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Patient Voices Prevent Tragedy

4/14/2017

 
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Last time on the blog, I talked about culture change. Culture change takes bold leadership—leaders who solve problems by putting quality first. Easy to say and not always easy to do.
 
Sometimes those leaders are patients and patients’ family members. When patients are bold enough to speak out, hospital caregivers better listen. Why? Because including patient voices can prevent future tragedy. I like this definition for tragedy from Merriam-Webster: “a very bad event that causes great sadness and often results in someone’s death.”

Watch this video of a young mother's experience of tragedy:

​Here’s how this mother’s story ended: An air ambulance was finally arranged for the baby. The mother had been trying to get her baby help for more than a week. She was frantic – her new baby died seven minutes after the helicopter landed.
 
The reason this mother could be as positive as she seemed in the video was that time had passed. When I spoke with her she wanted to tell her story, she asked that she be videotaped. She’d been invited to participate in a Lean 3P Clinic design event JBA conducted in Saskatchewan. Even though her concerns were discounted in more than two dozen interactions with the healthcare system, she was enthusiastic about trying to make sure such tragedies don’t happen again. She showed tremendous courage, and decided to become part of the solution for others.
 
Don’t misunderstand me, I’m not calling out Saskatchewan, there are many wonderful positive stories in that great Province. What about Seattle you might ask? Here in Seattle we saw another tragic example of a patient’s voice being silenced. Talia Goldenberg went in for elective surgery to fuse her neck, due to a rare joint-tissue disorder. After the surgery, her father, an MD, could tell something was seriously wrong with his daughter’s airway. Nurses moved her to the ICU. But then, in a critical mistake, the surgeon who performed the surgery ignored the father’s pleas and removed Talia from the ICU. Later, Talia suffocated to death in front of her father. If the surgeon had listened to Talia’s father instead of his ego, Talia would have survived. Tragedy.
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Left to right: Me, patient advocate Heather Thiessen, and JBA consultant Tina Hallberg.
​At JBA, we make patients part of the transformation process. Here’s Heather Thiessen’s experience collaborating with hospital staff:
“I was part of a design group for the adult ED. It was my second Lean event and so exciting. In my many years as a patient, I had never been asked what I think. But who better to help when making changes? We see waste and safety issues daily, but who do you tell? More often than not, our voices in the past would be hushed or we’d be told we don’t know what we are talking about.
 
Studies have shown that families are often the first to see when a patient is failing health-wise. When that’s not heard, that patient is in danger. My husband is a prime example. When I was hospitalized for my myasthenia, he could recognize when I was not doing well, especially when he had been away at work. He had that fresh perspective and knew if something was not right. He would ask the nurses, “What is wrong with Heather?” He knew right away if something was out of my normal. Often, if his observations were dismissed, I would have a trip to the ICU that evening.
 
This is why the patient and family voice is so critical. We were able to bring our perspective to the table, and what was so amazing in the ED design event is that everyone’s “professional hat” was not brought to the table. Instead it was, “How can we all come together to make sure we build a patient- and family-centered, safe hospital?” I am still part of the group that meets regularly on updates and decisions, with the patient and family voice first and center.
 
As a patient and family advisor I was so respected, and my thoughts and ideas were acted upon —  and that was a distinct change from the past.  Patients, for the first time in my 20 years of being a patient in the region, were seen as a valuable part of the team.”
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​Patient voices help hospital staff see problems before they become tragedies. Patient voices come up with solutions that hospital staff can’t.

Bold Leadership for Culture Change

3/31/2017

 
Fundamentally, Lean is about changing the paradigm of how organizations work. In traditional organizations, decisions are handed top-down, and lower-level staff have no say. In our hospitals, that means that deadly mistakes go unreported for the sake of following orders. Nurses and doctors are frustrated. Patients feel lost in the process. Lean gives us the tools to end this mismanagement.
 
Lean makes every employee, patient, and family member a valued part of the care process. Every person participates in quality control. The results? Better care, zero defects, and a richer bottom line.
 
But culture change is difficult. Any type of change, even if it’s good, meets resistance. People’s lives are on the line—no one wants to take chances. That’s why culture change requires bold leadership, a bold vision. Leaders must believe in their organization’s ability to deliver the highest quality of care. Leaders must work day and night to get everyone on board, to build new bridges between patients, care teams, and staff.
William Edwards Deming said it best: 
“To successfully respond to the myriad of changes that shake the world, transformation into a new style of management is required. Then to take is what I call profound knowledge – knowledge for leadership of transformation.”
“Our staff and physicians already felt they were focused on patients, but the structures and processes we used were largely provider-centric. We were often only giving lip service to listening and responding to what patients and families really wanted. In my organization, we had prepared the ground through our work on patient- and family-centred care, but even so, a Lean management system required far more courage.”
      
– Maura Davies, CEO of Saskatoon Health Region
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Me with Maura Davies

​When healthcare CEOs and presidents take these courageous steps, transformation happens. 
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​Fewer falls. More successful surgeries. Chemotherapy patients in and out faster, and back home to recover.
 
Changing the culture to be open to criticism at all levels is a huge shift. Yes, it’s difficult. But it saves lives.

