Joining me for episode #222 of the podcast is Erin S. DuPree, M.D., FACOG, the Chief Medical Officer and Vice President for the Joint Commission Center for Transforming Healthcare. Dr. DuPree is an OB/GYN by training, was previously the Chief Medical Officer and Senior Vice President for Medical Affairs at The Mount Sinai Medical Center in New York City. She is a certified Six Sigma Green Belt and is also a TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) master trainer.
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One thing we have in common is both growing up around Detroit, being exposed to the auto industry and the ideas of W. Edwards Deming early in life.
In our conversation, Dr. DuPree explains the mission of the Center — transforming healthcare into a high reliability industry — and why that requires not just tools, but culture and leadership commitment. We talk about her early exposure to W. Edwards Deming's ideas (via her father's career in the auto industry), how that shaped her approach to improvement, and why preventable harm remains such a serious challenge in healthcare.
Dr. DuPree shares stories that reveal both the progress and the gaps: from simple failures in hand hygiene to wrong-site surgeries and mislabeled instruments. She outlines how Lean, Six Sigma, and change management form a complementary toolkit for sustainable improvement, and why engaging physicians, leaders, and frontline staff is critical. She also highlights examples of hospitals reducing harm — such as preventing falls with injury — through disciplined, systematic improvement.
This episode is a reminder that while healthcare has achieved remarkable innovations, reliability and safety must be built deliberately. Dr. DuPree offers both cautionary lessons and hopeful proof that transformation is possible.
You can read her full bio here.
For a link to this episode, refer people to www.leanblog.org/222.
For earlier episodes of my podcast, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts. You can also subscribe and listen via Stitcher.
Transcript:
Mark Graban: Hi, this is Mark Graban. Welcome to episode 222 of the podcast. It's May 20, 2015. Joining me today is Dr. Erin DuPree. She is the Chief Medical Officer and Vice President for the Joint Commission Center for Transforming Healthcare.
Dr. DuPree is an OB/GYN by training and she was previously the Chief Medical Officer and Senior Vice President for Medical Affairs at the Mount Sinai Medical Center in New York City. She's a certified Six Sigma green belt and is also a TeamSTEPPS master trainer. One thing that we both have in common is growing up around the Detroit area, being exposed to the auto industry and the ideas of Edwards Deming early in our lives. So in the podcast today, topics include her role and what the Center for Transforming Healthcare does, how she first got involved in healthcare and quality improvement, in particular Lean and Six Sigma. Of the different estimates about the number of patients harmed or killed each year due to preventable medical error, which numbers does she think are most accurate? What are some of the barriers to improvement in healthcare? And at the end of the podcast, she shares a personal patient story that helped her see some of the harm that occurs and the need for improvement in healthcare. So if you'd like to see Dr. DuPree's bio, learn more about the Center for Transforming Healthcare, there's links to all of that if you go to leanblog.org/222. Again, our guest is Dr. Erin DuPree. Erin, thanks so much for being a guest today.
Erin DuPree: Well, thank you, Mark. It's great to have the opportunity to talk with your audience.
Mark Graban: So can you start off by introducing yourself and your background, obviously a medical background, and then maybe also talk about the Joint Commission Center for Transforming Healthcare as well?
Erin DuPree: Well, sure. I work right now as the vice president and chief medical officer of the Joint Commission Center for Transforming Healthcare, where I lead the groundbreaking work that we're doing. And for those of you that aren't familiar with the Joint Commission, the enterprise is actually comprised of three nonprofits. The Joint Commission accredits about 90% of the hospitals in the United States and also accredits healthcare organizations in a number of settings. So that's actually one of the nonprofits that people in healthcare are generally familiar with. There are two other nonprofits, Joint Commission Resources, and that's essentially our education consulting arm. And the newest nonprofit, the newest branch of the Joint Commission Enterprise is the Center for Transforming Healthcare. And that's the branch that I lead. It was formally launched in 2009, and the mission of the center is to transform healthcare into a high reliability industry.
Mark Graban: And how did you get involved from being a physician, getting involved in healthcare quality, then getting involved in Lean and Six Sigma?
