A funny comment and a serious one.
I went up to one of the floors of our hospital one night this past weekend to visit a patient. As I walked past the nurses' station, one of the nurses recognized me and jokingly called out to her colleagues and the interns, "Look who's here! Do everything right!"
We all had a good laugh.
The serious one is offered by IHI's Jim Conway on the post below, "Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders must put in place systems that support great practice by people who suffer from being human and will make mistakes.” Health care takes great people AND great systems. No matter how good you are as a healthcare professional you will make mistakes. We must have systems that catch your “humanness” before it gets to patients and causes harm.
Hi Paul - I've been reading your blog for some time, and as a current applicant to med school I've found it very meaningful and hope-inspiring. But this is the first time I've commented, and I just wanted to add on to the systems comment. I think it's not enough for a system to merely "catch" humanness; it also needs to emphasize the positive aspects of humanness. Being currently in IT, many organizations suffer from systems that dehumanize both workers and those we serve; the best, though, minimize the negative impacts of being human (error, inconsistency, forgetfulness) while maximizing the positive ones (personal warmth, empathy). As for idiosyncrasies that may be good or bad... I'm not sure systems can be an answer for those.
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Aaron Montano
Of course the next step after you catch a mistake is...to correct it, right? I found a lot of systems at work, and working well I might add, but the front line leadership was afraid to or didn't know how to implement a corrective action plan. So as much as we need good systems in place, we also need good people at every level who are "empowered" to "do everything right" and to "make sure everything is done right".
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ReplyDeleteMatthew: The trick is to create a culture where somebody catching your mistake feels *supportive* rather than threatening. It's hard to reconcile that with accountability, because deep down we all know that we make mistakes and we'd rather deal with them privately.
I think what most organizations end up with is a culture where mistakes are seen as exceptional events, and vigorous accountability means reacting dramatically to the few mistakes that are exposed by chance. I believe that is why so much work is unhappy, because there is a disconnect between who we know ourselves to be and who we must pretend to be.
If I were to imagine the ideal organization I'd like to work in, it would be one where mistakes are so routinely caught that people became desensitized to exposure, and that over-reaction to every mistake discovered would be simply impractical. Such an organization would be capable or learning, and the biggest obstacle to professional growth would be absent from it.