In a Lean culture, the mindset is that “problems are treasure” or “problems are gold.” By honestly identifying problems, we can solve problems and prevent them from occurring in the future. Problems in healthcare can include medication errors, laboratory specimen mixups, and other problems that can harm or kill patients. The stakes are high.
Traditional organizations pressure people into hiding or covering up problems. When people cover up “near misses,” that's particularly tragic because yesterday's near miss might become tomorrow's patient harm if we don't understand and solve the problem.
Yesterday, I got two different emails from people at different systems complaining about how the culture drives people to hide problems — there is direct fear of being fired… so people cover things up to protect themselves, putting patients in jeopardy.
Lean thinkers realize that most problems are caused by the system, not so-called “bad apples.”
If only it were so easy as to fire all of the “bad apples.” If we fired all of the bad apples, safety would improve and patients wouldn't be harmed, right? Let's just figure out a way to predict WHO will cause an error… and proactively fire them. But, that doesn't work, because in a bad system, any good person might be involved in an error (which is not the same as saying it's “their fault.”)
We can't proactively fire people to improve safety, but we can try to improve the hiring, training, and supervision processes. If there are truly “bad apples” in the organization, isn't that the organization's fault for hiring them, or not training them properly, or not supervising them?
See this article that was in the news recently: “Hershey Medical Center addresses flawed lab procedure.”
The headline isn't “Hershey Medical Center fires lab technician” but that's what happened.
The problem is probably the procedure, the process, or the system… but a person got fired. Will that really solve anything or prevent future problems?
From the article:
A lab technician at Penn State Hershey Medical Center failed to follow proper procedures when conducting a genetic test used to help physicians decide on cancer treatments, affecting the test results of 124 patients, the organization said this week in response to an Intelligencer Journal/Lancaster New Era inquiry.
Penn State Hershey determined the flawed procedure was used from March 2013 to March 2014.
Read that again. The “flawed procedure” was followed for A YEAR.
The technician (just one of them?) “failed to follow proper procedures.”
If that's true, whose responsibility is that? That's management's responsibility to make sure people are trained properly, that they have the right supplies and equipment, and that they are indeed following procedures.
This is a point I made in my book Lean Hospitals, that “standardized work” is not just about writing procedures… it's about proper training and supervision. Supervisors and managers have a responsibility to check and see that procedures are being followed. They can't just sit back and blame and punish somebody after the fact. The wrong procedure being used for an entire year is a management failure, plain and simple.
What other procedures are not being followed in that hospital? Managers must take responsibility, whether it's a taco restaurant or a hospital.
As I wrote about in that LinkedIn article:
We often see similar things in healthcare, where the stakes can also be a matter of life or death (with outcomes worse than food poisoning). If you recall the case of the actor Dennis Quaid's twins being harmed by a preventable medication error at the famed Cedars-Sinai Medical Center, leaders blamed employees for systemic problems.
The Chief Medical Officer said:
“This was a preventable error, involving a failure to follow our standard policies and procedures, and there is no excuse for that to occur at Cedars-Sinai.”
You can't just beat your chest after the fact when you've discovered that people weren't following policies and procedures. It's your job as a manager (or a CMO) to be proactive and make sure people are following procedures.
Back to the Hershey Medical Center story:
“The technician in question is no longer working there, Penn State Hershey said.”
We can only assume they were fired.
Looking back to this pathology specimen mixup, the case involving the patient Darrie Eason, we saw similar reactions:
“[The CEO] said the technician responsible for the mixup also no longer works there.”
In that case, the supervisor admitted they KNEW the technician wasn't following standard protocols… but the technician got fired when when it all hit the fan. Was the supervisor fired? Was the CEO?
The beatings will continue until morale improves… and the firings will continue until safety improves?
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Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:
This also shows how accreditation can’t ensure quality or safety either:
I hope “appropriately addressed” means more than the technician no longer working there.
From LinkedIn:
Empress Carol: Health and safety should always rein! Why? People, sillies and stupid left brain thinkers screwed us up! Time for change!