Erin DuPree: Sure. I was actually surrounded by quality principles as a child, which I learned later. I grew up in Michigan, and my father was a mechanical engineer for the auto industry at General Motors and actually worked with Deming and others from Deming's team during his time there. So without even realizing it, I think it was infusing my home life as I grew up.
Mark Graban: Yeah. And we discovered that when we talked before. The listeners don't know that. That we share some common background. We're both from Michigan. Our dads were both engineers in the auto industry. And there was both that exposure to Dr. Deming.
Erin DuPree: Right, exactly. So I became an obstetrician, gynecologist, went to medical school, and then as a clinician, I delivered thousands of babies, did hundreds of surgeries, and quite honestly, I saw harm occur to patients that was preventable. I saw the systems not working, and I saw horrible things happen. And I saw a need for improvement. I saw a problem and I wanted to fix it, quite frankly. And I was very fortunate to have the opportunity to undergo green belt training as a physician years ago when that wasn't the case for most physicians. So it really helped to give me the tools to make changes in health.
Mark Graban: And was that green belt training, was that sponsored by a hospital or health system where you were practicing?
Erin DuPree: Yeah, exactly. It was sponsored at the healthcare system that I was working and they actually had had GE come in, do the training at the time as that organization was building up their own internal training capacity. So it was one of the earlier waves of training at that organization that I was part of and our class had about 20 people and I was on a project team with four people. It was great. I learned a lot.
Mark Graban: Now, we have listeners who are maybe still on the manufacturing side of things or in other industries and people who are not around healthcare often don't know about instances of preventable harm or how these things occur in healthcare even with well-trained people and everybody who is obviously well educated, cares a lot, works hard. What are some of your thoughts around why these things, why harm still occurs or maybe a story or an example that you could tell about that perhaps?
Erin DuPree: Well, I think they're exposed to the amazing things that are happening in healthcare today. I mean, there's robotic surgery, there's new therapeutics, there's innovation everywhere. Healthcare in the United States is really amazing. Yet with all of that comes an increase in complexity and an increase in risk, quite frankly. And that risk is high. Studies show that healthcare workers wash their hands only 40% of the time. And for those not from healthcare, that impacts the event of healthcare-associated infections. So many healthcare-associated infections are preventable. And hand hygiene is one of the simplest things to do. You'd think it's simple, but it's not so simple. Right. Only 40% of the time. So that complexity and what's on the front line staff, what's on their plate right now is all part of it. Medicine right now is essentially practiced like a craftsman's art. I mean it's practiced like the art of medicine. Yet it's more complex than many things today. And yet we're still approaching it in a very one-off way. As opposed to really taking performance principles and applying them to healthcare.
Mark Graban: Yeah. And taking a look at systems and I'm curious to hear some of your thoughts about high reliability organizations since you used that term. Before we delve into lean and Six Sigma for people who aren't aware, how would you summarize what the high reliability organization principles are?
Erin DuPree: Well, first of all, it's not healthcare today, but what it is. The principles really, it's those organizations, those industries that are complex, that are risky, that go for long periods of time without accidents, without harm. And the term was coined in the late 1980s by researchers at the University of California and Berkeley, including Karl Weick and Kathleen Sutcliffe. What these organizations do really well is they anticipate harm. They anticipate it really well with a preoccupation with failure, a sensitivity to operations, which is something all of you as leaders, lean folks, understand how operations differ in different places. And for those of you that aren't familiar with Weick and Sutcliffe's work, their book Managing the Unexpected is really a great primer on high reliability organizations, or HROs, as you will hear them sometimes referred to. But what these organizations do is they also realize that errors will continue to occur. You can anticipate harm, you can hope that it won't happen, but sometimes it does. And then you have to contain those errors from actually causing harm. And that's really that commitment to resilience that you find in high reliability organizations. I think the overarching theme that you see with high reliability organizations is a collective mindfulness. They're all on the same page. They have the same mental model of what they're trying to do, which is have safety first. Safety first is first and foremost. And the truth is, in healthcare, many people don't even have an awareness that it's an unsafe industry. So bringing those reliability principles from nuclear power, from commercial aviation is huge. We have small pockets of reliability in healthcare. For instance, blood transfusions have come a long, long way since the 1970s and early '80s. Anesthesia for a healthy patient, very different than it was in the 1970s. Those small pockets of healthcare have done really well with reliability principles. Yet most of healthcare still can be very uncoordinated, can be very unsafe. There were 600 fires in operating rooms last year. There are 40 to 50 wrong-site surgeries in this country, best estimates, each week. So there's still a fair amount of harm and lack of reliability, whether it's those routine safety processes like hand hygiene or patient identification and then these horrible adverse things, these never events that still happen.
