Wednesday, January 26, 2011

Defining a defect

From Charles Kenney's book Transforming Health Care, about Virginia Mason Medical Center's journey:

Implementing the program was not a simple matter. Defining a defect in a medical setting presented a challenge.... [D]octors pushed back. The argued that many instances of harm -- ventilator-acquired pneumonia, for example -- should not be considered an error because these things happened in medicine. Complications, they argued, were inevitable.

This is a typical assertion, based on a belief that there is a statistically irreducible amount of harm that must occur in medical settings. There may be such a statistically irreducible amount, but most hospitals are not close to the potential minimum. As Gary Kaplan and his team showed, and as shown at BIDMC, setting an audacious target of zero defects and organizing work to reach that target can enable the people in a organization to reach or get mighty close to that target.

Joseph Gavin strived for such a goal in space flight. Others are doing so in medicine.

Real transparency is a concomitant of success in such a transformation. You cannot improve what you do not acknowledge to be flaws. That is why I pound away below as to its importance and as to why misuse of transparency is unethical.

In her humorous way, Ethel Merman tried to show us the way when she decried the view that "these things happen." But this is deadly serious. Those who stand in the way are causing death and injury as clearly and directly as those who wield weapons.

If you cannot see the video, click here.


Anonymous said...

I am reading that book on your recommendation, Paul, and one thing that struck me is the necessity for passion and urgency, such as you demonstrate here, in implementing patient safety. Virginia Mason's transparency on their patient death from inadvertant IV chlorhexidine administration not only helped other hospitals avoid the same error, but galvanized their leaders and staff with an absolute determination to honor their dead patient by redoubling their efforts. I believe that this power of story, effectively utlitized by patients and their advocates such as you to enable and encourage transparency, will overcome the inertia and fear exhibited by our respective colleagues in administration and medicine. Is any other outcome acceptable?

nonlocal MD

Mark Graban said...

I think it's very much keeping with the Lean philosophy that we must constantly strive for perfection, even if we do not attain.

As Paul O'Neill says, any goal other than zero patient harm is unconscionable.

But as Dr. W. Edwards Deming said, "by what method?" We need more than just a goal.

The Lean philosophy helps give us the goal and the methods of Lean, along with methods from aviation safety, etc. give us the method to get there.

Thanks for highlighting this important issue and the needed mindset shift.

nasov said...

Winner: Best Ethel Merman reference!