Back in February, I blogged about the silliness that was the end of the Academy Awards, when the wrong winner for “Best Picture” was mistakenly announced.
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As with many things, it was a systemic problem with a number of causes, as I tried to uncover and articulate here.
I think there are many “Lean lessons” to be learned from the incident, about the design of effective systems, error proofing, training workers to speak up, etc.
I recently addressed some of the supply chain management lessons involved in the Oscars. It turns out these are also just management lessons… and maybe not just for healthcare…
Here is the piece I published on LinkedIn:
What do you think? Please comment on LinkedIn or as a comment here on this post.
In a recent Cardinal Health survey of more than 400 hospital stakeholders (nurses, physicians, service line leaders, and supply chain administrators), 57% of respondents reported a physician not having the right product needed during a procedure. As a result, 69% said they knew of times a patient had to wait because the hospital didn't have the right supplies available. Worse yet, 18% said a patient experienced an adverse event because the hospital didn't have the right supplies at the right time.
Here is a video where you can learn more about the survey:https://www.linkedin.com/pulse/api/edit/embed?embed=%257B%2522type%2522%253A%2522video%2522%252C%2522title%2522%253A%257B%2522localized%2522%253A%257B%2522en_US%2522%253A%2522The%2520results%2520are%2520in%2521%2520Cardinal%2520Health%2520Hospital%2520Supply%2520Chain%2520Survey%2522%257D%257D%252C%2522description%2522%253A%257B%2522localized%2522%253A%257B%2522en_US%2522%253A%2522We%2520know%2520the%2520supply%2520chain%2520plays%2520a%2520critical%2520role%2520in%2520hospital%2520operations.%2520But%2520we%2520wanted%2520to%2520know%253A%2520how%2520do%2520hospital%2520stakeholders%2520gauge%2520its%2520importance%252C%2520and%2520how%2520does…%2522%257D%257D%252C%2522author%2522%253A%257B%2522name%2522%253A%2522Cardinal%2520Health%2522%257D%252C%2522provider%2522%253A%257B%2522name%2522%253A%2522YouTube%2522%252C%2522display%2522%253A%2522YouTube%2522%252C%2522url%2522%253A%2522https%253A%252F%252Fwww.youtube.com%252F%2522%257D%252C%2522request%2522%253A%257B%2522originalUrl%2522%253A%2522https%253A%252F%252Fwww.youtube.com%252Fwatch%253Fv%253Di5MweGMVEG4%2522%252C%2522finalUrl%2522%253A%2522https%253A%252F%252Fwww.youtube.com%252Fwatch%253Fv%253Di5MweGMVEG4%2522%257D%252C%2522images%2522%253A%255B%257B%2522url%2522%253A%2522https%253A%252F%252Fi.ytimg.com%252Fvi%252Fi5MweGMVEG4%252Fhqdefault.jpg%2522%252C%2522width%2522%253A480%252C%2522height%2522%253A360%257D%255D%252C%2522data%2522%253A%257B%2522com.linkedin.treasury.Video%2522%253A%257B%2522html%2522%253A%2522%253Ciframe%2520scrolling%253D%255C%2522no%255C%2522%2520allowfullscreen%2520src%253D%255C%2522%252F%252Fmedia.licdn.com%252Fembeds%252Fmedia.html%253Fsrc%253Dhttps%25253A%25252F%25252Fwww.youtube.com%25252Fembed%25252Fi5MweGMVEG4%25253Ffeature%25253Doembed%2526amp%253Burl%253Dhttps%25253A%25252F%25252Fwww.youtube.com%25252Fwatch%25253Fv%25253Di5MweGMVEG4%252526feature%25253Dyoutu.be%2526amp%253Btype%253Dtext%25252Fhtml%2526amp%253Bschema%253Dyoutube%255C%2522%2520width%253D%255C%2522480%255C%2522%2520frameborder%253D%255C%25220%255C%2522%2520class%253D%255C%2522embedly-embed%255C%2522%2520height%253D%255C%2522270%255C%2522%253E%253C%252Fiframe%253E%2522%252C%2522width%2522%253A480%252C%2522height%2522%253A270%257D%257D%257D&signature=AZXYSBhivEVjmVS4HC6-K5H2ScIs
Having worked with different hospitals around the world for almost 12 years, none of this was surprising. I was actually surprised the numbers in the survey weren't higher.