Mark Graban: Yeah, well, I had a chance last year here in San Antonio. There's a academy for high school students are transitioning into their first years of college, they have what they call their health professions academy. And these are kids who want to be nurses or physicians and all sorts of different career paths. And they're getting started in initial health jobs. And I was talking to them in their class and I brought up the idea of preventable harm and the need and hopefully the opportunity for them to be involved in these improvements. And you know, kind of even talking about the idea of, you know, one instance of a wrong-site surgery, their jaws dropped and hit the table. And I asked them, “Well, how does that happen?” And they were really, they had good instincts. They said, “Well, it's probably miscommunications or lack of planning.” They were very intuitive. They didn't say, “Oh well, those doctors are bad.” I was really impressed with their maturity and sense about how things like that occur because it is shocking.
Erin DuPree: Right. Well, and part of it is really the history of medicine in that performance was really thought to really just revolve around having a good doctor and that that's all that mattered in healthcare was as long as you had a good doctor, you received good health care. Well, that's not the case in healthcare in 2015. The complexity, exactly. It gets at handoffs. There's 20 people involved in the care. There have been studies that looked at the care in the emergency room.1 If you're there for a few hours, the number of process steps is staggering. It's like 10,000. And you know that the instances of harm in healthcare are real. It's painful to think about. People fall, people think, “Oh, somebody fell.” Well, people die from falling. 11,000 people die each year from falls in the hospital. I mean, that's the size of the town I grew up in.
Mark Graban: Now, before we talk about some of the other pockets of success and things that are happening to improve the problem of preventable harm, there's so many different studies and numbers that get bandied about. The study from To Err Is Human estimated 44 to 98,000 deaths each year. There's more recent studies that put the number anywhere between 200 and 400,000. And all these different estimates have some flaw in their approach. Are there certain numbers that you think are more reliable or how could we determine numbers the best we can?
Erin DuPree: I think there are no reliable estimates, quite frankly. We know that patients are being harmed, but the numbers and the estimates vary really because there's no central source of information. And also everyone measures harm in a different way. What a patient thinks is harm, a surgeon might not necessarily, and vice versa. And even across one discipline in healthcare, some of my OB/GYN colleagues, some would say something is a complication, others wouldn't. So we don't even agree on what harm is in healthcare, which makes it difficult to measure. Each of the studies that you mentioned, they measured a little bit differently. So what we do know is that every single case of harm is one too many. It could be your brother, it could be your mother, it doesn't matter. And that's where really the center, the work we do here and the participating healthcare organizations that we work with, they use Robust Process Improvement methods and tools and we coined that term here at the Joint Commission to really include Lean, Six Sigma and change management tools. And we use that approach here internally for our business processes. And we partner with organizations across the country and around the world with that approach.
Mark Graban: Yeah, so can you maybe elaborate on that? Because I'm working with a health system right now that has me in to help them with Lean and Kaizen. And to them that's a piece of robust process improvement, which is one of the key factors towards becoming a high reliability organization. So could you elaborate a little bit more on how you think those different methodologies work together and how the center explains that or helps people with that?
Erin DuPree: Yeah, well, it's all about improving the big Q quality. And quality is really everything. It's the performance of the organization. And these healthcare organizations are all trying to deliver great care, let's face it. I mean, they don't want to cause patients harm. They're not going to work to cause harm each day. And these tools can really help to bring out the… to remove the inefficiencies, the waste in healthcare today. They can improve the accuracy of the many, many process steps that occur, get rid of variation where there shouldn't be variation.2 They can improve the effectiveness of healthcare and importantly, ensure that healthcare is really aligned with the values and goals of a patient. And to do all of that in healthcare, we need acceptance and accountability over the massive changes that that requires in healthcare. Because it's a 180. I mean from where healthcare is at today, these are big changes, it's transformation and how do you manage that change? And so the change management tools are really, really important. And in fact, many organizations in healthcare are starting to realize that's actually where they need to start is with change management. So I think they're all very important. I mean healthcare with where it's at, with this level of harm. We need the toolkit needs to be fairly large, and I think the importance is really having that consistency as an organization around your performance, a disciplined, systematic approach to improvement. And an organization from the leadership level needs to bring that in and support that effort and allow the frontline staff to have it be the way they do business, that they have the tools to improve.