Steven Kiebach: The traditional organization is good at hiding problems, because fear is quite prevalent. I saw that in the Mfg side. And especially when you look at the safety side of it of how many injuries go unreported. But aside from that just problems in general, you have managers that don’t want to address real problems and employees fearful of what “happens to them” with errors & bring forth problems. Interesting article bit on Hershey Medical as that hospital is less than an hour from where I live.
Jack Parsons: Also people are afraid to propose solutions in this kind of environment.
Stephen Glassic: These issues are always more complicated than what is revealed. The short sighted public seems to be satisfied when someone’s head rolls but very often there are multiple factors that have led to the mistake occurring. We can only hope that once the token sacrifice is made, that the systemic issues that ultimately led to the mistake are addressed and corrected. Otherwise, that person’s replacement could be set up to make a mistake in the future. Maybe not the same mistake, but caused by the same systemic problem or problems. Maybe they will be lucky if it doesn’t affect a patient’s health.
Great post Mark. I am in total agreement.
While reading, I kept thinking if a hospital fired someone for making a mistake, they may decide to not fill that position again in an effort to reduce costs. This just adds more overburdening of the staff which leads to more safety risks & errors.
Seeing the blame culture in action makes my blood boil. It’s patently unfair to people-both patients and associates. When a healthcare worker feels threatened, they are not only more likely to hide problems, but I’m inclined to think that the pressure placed on them can actually create more errors (that they then have to hide). Everyone loses in that atmosphere. I’m optimistic that we have turned a corner in our health system, but I wonder if it makes sense to propose, to the CNO, that these policies be uncovered and eliminated immediately? We uncovered one, and It’s probably not the only one.
When we see anything happen (good or bad), the first question management should ask is “What system(s) might be driving that behavior?” We should stay with that question for a good, long while. Sometimes the question might be directed to the individual, but only after management has studied the system which means doing so WITH the people. Only management can lead the discussion and set the climate for making “focus on the system” possible and a priority. Sometimes it IS the individual, but we do great harm (with unknown and unknowable consequences) if we rush to this conclusion too soon.
Management should ask the question even when the system is working well. Perhaps it can be improved? But you cannot work on every system at once, that’s where some prioritization is required. I think that’s why we work on the “failing systems” (bad outcomes) first, but we should not stop there. And when we work on the failing systems, we dare not blame the individual without first studying the system(s) (management’s responsibility).
Great comments. I heard a CEO go on and on Thursday about accountability. He never defined the term. I wanted to ask, but he didn’t leave time for questions at the end.
He talked about spreading accountability. Holding people accountable.
He claimed that led to quality improvements and patient safety improvements (although the data he showed said they were in the 50th to 75th percentiles on most measures).
He talked a bit about systems, processes, and culture and the need for leaders to model behaviors.
I just came away unclear what “accountability” meant. I hope it didn’t have the common meanings of “we blame people for problems” and “hit your targets or else.”
“Accountable” is an exhortation. It is based on using fear as a motivator. “Hold everyone accountable” is an artifact of the prevailing style of management – the mythology of management. It does nothing to improve the system or the results, but only makes matters worse. it also reveals how far we have to go before we will see real improvement. No amount of work on processes, techniques or even systems will make a difference because the true root cause is the way that top management thinks.
This is more than opinion, it is based on knowledge. Some selected quotes from W. Edwards Deming may illustrate this”
Chapter 4, “Out Of the Crisis”, elaboration on point #10 “eliminate slogans, exhortations and targets for the workforce”, p. 69-70.
Chapter 1, “The New Economics”, How Are We Doing? p. 14. “Make everyone accountable” is on the list of typical solutions to the problem of quality in Western management.
Chapter 2, (same book), The Heavy Losses, p. 41, “When a company holds an individual accountable for a goal, it must provide him the resources for accomplishment”.
I suppose some people get irritated when I continuously quote Dr. Deming. I’ll keep doing so until people actually read what he said and take his advice to heart.