20s):
And then we have to be able to have these systems and processes the communication in place to bring us back, you know, to be able to communicate with each other. Another great example I had was another medical error and it was another retained sponge or another sponge that was left in a patient. And this one was a little different scenario. We had done a procedure and the individual actually participating in the surgical procedure as part of the surgical team knew that there was an incorrect sponge count. Right? So we went through the procedure, we had the team in place at the end of the procedure. The individual knew that there was an incorrect sponge count.
John Ervin (36m 2s):
But as we talk about the culture of an organization, the culture of group dynamics, that individual did not feel comfortable speaking up. Right. Right. And we use that word speaking up all the time. Right. It seems really easy, but when you're under pressure and you have a culture in place that they don't haven't for years kind of allowed speaking up or you just don't feel personally. Yeah. The end result was we had to retain sponge in a patient and I'll never forget after that retained sponge meeting the, the family member in a private room and explaining to them that we had, you know, a sponge left in their family member. Right.
John Ervin (36m 42s):
And amazingly, the person was very calm and very understanding. And luckily we realized it at the end, but you know, that individual was not a bad person. They weren't incompetent. But as we look back and we did our after-action review of, of that situation, we found that the things that were being talked about in the room at the time between the team, you know, they weren't the most appropriate things, you know? So
Mark Graban (37m 11s):
People were, there were distractions. Exactly. Yeah. Cause in the cockpit, they talk about the sterile zone where I think, you know, anywhere within 10,000 feet of the ground, there is no chit-chatting about the super bowl or your family, correct. Or you know, things that are not correct on task. Correct.
John Ervin (37m 25s):
Correct. Yeah. And that, what we found was that led to, again, that culture of not feeling that I can speak up. Yeah. And it was a lesson learned, I think for myself as a, as an administrator, obviously the team learned, and I'll never forget the surgeon afterward. The surgeon told me this has never happened to me in over 30 years. Wow. And it was the first time ever.
Mark Graban (37m 49s):
And, and the one thing that frustrates me about healthcare is that, you know, you hear a lot of these stories where it's like, well, that was the first time ever, but it's not the first time ever anywhere in healthcare. Right. And it seems like in healthcare, different organizations go through their own exploration and discovery of the first time we gave adult dose heparin to a child by mistake, you know, that happened famously at Cedars Sinai, Dennis Quaid's twins at it probably had never happened there, but it had happened previously at other hospitals, correct. Where the known risk factors are identical and the situations are identical. And you know, it's just, if I could, you know, kind of snap my fingers and change the world, I, I would wish hospitals and, and medical, you know, surgeons, doctors, nurses would, would learn more from other people's errors.
Mark Graban (38m 37s):
And so instead of falling back on, well, I'm not gonna do that. Realizing we're all human. We all need to do our best to prevent errors and incorporate those past failures into our own good processes before we make that same mistake ourselves. Right.
John Ervin (38m 52s):
Yeah. I think you make a great point and I'll give you another really good example. Several years ago, there was a hospital in Rhode Island over a period of a couple years, they had wrong site surgery. That basically means that they operated on the wrong body part three times.
Mark Graban (39m 8s):
And you think, how could that happen?
John Ervin (39m 10s):
Yeah. I mean, same organization, same environment, three times. And through that again, I talk about lessons learned all the time. You know, they did an after action review and they brought in an organization called the joint commission, which is the organization that basically accredits hospitals around the country.
Mark Graban (39m 29s):
Does joint commission invite themselves in or were they brought in? They were
John Ervin (39m 33s):
Brought in, okay. They were
Mark Graban (39m 34s):
John Ervin (39m 34s):
Again, when you have medical errors, the joint commission comes in to inspect your organization and literally find out, you know, what's going on. And are you following your proper policies and procedures or you're following safe evidence based care. Now through that, you know, sometimes it takes some of those never events like that to kinda where you get an epiphany. So through that, the joint commission to their credit established a program called the wrong site surgery project. And they went around the United States and they chose specific hospitals to be involved in a joint project. And they were all in different regions of the United States, different size hospitals.
John Ervin (40m 19s):
And we were luckily to be part of that process at a hospital I was at. And it was amazing what we learned through that process because when you look at any situation and if you think of Steven Covey talks about different paradigms, you know, in his, in his book, you know, seven habits, he has a picture of a woman that may look really old to some people. But if you look at it a different way, she might look really young to some people. So how do we look at paradigms? Right? So what the joint commission came in is they really taught us through, you know, a lot of data collection, a lot of validation, you know, just hands on, just speaking and collaborating with different physicians and team members that it's not just about the end point of counting sponges or making sure that process is done.
