I was walking through Boston Common this morning and saw a woman with a homemade sign that said something about patient safety. I stopped her and asked about her sign. She reminded me that today, July 25, is the observance of National Patient Safety Day.
Duh. I always lose track of the specific day. She could tell my recognition of what she was talking about and she asked if I worked in medicine (out of curiosity, I could tell, not because she wanted to slap me). I told her, yes, that I worked with hospitals on quality and process improvement and that (although it sounds cheesy) EVERY DAY is (or should be) patient safety day. She agreed.
Her father died, arguably due to a medical process error. She said he had a lab value was in the “critical” range. The report sat on a fax machine print out tray (in a doctor's office, I presume), where it went unattended. Her father's condition worsened during the time the report went unread and she ended up calling 911 and he soon passed away. It sounds like something that wouldn't have been fatal if the test result had been picked up fast enough.
I expressed my deepest condolences to her.
We chatted and were in quick agreement that this an avoidable PROCESS error. It wasn't a clinical error, where the test result was wrong. This was a case where the Value Stream wasn't well designed. There were holes and gaps in the process.
So while every day should be Patient Safety Day, the express purpose of today is to remember and commemorate those who have been harmed or killed because of medical errors, including process errors. Our conversation today helped put that in perspective.
Becky Martins, like many other families members or loved ones of medical error victims, has thankfully channeled her energy into education and prevention, not anger and revenge. She runs a website called www.voice4patients.com/. This is similar to, and she is familiar with, the work of the Josie King Foundation, I invite you to check them out as well.
We were also in agreement that the path to improvement is NOT blame and punishment, but rather prevention, awareness, and adherence to standardized processes that could prevent tragedies like her fathers.
Final thought — to those working in the Lean world…. Lean is NOT primarily about efficiency, speed, flow, productivity, and cost. Those are nice side effects of a focus on Safety and Quality as primary goals. This philosophy is taught at Toyota, that safety and quality come first. The same should certainly be true. If you hear someone say (as I've heard many times before), that “Lean is about flow and Six Sigma is about quality,” I hope you'll correct them, respectfully, on that point.
There's no more important mission than improving the quality of care and patient safety. That's why I'm glad to be part of the Lean Enterprise Institute effort and the partnership with quality-minded Lean Thinkers like Dr. John Toussaint.
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Thank you for reminding us again about the how the tragedy of medical errors affects real people. One comment – it's interesting to debate the chicken and the egg re: speed and efficiency vs. safety and quality. Lean's primary metric is time. Always has and always will be. That said, shortening time REQUIRES that quality is improved because it's the net result that matters. Shorter patient throughput with eroding quality hasn't solved a thing and costs (on many levels) far more. The problem with focusing on quality first and foremost is that improvement teams often build in more checkpoints and inspections instead of focusing on the root causes for medical and administrative errors. Safety too goes without saying. Similarly, you can't shorten overall time if you erode safety because you'll be engaged in more costly and time-intensive activities to fix the problems poor safety or quality have produced. Focusing on time reductions reveals wasteful practices, many of which actually produce errors. Not all lean practitioners practice alike, but those who embed quality and safety into time reductions are practicing in the spirit in which the Lean approach was intended.
Hi Karen, thanks for your comment.
It is a bit of a chicken-and-egg scenario, you're right. I'd agree that focusing on quality by just adding more inspections isn't very lean at all. That's why I teach a very balanced view of flow and quality, quality and flow, how they are intertwined in a positive way when done right. We'd prefer quality through standardized processes and error proofing over inspection, any day.
I think we're on the same page with your final comment about quality and safety being done WITH time reductions.
The reason I emphasize quality and safety as a primary motivator is to get the hospital staff on board. Leading with or talking primarily about efficiency turns some people off, if their past experience was that greater speed meant worse quality. That's not how it's done in a lean world, but how it's done in older, traditional "improvement" (ala the famous Lucy candy factory episode). That's not what we're going for with Lean, but that's often what's in people's heads until they're taught the lean way.
Thanks, Mark. Agree on all fronts. The only thing that I think bears exploring a bit more with healthcare execs is helping them to see that they are a real business enterprise and cost overruns are a key contributor to the mess we're in. I had a hospital CEO last year make me vow to never speak about expense reduction or margins to anyone on his staff. Silly and damaging demand. Healthcare, with their deeply entrenched paradigms will never get Lean if they don't recognize the business realities that every other industry confronts. And you know what – that hospital has done very little to improve, in large part because they have no sense of urgency around cost. Meanwhile, they lost money for the first time last year — and a lot of it — and are now in a pickle. So, yes, we agree and I think we'll serve the industy best by helping transform their thinking into that where both cost (efficiency) and quality share the stage.
Unfortunately, the loss of critical lab test results happens too often. It's predictable, too, of course, given the design of the system. An example of the costs of a misplaced diagnostic test result appears here.
In some hospitals, an out-of-range lab value on certain tests automatically generates a page to the doctor, giving the signal the urgency it deserves.
But until such changes occur reliably throughout the healthcare system, patients, or their advocates, should actively look for their test results.