Mark Graban: So I'd be curious to hear more about your views and the center's views on the change management piece because I think our listeners here know Lean. They know probably Six Sigma and how Lean and Six Sigma can fit together. I see a lot of cases where organizations struggle because they're not using maybe the full Lean principles and engaging everybody in improvement. They're forcing changes or they're only focused on cost or they're doing things that might not… I see a lot of those issues, lack of communication or lack of engagement come down to change management.
Erin DuPree: Absolutely. I mean, I have an example from a healthcare organization that I worked at previously and there was a big initiative that I was leading and I had my change management skills, and I was getting some pressure from above to move forward in a certain direction. And I personally knew it was going to be a waste of time because one of the key stakeholders, having done a real stakeholder analysis, was very resistant and was going to subvert the process. So if I didn't get that person on board, we had great things to work on and deliver from a solution perspective. And the frontline and middle management folks were totally excited about it. But one of the key leaders was not totally there. And I didn't really know this person. I mean, I knew of him, we'd been in meetings together, but we hadn't really worked on anything together. So how was I really going to approach that? Using the tools to work through that, I came up with a strategy, working through that that changed the dynamic and he became the biggest cheerleader. And that's what happens over and over again when you use the change management skills effectively. You get people on your team, you figure out how to work through those difficult situations.
Mark Graban: Well, it seems like a lot of it, even in the scenario you're describing, it takes some time, it takes some effort. It takes leadership skills of trying to understand somebody's perspective instead of just trying to force a change on them. And I see organizations, my favorite question back to people kind of ask, “We're having trouble engaging our physicians.” And there's a tone that often makes it sound like they're blaming the physicians. And usually my first question back is, “Well, what are you doing to engage them?” It's a very active process. That engagement or buy-in doesn't just magically happen or we probably shouldn't expect it should happen after sending out one memo.
Erin DuPree: Right, exactly. That's what we see here a lot too, at the Joint Commission. It does take time to engage the stakeholders, but I think it actually saves time, quite frankly, because you end up developing solutions that are more sustainable and you, I mean, the organization really can rock and roll then. Then you're really transforming things. And it's true. Bringing the, for instance, in the case that you mentioned, bringing physicians on board, it's really about, I mean, they want to improve care, they don't want their patients hurt. But they oftentimes don't understand systems and the complexity of healthcare. Today they don't either. They're learning this about safety and reliability too. So to bring them in and ask for their opinion and what matters to them, that starts to change the entire dynamic of the conversation. And the solution, actually you will develop better solutions with the engagement of those folks.
Mark Graban: Well, I think you make a great point, that investment in time can lead to time savings down the road. There's a Toyota-ism, I'm sure you've probably heard of, this idea of “go slow to go fast,” that we're laying the foundations, we're talking to people. And a lot of times people are impatient. They realize to their credit, “Okay, we need to improve quality, we need to reduce patient harm. We've got no time to waste. Rush, rush, rush.” And then people sometimes feel steamrollered or they get defensive and we have things slow down.
Erin DuPree: Absolutely. If you don't have the buy-in and you're implementing something, it will fail. And ultimately facilitating change requires planning, it requires inspiring people. So there are tools in change management about inspiring people, because unless there are some people that are naturals at that, but most people don't think that way or act that way. So we all need to learn those ways to inspire people around us to be up for the big change. Because change is difficult. Right. And, you know, and then importantly, how do you launch that change initiative? There are certain ways to launch successfully and to align the operations around that launch. There are tools to help with that. And then importantly, how can you sustain that change over time, going forward?
Mark Graban: Yeah. I forget whose definition it is. I heard somebody say that a definition of leadership was inspiring people. So that's what your use of that word reminded me. Inspiring people to do things they might not otherwise do. And that's different. I think then it's certainly not a matter of forcing them to do it. But change leadership, I think, requires people to find common ground where people want to participate in Lean or Six Sigma initiatives. I think that's a difference than a lot of organizations say, “Well, it'll be faster. We'll just force them to do it.” And I don't think that really works.