John Ervin (41m 9s):
You have, there's a pre-planning that needs to be done. And then a post planning. And we went through this really interesting process where we found even how we write down words on a schedule, you know, in the operating room or when the surgeon's office is calling the office at the hospital to schedule a case. If there's abbreviations written down incorrectly, you know, or it's supposed to be left side and they, in the old days, we would, we would write an L and circle, circle it as left. Well, we stopped doing that because we found that you have to go down to the most minute detail to really look at your processes and systems and how even the most minute details can impact.
John Ervin (41m 57s):
And you might think, oh, well, how I get a case scheduled from the office? Oh, it was, it was, you know, they made a spelling mistake on the, on the piece of paper that was sent over or faxed over that could end up in the wrong site surgery. Yeah. So it was interesting to go through that process. Yeah.
Mark Graban (42m 10s):
And, and there's, I think a good systems engineering process teaches you to be proactive and the, the high reliability organization's framework, you know, among the different, the five main principles there includes, you know, a focus on operations. Like you're saying, looking at those details and, you know, having a bit of an obsession about, well, what could go wrong, you know, and, and designing that risk out of the system, whether it's now you have band abbreviations so that we don't get the wrong units on a medication or best practices around when you, you know, looking at trailing or leading zeros in numbers, trying to prevent mix up.
Mark Graban (42m 53s):
You know, I think pretending that it's not gonna happen or ignoring the risk is not a good strategy instead of actually figuring out, like you said earlier, how to engage everybody in being able to point out risks and, and solve them together, that's Kaza.
John Ervin (43m 8s):
Correct. It was funny. I'll never forget the first time after we went through that process with this organization, one of my nursing team members, we printed out the schedule every day. So we started doing every single day, what we call huddles in the operating room. So we would look at the schedule the day before, and we would have a huddle with all the right people in the right room. And I'll never forget the first day we printed out our revised operating room schedule and it used to be maybe two pages. Now it was like six pages, right. And it took us almost an hour and a half to review the schedule and go over it. Right. And, and the comment again was, well, this isn't how we've done this, this isn't how we do it.
John Ervin (43m 50s):
This isn't our, our schedule. How are we gonna read this thing? So again, you know, we learned that we have to overcome that. I always call it inertia where, you know, look at the data, look at the best practices, look at the evidence based medicine. And sometimes it's hard and painful. You know, sometimes you're feeling the pain, but we really learned a lot about that process. And I think in the end, we all benefited. I think the patients really benefited a lot and the team members as a whole really understood that, you know, the key point was you have to look at the whole picture. Right. You know, in the process. So
Mark Graban (44m 25s):
John Ervin (44m 26s):
Was very powerful, I
Mark Graban (44m 27s):
Think. Yeah. Well, great. Well, John, this has been a really good discussion. I, I think we'll go ahead and wrap things up here. We, we could talk, we have previously without a recording going talked about this kind of stuff for hours, but maybe I'll invite the listeners. You know, if you have questions we can play, ask an or leader. Yeah. That would be fun. And maybe do a, a follow up podcast. There's so much more we could explore. Okay. But do you have a final thought to, to leave people on John about either, you know, the state of patient safety or where you hope things are gonna be going in
John Ervin (44m 57s):
The future? Sure, absolutely. I think the thing that I've learned, especially in the last several months is, you know, and we had a great meeting this morning with a group of individuals here in, in San Antonio, I think in the end and me and mark have gone back and forth with this over the years in the end, you know, it, it's super important to have systems and processes in place. It's super important to standardize these processes, but in the end, it's really about the people. And it's about providing the people with a platforms for success as I call them. And there's numerous ways that those platforms for success can be provided, but in the end, it comes down to people, especially in healthcare, it's a people business and it's about leadership and it's about making team members and individuals feel part of the process and that they can make a difference in the end.
John Ervin (45m 49s):
And they have the ability, like you mentioned earlier in the Toyota manufacturing company to pull that cord and stop the process. And I think that's a lesson learned, I think that I've learned over the years, so.
Mark Graban (46m 1s):
Okay. Well, that's great. So it's all about people, John you're good people. Yep. Thanks for, thanks for being a guest here today on the podcast, sharing some of your experiences with us.
John Ervin (46m 9s):
It's been fun. Thanks Mark. I appreciate it.
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