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Patricia Morrill

Customer Care

Lean Improvements for Patient Safety

Making preventable harm a priority for continuous improvement

Published: Monday, September 25, 2017 - 12:03

Do all employees in healthcare understand how their jobs link to patients in some way? If they do, then they are more likely to know the importance of service excellence.

Does every leader, physician, and employee know the statistic that preventable medical errors are the third leading cause of death in the United States? If they don’t, then they aren’t aware of the severe disconnect between service excellence and preventable harm. Organizations that are truly focused on service excellence realize the necessary connection to system-wide process improvement.

To make sustainable improvements, individuals must first be made aware there is a significant problem and that it needs attention every single day with every patient. This heightened awareness helps them see the link to co-workers and other team members and be more willing to speak up in honor of a shared vision to reduce preventable harm.

Making preventable harm discussable is paramount to eliminating it. What could possibly be more important than keeping patients safe? It is not just the role of physicians and nurses; it is everyone’s job. But unless it is made crystal clear how each individual’s job links to the patient in some way, nonclinical employees will believe it is not their responsibility. By encouraging open discussion about errors in staff meetings, leaders can coach employees to think as a team with a common vision to prevent harm. This can be reinforced more so in leadership rounds where work takes place vs. in conference rooms. If leaders don’t take the time to truly understand the work of their areas of responsibility, then how can they be effective coaches?

Perhaps more healthcare organizations need to implement management financial incentives to meet target measures. We all know that money talks—it makes those targets personal and attracts more attention.

The complexity of preventable harm is that it is not always immediately obvious or measured. That’s why every employee must commit to do his work right the first time. And, if there is a concern about a situation, to immediately take action to fix it—or to call on someone who can. Here are a few examples of desired behaviors when opportunities exist to make things right:
• A greeter at the information desk who sees someone struggling to walk through the entry doors
Might they need assistance and/or a wheelchair to avoid a fall?
• A registrar on the phone who gets interrupted while asking a patient questions, then forgets to give important instructions when returning to the call
It would be OK to state, “I was interrupted and I want to make sure we covered everything.”
• A housekeeping staff person who repeatedly tells his supervisor about a furniture maintenance concern in a patient area
How about going straight to the maintenance department instead, and even submitting a photo of the specific item needing to be repaired?
• A receptionist for a waiting room who overhears a patient tell the person with her that she feels like she’s going to faint
It’s OK to approach the patient and admit that you overheard her and ask if she needs to see a nurse right away

These examples can give employees an understanding of the positive effect they can have with patient safety. For example, one of my roles in a health system was serving as chair of the space committee that oversaw facility utilization in three hospitals. I started by asking the executive leads for each hospital to make the rounds with me to ensure they had seen every part of the hospital they were accountable for, and I took photographs of areas and items that needed attention and shared these with the space committee and/or department managers. My actions as well as the examples above are ways to encourage everyone in healthcare organizations to learn to see more intently, actively listen, speak up, and step up to raise awareness. This should be included in staff training so the behavior becomes a natural part of the healthcare culture.

Healthcare organizations are used to providing staff training for new computer applications and new technologies, but do not always include training in soft skills such as relationship building, teamwork, collaboration, or even service excellence. If there actually is formal classroom training, leaders still need to follow up with coaching moments directly within work places to model behaviors of open and respectful communication to encourage team building.

Wouldn’t it be great to work with a team that cares? This team would include people who actively:
Continuously learn—by watching how co-workers and leaders handle situations and by seeking out needed learning opportunities
Ask questions—of patients, co-workers, physicians, and leaders when unsure, and encourage ideas for improvement
Respect relationships—treat patients as people, not medical record numbers, and treat co-workers as valuable partners
Engage—who listen to patients and co-workers and keep a watchful eye. Actively serves as a committed team members to prevent harm
Speak up—when something doesn’t seem right and needs attention, who work as a patient advocates to prevent harm

To keep patients safe from harm, we need collaborative work teams to trust each other so they will ask for help when they need it.

Healthcare leaders must be role models for desired behaviors, as well as coaches to develop the workforce. That means they must be visible and accessible. What doesn’t work is making assumptions that employees will figure things out on their own. We are not going to turn the tide on the high incidence of preventable harm until leaders become intentional in making harm discussable and a top priority.

Ownership must start at the strategic level. Every executive needs to be accountable to:
• Raise the level of urgency of preventable harm
• Make preventable harm a strategic initiative, known to the entire workforce
• Immerse in understanding the work of areas of responsibility by going—as a trusted partner—to where the work actually takes place
• Personally demonstrate how to build relationships grounded in respect for the value of each person, both patients and employees
• Illustrate how errors are process and system problems to be corrected quickly without blame of individuals

My observations, both professional and personal, of patient care environments has shown me repeatedly that nurses are masters at workarounds. They will make do with whatever they have to take care of their patients—while also being continually interrupted. This does not make for safe work conditions and can lead to patient harm. It is important for leaders to observe how work is performed and really see the challenges that employees face every day trying to do their work.

As an example, I watched how a nurse gave medications to her patient in a hospital room, and it became obvious that she didn’t have the work space she needed to provide expected quality of medication administration. More than a dozen medication packets needed to be barcoded into the electronic record then the nurse placed the packets on the patient’s bed (not a flat surface) to then open and give to the patient. Some packets fell to the floor (these were assumed to be empty, but were they?) and were left for housekeeping to pick up.

For some leaders, the first reaction would be to blame the nurse for not doing her work correctly. However, a leader who builds relationships as a trusted partner would take action to get the work space problem corrected. That doesn’t mean waiting for maintenance to install a work surface; it means having a mayo stand or some other portable item brought into the room(s) right away.

What healthcare must learn from the factory floor is to stop the production line when things are not proceeding as expected to correct problems and avoid defects.

Making the time for corrective action should be not just acceptable behavior, but imperative.


About The Author

Patricia Morrill’s picture

Patricia Morrill

Patricia Morrill (PMP) has 30 years of healthcare experience spanning operations leadership, project management, performance improvement, risk analysis, work flow and facility assessments, and Lean facility planning. She is author of The Perils of Un-Coordinated Healthcare: A Strategic Approach Toward Eliminating Preventable Harm.


Do they work to improve safety or argue about the data?

"Does every leader, physician, and employee know the statistic that preventable medical errors are the third leading cause of death in the United States?"

They might know that study, but they also might put more effort into debating the accuracy of the studies and extrapolation by Makary and others that led to the 440,000 Americans per year number. 

Even if the number is 44,000 Americans dying each year due to preventable medical error (the lower range of earlier estimates), that's a huge problem.

I agree that hospitals need to focus on their most important problems first. Too many hospitals focus on traditional cost-cutting and efficiency as a goal (or they mislabel their layoffs and cost cutting as "Lean").

Patient safety, employee safety, and quality need to be the TOP priorities. 

In manufacturing, the Lean dogma says "overproduction is the worst form of waste." That might bankrupt a company, but it probably doesn't kill anyone.

In healthcare, the waste of defects, harm, and errors isn't just a business issue - it's a moral issue and a public health issue.

Quality starts in the boardroom?

Thanks again for your piece.

One other thought:

"What could possibly be more important than keeping patients safe? It is not just the role of physicians and nurses; it is everyone’s job."

Everyone has a role to play, but would you agree with Dr. Deming's assessment that quality (and safety) start in the boardroom?

We can't just tell nurses, pharmacists, and other front line caregivers that they are responsible if leaders don't (as you said) lead by example AND create a system that allows people to be successful.