Erin DuPree: Yeah, force-feeding doesn't usually work. At the center, we've actually developed a great tool to inspire leadership around reliability and performance improvement. It's called the High Reliability Self-Assessment Tool. It's an organizational assessment tool around leadership, culture, and performance improvement. And it really allows a senior leadership team to talk about some of those issues and come to consensus and inspire them to take those first steps towards really having an approach to performance and reliability. So that's coming out actually later this year from the center. It'll be available to all accredited organizations.
Mark Graban: Okay. I was going to ask if that was something online, but not yet. Later this year.
Erin DuPree: It's coming very soon. It'll be early this fall. Yep.
Mark Graban: So in your talks with different organizations, I'm curious, maybe other than some of the communication or change management issues, are there other barriers, maybe particular barriers in healthcare that slow or prevent the adoption of Lean and Six Sigma as a way to improve?
Erin DuPree: Well, I think we just spent time talking about. The biggest barrier is that it requires change, and nobody likes change. I mean, leaders will put up questions about the time and the money and the return on investment without understanding that it will actually pay for itself really quickly. The thinking that if they just train a few people in the organization and that's enough. It's not. It has to become the way the organization does their business. There needs to be eventually a critical mass of understanding of the principles. That's really, really important.
Mark Graban: Yeah. And one of the things I wish would never happen is coming into a hospital to do training. And the senior leaders, they've got a bias. So they think, “Oh, it's the frontline staff that need fixing.” And a senior executive or sometimes it's the CEO, will come in and kick off things and then leave. And I, I always enjoy it so much more, and I'm so much more optimistic about things in those cases where the CEO and the CMO and senior leaders are there in the room and they're learning and they're participating in these discussions and they're leading. They're laying the groundwork for what's going to happen outside of that training class, which, you know, it's something I can't just fall on a few individuals, like you said, or the frontline staff and managers.
Erin DuPree: Absolutely. That's the best to see. When you really see the senior leaders sitting down, wanting to learn the principles and detail too, you know, they're very invested and it's difficult to see. There is a lot of that where the leadership believes it's just a problem with the frontline staff. And if we just got a different middle manager or this or that, it'll fix that problem. And the bottom line is we're all human.
Mark Graban: Yeah.
Erin DuPree: We're all flawed in different ways. And part of what Lean and Six Sigma the approach can do is really put in better processes in your entire organization around hiring, for instance, or wherever in the chain your issues are. Potentially, it can help support that.
Mark Graban: Yeah, maybe we're on the same page here. You talk about hiring practices and one of my favorite questions to ask if people are kind of going down the blame the employees path or, “Well, we've got bad employees or our employees won't have good ideas,” is to ask, “Well, who hired them?” or “Who demotivated them to the point where now you think they don't want to participate?” Those are system issues. Yeah.
Erin DuPree: Yeah. And again, it comes down to leadership and that positive spin of supporting those around you and allowing them to do their best work and supporting them and giving them the tools to do that. And the tools are really Lean and Six Sigma, and really those allow frontline staff to be innovative and to be creative and to work together as teams across silos. I mean, that's what the approach really does.
Mark Graban: So let's delve into that a little bit more. Curious to hear your thoughts on the overlap or the blending or the combination of Lean and Six Sigma. And maybe in that discussion, if you've got a favorite success story or an example about how that's helped in healthcare. It would be great to hear.
Erin DuPree: Lean and Six Sigma, the tools are really complementary. That's truly my belief and I'd love to have a longer philosophical conversation with you because I know there are many proponents of either methodology and those of the blended. And, you know, I'm speaking from really my own training and knowing that, which I'm happy to always learn more. But it's really that, like I said earlier, we need all of the tools and if there's any limitation to some of the approach of one or the other, we can't have that in healthcare. We need a very robust approach to it. And I think Lean in healthcare today has actually brought in some of the Six Sigma principles and vice versa. I mean, I'm seeing some of that overlap in both directions, quite frankly, as it evolves. You know, I'm curious what you're seeing too, Mark, from your perspective, but that's, you know, I'm starting to see merging of sort of original concepts anyways with the way things are being implemented at various organizations.