What is surprising, however, is what the Cardinal Health Supply Chain study made me think of: The more public mix-ups at major award ceremonies, such as the Miss Universe® pageant, the iHeartRadio® Music Awards and, most notably, the 2017 Academy Awards®.
Why the Oscars® Mix Up was a Supply Chain Problem
On February 26, 2017, a worldwide audience watched an embarrassing supply chain error live on television. The chain of errors — including duplicate winner cards on each end of the stage and insufficient failsafe procedures — led to a PricewaterhouseCoopers (PwC) employee handing Warren Beatty the Best Actress card instead of the Best Picture card. After Beatty was understandably flustered and confused, Faye Dunaway read “La La Land” as the winner of Best Picture. Chaos ensued, as it was discovered (and eventually announced) that the winner was actually “Moonlight.”
Social media erupted with blame targeted at Dunaway and Beatty for making the wrong announcement. As with many more meaningful supply chain problems, like those we see in hospitals, it's unfair to blame the people at the “sharp end” of the process, as they say in healthcare. Just because somebody was involved in the error (or was present at the point it was detected), doesn't mean that their proximity equates to fault. As happens with some medication and medical device errors, small labeling combined with people placing too much trust in the system (or being under time pressure) very likely contributed to the accident.
It seemed that Dunaway and Beatty were either afraid to speak up or were confused about how to do so. We could ask why they weren't better instructed about what to do if they suspected an error (poor training is a system issue, of course).
When the Errors are Hidden and the Stakes Are High
In contrast to the very public Oscars® snafu, hospital supply chain problems are very private. Like other hospital errors, they might not get reported as often as they should.
Healthcare professionals are sometimes left to deal with a suspected problem alone, without good processes for how to raise the issue or ask for help. As with many hospital problems, there's not a single root cause for what happened- just a number of contributing factors. It illustrates the “Swiss cheese” model that explains how errors occur in a complex system: All the holes have to line up just right for something to go wrong.
And the stakes couldn't be higher. Nobody was physically harmed at the Oscars®. Nobody died. The potential consequences of hospital supply chain problems are much more serious.
The good news is, that supply chains are fixable, whether it's through learning best practices from other industries or adopting modern supply chain technologies. Just as Beatty and Dunaway shouldn't have had to rely on people backstage being careful, healthcare professionals shouldn't have to rely on people manually counting items (something that is done in the organizations of 78% of the Cardinal Health survey respondents).
When expired, obsolete, and recalled products are left on the hospital shelf, it puts patient safety at risk. Is the lesson that everyone should be more diligent about removing products? Being careful might be helpful, but it's not sufficient for quality, especially if we have a process that's not designed well. A better strategy is to make it harder to make a mistake, by introducing a more effective process, which may include technology improvements.
When a problem occurs (or is even suspected) in an operating room or another part of the hospital, it's crucial that everyone feels safe speaking up. Leaders need to teach people how to speak up, and maybe even more importantly, they need to respond when people do speak up — both to address the immediate situation and to improve the process in ways that prevent future problems from occurring.
Poor processes, including supply chain processes, lead to results that aren't as good as they can be. Better processes mean better support for healthcare professionals. This means better care for patients, which leads to better results for all. When nurses and other staff spend less time searching for supplies, they can spend more time with patients, which means fewer preventable errors, better patient satisfaction, and better outcomes… not to mention more satisfied staff, all of which lead to lower cost.
If you and your colleagues were chuckling about the Oscars® the day after their mishap, I'd encourage you to step back and think about how often similar problems occur in your organization, with similar causes. Are hospitals putting good people in a bad position, setting them up to fail?
As they say, a bad process defeats good people every time — at the Oscars® and in hospitals. That's why we need better processes, not more careful people.
About Cardinal Health Supply Chain Survey
This study was fielded Oct. 19 – Nov. 4, 2016, using an online survey methodology. The samples were drawn from
SERMO's Online Respondent Panel of Health Care Providers, which includes over 600,000 medical professionals in the United States. The study included 403 respondents total, including frontline HCPs in hospitals (n=201), service line leaders in hospitals (n=100), and hospital/supply chain administrators (n=102).
Disclaimer: This content is sponsored by Cardinal Health. Mark Graban received compensation from Cardinal Health for participating in this educational program.
© 2017 Cardinal Health. All Rights Reserved. Miss Universe is a registered trademark of IMG Universe, LLC, iHeartradio is a registered trademark of IHM Identity Inc. Academy Awards and Oscars are registered trademarks of Academy of Motion Picture Arts and Sciences.
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