This blog post is a collaboration with a Lean healthcare consulting friend of mine, who heard another unfortunate story from his sister, an emergency room nurse. This was the first story, before things got crazy.
This morning, I learned of an unfortunate event that occurred with nursing staff at a hospital in a major American city.
Nurses and other providers within that hospital face a shortage of critical personal protective equipment (PPE), particularly N95 masks, as is the case all over the country.
The nursing staff was faced with caring for patients without a good alternative to the critically-important N95 masks.
In response, the nurses were resourceful enough to sew together homemade masks so that they could continue to care for patients. Although the sewn masks are not a great alternative, they offered some protection against blood, body fluid, and aerosol exposure for the nurses. Masks like this are said to not protect against the coronavirus, as this website says (and it's a site that's calling for volunteers to make fabric masks).
The nurses used their homemade masks throughout their shift. Given that there was no process for cleaning the masks for reuse, the nurses decided that they would take the masks home and wash them for the next shift.
Prior to the completion of their shift, the unit leadership notified them that they were out of compliance with PPE and threatened to terminate them both for using their masks and for planning to take their masks home so they could wash them and reuse them on their next shift.
What???
These nurses were trying their hardest to care for patients in the face of a really challenging (and dangerous) situation. The conditions they were working in forced them to develop alternatives in order to continue to care for their patients. Instead of being rewarded for their ingenuity, doing the best they could, they were threatened with termination.
While this is an extreme case (yet believable… and hopefully rare), it serves as an example of how the underlying situation, system, or process drives a behavior. People will find creative workarounds in an attempt to solve problems in order to meet a customer's need (or their own need).
Unfortunately, in many of those cases, leadership resorts to placing blame on the people rather than the broken systems and processes that they have to work in.
Is it the fault of the nurses that they don't have the proper PPE? Of course not.
Shingo Principles
The Shingo Institute's “Guiding Principles” of organizational excellence teach us that there are certain principles that govern human interactions in any organization. Principles are like laws in that if we don't follow them, there are consequences. One example is the law of gravity, which governs how we design things in the physical world around us to keep people safe from its ever-present force. We suffer from negative consequences when we don't adhere to principles that guide human interactions.
In the Shingo model, one key principle of organizational excellence is the principle of focusing on the process.
From the model:
“All outcomes are the consequence of a process. It is nearly impossible for even good people to consistently produce ideal results with poor processes. It is human nature to blame the people involved when something goes wrong or when the resulting product or service is less than ideal. But in reality, an issue is usually rooted in an imperfect process, not in the people involved.”
When things go wrong and employees have to develop workarounds to problems they encounter, this principle teaches us to focus on what is wrong with the underlying process. Behaviors (good or bad) are an outcome of systems, processes, and tools.
As leaders, it is our job to make sure that systems, processes, and tools are aligned to produce outcomes that are desirable. If people are not behaving in ways that we expect, the first place we need to look is our systems, processes, and tools that guide behaviors. By focusing on the behaviors of individuals, we are placing blame in the wrong direction. Threatening to punish those behaviors can lead to additional bad consequences.
One of the clearest examples of this is when a health care worker identifies an error in caring for a patient. In example after example, the solution is to make the health care worker “accountable” for the error. “Solutions” can range from re-training to disciplinary action — up to and including termination (or, sadly, jail time). In environments that are fear and blame driven, healthcare workers will remain silent when future errors occur in an attempt at self preservation.
The behavior of “staying silent” is not ideal, but it's completely driven by the system. And, as Dr. Deming said, senior leaders are responsible for the system.
See a previous post about this dynamic of fear:
In contrast, leaders who focus on blaming the process and not the people will find that team members approach them more readily when things go wrong. This leads to an organization of learners who see problems as treasures and encourage their peers to call out problems when they see them. This allows us to fix problems in a way that prevents recurrence.
Many of the Shingo Guiding Principles apply in situations like these:
- Respect every individual (respect the nurses who are trying to get by)
- Lead with humility (don't pretend like you have all the answers)
- Seek perfection (but don't blame people for being imperfect)
- Embrace scientific thinking (so we're not just trying random solutions)
- Focus on process
A Positive Example
Another Lean healthcare consultant I know (a colleague from the firm Value Capture) shared a more positive example when he shared a tweet earlier today:
A news story from Minneapolis/St. Paul station KARE 11 shows how “a doctor and his team have come up with a low-cost solution to the ventilator shortage.”
Here is the video:
“The first version was full-on MacGyver,” Dr. Stephen Richardson said while laughing.”
The approach seems to really illustrate the expression, which comes from Toyota, of “using creativity before capital.”
“Just like wham, this idea kind of came into my head,” Richardson said. He recalls thinking, “‘I wonder how we could just automate using an Ambu bag…could we make a machine that could squeeze that for us?'”
“Ambu” bags are the readily available equipment paramedics use to manually resuscitate patients.
When we frame the problem as a “lack of ventilators, the natural response is to say “we need more ventilators” as a solution — and that would certainly be ideal. But what if we can't get enough of them?
The idea out there is for manufacturers to switch over from their existing products to suddenly start making ventilators. But how long will that really take? One article says it might take “months” for automakers to get production up and running. We don't have that kind of time.
The countermeasure in the video might be the type of thing we come up with when we frame the problem as something like “patients need help breathing.” The approach that Dr. Richardson started experimenting with used materials and equipment he could get NOW. Not in theory, but in reality.
He worked with a local company and its engineers to get a working prototype right away. They tested it right away on pigs.
The team working on the project is giving away their design for free on-line and has already received calls from people in Pakistan and Saudi Arabia asking about the latest prototype which could be completed as soon as Monday the 23rd.
They hope to be mass manufacturing the low-cost ventilators within two weeks.
“We have a ventilator that I would be comfortable with someone taking care of me (with) in an ICU or in an operating room,” Richardson said.
It's possible that the FDA will waive the usual approval process in these unprecedented times.
Let's hope that his leaders didn't get upset with him once they saw this story on TV or the internet. Does Dr. Richardson have leaders who are more progressive? Are his experiments less visible than what the nurses are forced into experimenting with, mask wise? Is it different because he's a doctor?
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Nurses are being threatened with “on the spot termination” for wearing masks??
News story about shortages:
One Mask Only: Coronavirus Docs and Nurses Forced to Make Terrifying Compromises
Another article:
“We Are Desperate”: 10 Nurses And Doctors Explain What It’s Like To Fight The Coronavirus Without Enough Face Masks
Help breathing instead of ventilators as the core need—a powerful reframing, one of many you make in this post, Mark. Thank you!
Thanks, Amiel! I hope you are well…
Thanks, Mark. Our kids seem happier at home than going to school, so we’re lucky in that and many other ways. Still holding our hearts out for others. My best to you!
Another sad set of stories:
<"https://www.nytimes.com/2020/04/01/opinion/coronavirus-doctors-protective-equipment.html?referringSource=articleShare">‘I Do Fear for My Staff,’ a Doctor Said. He Lost His Job.
Health care professionals are being punished for protecting themselves, and us.