Mark Graban: Yeah, I mean, I agree that there's, you know, there's overlap and we shouldn't argue about, “Well, you know, statistical process control. Is that a lean method or a Six Sigma method?” Well, it actually predates both. And so let's, let's use methods that work. I, you know, there are statistical methods in Six Sigma. I mean, it's math, it's statistics. My only complaint has been, you know, and readers of my blog will know this, is that I think sometimes there's just sort of a, in the blending, there becomes a blurring or sort of a watering down of Lean where, you know, I see a lot of hospitals doing a great job with kind of a lean culture change. And they have, you know, some Six Sigma experts, black belts and people who go in as needed and go help with projects. And I think that's a great approach.
Erin DuPree: Yeah, no, I think organizations are really learning how to integrate these themes into their work, you know, around that leadership commitment, the project deployment, the management approach that they're using around all of it, when to bring in the statistics, when to use what tools, the more that we can bring of that learning to healthcare. That's what we want to do here at the center, and that's why we really partner with healthcare organizations and the people doing the work across the country and around the world. Like I said, some of our work is International too.
Mark Graban: Yeah. So in the course of some of that partnering. Let me bring it back to the second part of the other question. Kind of a recent or a favorite success story of working with somebody to help improve quality and patient safety.
Erin DuPree: Yeah, well, one of our recent projects was actually preventing falls with injury. You know, I mentioned that we'd been focused on that and we had five of our center hospitals, and these are leading hospitals and healthcare systems that partner with us and the staff here, and they decreased falls with injury by 62%. I mean, that decrease is greater than any other collaborative published to date in the literature. And if other organizations use that robust approach that was used here by those organizations in the center, if a 200-bed hospital used that robust approach to falls, preventing falls, then they would avoid 72 falls with injury and a million dollars costs avoided. I mean, I don't know what healthcare organization can't. They need to do that today. The shrinking margins in healthcare are astonishing. So that's for instance, where really the blended approach of all three legs of that stool, the Lean Six Sigma and change management have really helped.
Mark Graban: And I mean, there's more and more studies. I mean, I think it's intuitive to a lot of people. And this would have been Dr. Deming's argument that improving quality and patient safety, I think is a big part of quality, that improving quality leads to lower costs. And we're starting to see more and more published studies in healthcare around patient safety initiatives having thankfully, a positive effect on the hospital's bottom line. And it seems like, you know, with reimbursement complexities and different incentives and penalties, it seems like it's a… or rewards, that's kind of an always changing landscape. But I mean, it seems like things are heading in the right direction in terms of cost, safety, quality all being improved at the same time.
Erin DuPree: Absolutely. Those organizations that have really invested in Lean and Six Sigma and change management, I mean, they're seeing returns on investment easily of 4 to 5 to 1, you know, so it's there, but it does take kind of moving forward. That evidence base is just developing in healthcare. It's relatively new. We sort of have to understand that. It just makes sense that if you improve your processes, you're going to improve the cost, you're going to create better value overall.
Mark Graban: I think, thankfully, we're at a point where people are skeptics who would say, “Well, that sounds good in theory.” Thankfully, the journal articles with that level of rigor that are helping prove this out.
Erin DuPree: Yeah, well, there are a lot of skeptics that think healthcare can just be run the way that it has been forever. And ultimately we're not at a place now. It's just the right thing to do given the patients harmed in healthcare today, number one. Number two and three.
Mark Graban: Yeah. And I mean, I think, you know, it's certainly the right thing to do. There are some who frame it as a moral obligation to protect patients or an ethical responsibility. And I think that's a pretty reasonable way of looking at it. But the fact that it's helping the bottom line, I would call that gravy, I guess.
Erin DuPree: Absolutely. I mean, it's really, you know, healthcare executives and boards, they're often uncomfortable with this information and it's really gotta be an all-teach, all-learn type of situation, to understand what quality is and become experts themselves.
Mark Graban: So do you have any other thoughts maybe on that point as we wrap up here? Things that you've seen that help influence executives and boards through your role. Other things the Joint Commission or the Joint Commission Center for Transforming Healthcare are doing to get more people, more executives and board members involved.