Using the Fishbone in Healthcare

3/17/2017

 
​At JBA, we’ve spent hundreds of hours working with fishbones. Healthcare is complex. Fishbone diagrams help us map all the components that go into a patient’s care.
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​For example: the procedures that lead to a successful surgery often cross many departments. A patient checks in at the registration desk. He’s passed on to the surgery floor nurses. The nurse preps him while the anesthesiologist puts the patient under. The surgeon meets the patient in the OR. In the moment, no one has the full picture. The fishbone shows us the whole picture.
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​With our clients at JBA, we start with our target. Maybe it’s improving patient consent for blood transfusions. We then create a fishbone to diagram all the roots causes of misinformation, confusion, or missed steps in the consent process. We end with a streamlined roadmap to improvement, seen below.
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​Here’s a video from the manufacturing world, where the fishbone concept originated: 

I Believe in Zero Preventable Deaths

1/20/2017

 
Today I want to talk about why I’m passionate about this work. I want to talk about preventable deaths due to hospital errors. I want to talk about transforming healthcare so we can get to a mindset where, instead of feeling as though mistakes are “only human” and perfection is out of reach, ZERO preventable deaths are acceptable. We have a roadmap for this goal: Shingo’s Zero Quality Control.
Why is it when deaths happen one at time, there is less attention than when deaths happen in groups of 5 or 10, even if they add up the same? Fact: hospital mistakes kill enough people every day to fill two 747 planes. That’s as if we allowed two full 747s to crash, EVERY DAY, and did nothing! Every two months, it’s like 9/11 is occurring again. In anything else, we would not tolerate that degree of preventable harm. But in healthcare, we do!
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Unfortunately, statistics only say so much. Here are the real faces of a few medical errors in Canada, where JBA worked on the Saskatchewan Province hospital system.
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A 45 year-old Manitoba man died of a bladder infection in 2008 while in his wheelchair in a waiting room for 34 hours. No one even offered to help him when he asked or started vomiting. In 2013, a woman in Nova Scotia had a breast removed after a lab error mixed up her biopsy results with another patient’s. And this woman in Saskatchewan – after almost four years of agony and complications – insisted on diagnostic tests that revealed a piece of surgical mesh puncturing her bladder.
 
Examples are everywhere in the world. People being hurt or killed because of preventable mistakes. In one case a monitor was left on a boy’s finger during an MRI. Burned his finger to the bone. Another example: During routine surgery the doctor didn’t follow standard protocols. The patient bled to death – bled to death— during a routine procedure.
 
The World Health Organization shows that 1/3 to 1/2 of these medical defects can be prevented. Well, how? Through a systematic approach to patient safety that focuses not on people (who indeed may make misatkes), but on processes, which can be made mistake-free. Applying Shingo’s Zero Quality Control method of Poka-Yoke CAN deliver safer, higher-quality care. That’s how!
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​This is a famous Shingo quote. In particular the last sentence: “In contrast, a zero QC system pursues the active objective of eliminating defects.” Not just “reducing mistakes,” which implies that some (lower) level of mistakes would be acceptable. No, you MUST believe in and pursue the objective of zero defects.
 
When JBA got to Saskatchewan, we applied Shingo’s method to one of the most broken systems: surgery wait times. Waiting for necessary surgeries hurts patients’ health outcomes. At the time, the average wait for non-emergency inpatient surgery was 294 days, and 291 days for outpatient surgery. That’s almost 10 months. 4,000 people waited more than a year! This was not acceptable.
 
We achieved results by changing a culture that believed that waiting and mistakes were unavoidable. Our mistake-proofing training began by forming teams and selecting projects where direct harm had been caused to patients. Teams selected defects ranging from timely triaging of hospital emergency department patients to incorrect or insufficient cleaning of hemodialysis machines. Standard requirements included value stream maps and thorough patient/procedure quantity analysis. Each team then went on our week-long North American Tour. They studied and learned concepts at manufacturing and healthcare companies, all reiterating that zero defects WAS POSSIBLE. When they got home, the teams implemented corrective action plans. They collected defect data in 30-, 60-, and 90-day follow-ups, and utilized PDCAs and A3 thinking. Projects were not considered complete until they could report out a defect rate of less than a 1%, with 76% of projects reaching completion.
 
Achieving zero preventable deaths and preventable harm is possible. It is the moral obligation of all healthcare leaders from the top down in all of our major healthcare organizations and systems in America to lead this effort.  I believe that our frontline caregivers are doing what they can within the system they have to protect patients but the current system isn’t working.
 
There are two leaders that have said it best, Atul Gawande and Donald Berwick, both MDs. In a quote from Gawande’s book “Checklist Manifesto” page 184:
"One essential characteristic of modern life is that we all depend on systems--on assemblages of people or technologies or both—and among them our most profound difficulties is making them work. In medicine, for instance, if I want my patients to receive the best care possible, not only must I do a good job but a whole collection of diverse components have to somehow mesh together effectively. Healthcare is like a car that way. In both cases having great components is not enough.
 
"Were obsessed in medicine with having great components—our best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well. This approach is wrong-headed. Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence. We give the example of a famous thought experiment of trying to build the world's greatest car by assembling the world's greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. What we get of course is nothing close to a great car; we get a pile of expensive junk.
 
"We have a thirty-billion-dollar-a-year National Institutes of Health, which has been a remarkable powerhouse of medical discoveries. But we have no National Institute of Health Systems Innovation alongside it studying how best to incorporate these discoveries into daily practice--no NTSB equivalent swooping in to study failures the way crash investigators do, no Boeing mapping out the checklists, no agency tracking the month-to-month results."
I am passionate about this work because I know we can do better. I know we use the Toyota Production System to save lives.

For more on how to achieve zero defects, check out my webinar here.
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    About the author
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    John Black, President and CEO of JBA, has implemented Lean improvements for four decades, first with the Boeing Company and later as a leading consultant in the healthcare industry.


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