#IHI Joseph Gavin, Jr., who died in November, was an aeronautic engineer who was intimately involved in the design of the first manned craft to land on the moon. He was also a key player in the rescue of the Apollo 13 astronauts. He was a remarkable fellow, and I had a chance to hear a tribute to him during this past week's meeting of the MIT Corporation. (He was in the class of 1941.)
One of the quotes ascribed to him during the presentation was, "There is no such thing as a random failure."
In this discussion board, a commenter says, with regard to that quote, "Amazing when you look at things now, that in the avionics industry of the time 'random' failures were acceptable! As he says, there is (almost) no such thing as a random failure... Everything has a cause, and in a safety critical system (or one-shot system like this), every failure cause has to be designed out..."
It strikes me that there is a parallel with medical care. I have discussed the problem of "These things happen" that often characterizes the delivery of care. I noted:
Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.
The science of process improvement can be applied to the delivery of care, as it has been to other high performance service and manufacturing industries. I hope my readers will excuse the degree to which I focus on this topic, but I cannot imagine a more important subject to cover.
This week, several thousand people will be attending the IHI Annual Forum to learn and trade information and stories along the theme of Taking Care. Maybe, if we learn well enough, we can say that "these things" no longer happen.
Here's Ethel Merman, to make the point in her own way. (If you cannot see the video, click here.)