Erin DuPree: Yeah, I think that, you know, I had mentioned the High Reliability Self-Assessment Tool that's coming out and we've also recently put out a new Patient Safety Systems chapter that's available to all the public. Everybody can download the Patient Safety Systems chapter and it's an excellent primer for leadership. It's all about leadership, commitment, the things to do to build a culture and performance infrastructure. I mean, quite honestly, I hope for that because as a clinician, as an OB/GYN, that's, you know, if that type of leadership had been in place, certain things wouldn't have happened. I mean, one of the things that I saw that was one of my many moments of transformation for me doing this work is, you know, I was taking care of a young, healthy woman, her first pregnancy, and the pregnancy went really well. I mean, she was in great condition and she went into labor. And my partner was on call that night. He was an excellent practitioner, super vigilant, great bedside manner, all those things. And the woman had a great labor, progressed very nicely. And when she got to fully dilated, the time when you pushed the baby out, the baby's heart rate, it just bottomed out. I mean, it flatlined. And he called for forceps to assist having the baby delivered. And the nurses on the unit were not familiar with forceps. They ran to the supply closet to get them and the ones they brought back and opened were the wrong ones. They had been labeled incorrectly and couldn't be used in this situation. They ended up having to open like six more sets of forceps before they found the correct ones. Minutes and minutes. The baby did not do well as a result.
Mark Graban: I mean, those of us who…
Erin DuPree: That was a moment of transformation for me.
Mark Graban: I can believe it. And I'm just curious, for those of us who don't have your expertise in this, we hear the word forceps and is it a matter that forceps are not used as often as they used to be and hence the unavailability or unfamiliarity?
Erin DuPree: Right. In those days, that particular time, it was a time of, I would say, transition, where not as many practitioners or organizations were as familiar with forceps. In the old days, everybody, all the obstetricians were great at forceps. But there has been some transition over the last 20 years and some practitioners are great and do them very well, and other folks did maybe one or two forceps pulls during their entire training period time, which is not enough to be an expert. So it really varies by organization because if you have experts there that can teach folks to do it safely, then you'll have some of those skills transferred on. But it's becoming less and less as organizations look at some of the complications from those procedures. And there are fewer and fewer people really capable of training at that level of expertise. And the safety of cesarean sections has gotten better.
Mark Graban: And I mean, your story kind of makes me think back to these high reliability principles. An organization with sensitivity to operations, I think, pays attention to what a lot of people consider mundane details about materials management and room stocking and labeling. And, I think to your point, the best OB/GYN in a bad system can't be as successful as they need to be. And their patients won't get the outcomes that they need.
Erin DuPree: Exactly.
Mark Graban: Well, I'm glad that you and the Joint Commission and your colleagues there are helping promote these ideas that you're working with organizations. Maybe. Can you wrap up if you want to give a final mention of the Center for Transforming Healthcare and how people can engage with you or how they can find you online. That would be a great way to wrap up.
Erin DuPree: Absolutely. Again, we partner with healthcare organizations, not just hospitals, but healthcare organizations, all settings. We're at www.centerfortransforminghealthcare.org and we would love to partner with you. We work with organizations in a variety of ways. And we always have new, great, innovative, leading-edge work going on and we work with organizations to support them when they're having difficulty with these complex topics and take it from there. We look forward to hearing from you.
Mark Graban: Well, I hope people will reach out and engage with you on a level beyond the regular accreditation interactions.
Erin DuPree: Exactly. I really want to clarify for the healthcare audience, the work of the center is separate from accreditation. It is very… people do need to understand we are part of the enterprise, but the work in the center is really for organizations to help them improve. We have a big firewall with accreditation, so that does not pass over to the surveyors the work that they do with the center. That's a big point to make to healthcare.
Mark Graban: Okay, great. So I'm glad you mentioned that. And I'm glad you're helping people solve these challenges. So again, our guest has been Dr. Erin DuPree. Erin, thank you so much for taking time to talk today.
Erin DuPree: No, thank you, Mark. Have a great day.
Mark Graban: You too.
Videos with Dr. DuPree:
Prevention Above All
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Mark- You posted podcast 221 not 222.
Oops! The “MP3 File” link was correct, but not the embedded player. I’m having trouble getting that updated, so there’s a different embedded player. Thanks for pointing out the problem.
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