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May 2014 Archive for High Reliability Healthcare

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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Leading improvement: Go to the gemba

May 28, 2014 | Comments (1) | 14993 Views

edupree4-14By Erin DuPree, M.D., Chief Medical Officer and Vice President, The Joint Commission Center for Transforming Health care

The knowledge needed for improvement is seldom found in the conference room.

Some of you may be familiar with the term “gemba,” while for others it may be new. Gemba is the Japanese term for “the real place.” So, going to the gemba is going to the place where value is created, where the real work is taking place. It stems from the Japanese mindset that when there is a problem, one should get as close to it as possible and learn BEFORE proposing a solution.

Problems are visible. For detectives, gemba is the crime scene. In manufacturing, it is the factory floor. In health care, it is wherever there is patient interaction. In hospitals, the real place can be on the units or in the operating room.
This gets me back to the conference room. How often have we as leaders in health care tried to solve a problem in a meeting when the real knowledge and real experts were at the bedside, delivering care? Too often in health care we jump to solutions. After all, we were trained to know the answer. When leading improvement, though, we must resist the impulse to ‘solve’ the problem right away. In practice, this results in short office meetings, with the brunt of the work being done in a gemba walk, on a hospital unit, for instance.
Health care leaders can achieve multiple objectives when going to the gemba. The main objective is to obtain a comprehensive understanding of the process through a series of interviews in the relevant place. In health care, this is often on the floors, in the operating rooms, doctor’s offices and labs. Sometimes, it brings us to the patient’s home. We are tempted to overlook this critical step in improvement, especially if we are rushed, think that we already know the answer, have preconceived ideas of the primary issues, or get consumed in large volumes of data. By going to the unit, observing and talking with care providers involved in the actual process at the actual place, one can obtain actual data, which is critical for improvement. The best improvement ideas often come from going to the gemba. Importantly, it also helps to build trust between management and front-line care providers -- a critical element in a safety culture.

The way to “go to gemba” was perhaps best expressed by Toyota Chairman Fujio Cho when he said, "Go see, ask why, show respect.” 

When taking a gemba walk, see if processes are designed to enable people to work toward achieving organizational purpose. Is leadership working to align people and process to achieve purpose? Be prepared to accept the differences in the process -- between what is and what it should be, much less what the organization wants it to be. You might find that the policy that you sweated over is found to be fictional because workarounds have been developed and training was inadequate.

Although it is the second element of Cho’s mantra, "why" is not actually the first question we want to ask at the gemba. First ask “what,” then “why,” then “what if” ... and, lastly, “why not.”

Finally, show respect. When visiting any gemba, through showing respect for the workers we also show respect for patients and the organization. Look for evidence of disconnects between stated objectives, perhaps those expressed in the organization's vision statements, versus what we actually observed at the gemba. Also look for signs of disrespect, such as overburdened nurses. Certainly as health care leaders, we respect people because we believe it's the right thing to do and simply because it makes good business sense. Respect means doing what we can to make things better for the people delivering care, which starts by not making things worse. The first rule of gemba walking is “Do no harm!”

So, next time you are in a meeting and find the group is trying to diagnose and prescribe a solution from the conference room, get up and go to the gemba. Confirm what is actually happening, as it is happening. It is one of the most important principles and practices of leadership.

Violence in the Health Care Setting

May 14, 2014 | Comments (0) | 21267 Views

By Paul M. Schyve, M.D.
Senior Advisor
The Joint Commission

Schyve 11 10Many physicians have witnessed it. A few of us have personally experienced it. All of us have heard about it – patients, nurses, staff or physicians injured or killed by violence in the workplace. 

Injuries to medical personnel in a war zone during military service are part of the job. That’s where a nurse or physician knows injury is a real risk. Unfortunately, the risks today occur closer to home in urban and rural hospitals – especially in Emergency Departments and substance abuse units – physicians’ offices and mental health clinics. 

Can this violence be reduced, and do physicians have a role in its reduction?

Physicians have ethical obligations to patients – expressed since the time of Hippocrates – to “first, do no harm.”  (Florence Nightingale extended the same obligation to nurses.) Traditionally, we associated this obligation to the clinical care each physician provides to his or her own patients. However, we now recognize that the culture, systems and processes that we work within are major contributors to safety in patient care. Consequently, we realize that to “do no harm” requires us to contribute to improving the culture, systems and processes within which all of our patients – both our own and our colleagues – receive care. To make our own patients safe, we must contribute to making all patients safe. 

Violence in the workplace is, in fact, a source of harm to our patients that we are obligated to reduce if we are to “do no harm.” To achieve this goal, physicians must become involved in assessing and improving the culture, systems and processes not only of clinical care, but also of the organizations in which we work – hospitals, clinics, private offices, etc.

But, as leaders in health care organizations, physicians also have an obligation to each other, nurses and other staff to create a safe environment.

Nursing is, in fact, one of the most dangerous professions, according to an article in Medical News Today and numerous other sources, In addition, if violence – from whatever source -- is ignored, nurses begin to believe that violence is endemic in their profession, and that organizational leaders, including physicians, have a “culture of acceptance” of violence. Nurses then leave for safer nursing environments or for safer professions. 

So what can physicians do? 

First, we can demonstrate our commitment to a culture of safety by avoiding intimidating behaviors in our interaction with colleagues (See Sentinel Event Alert, Issue 40, “Behaviors that undermine a culture of safety” . Second, we can urge and support our organizations’ leaders to making a reduction in violence a priority for the organization (See Sentinel Event Alert, Issue 45, “Preventing violence in health care settings” . And third, we can improve our knowledge and skills in detecting signs of impending violence and in de-escalating situations of potential violence.

Violence in the health care workplace is a threat to all – physicians, nurses, staff, patients and their families. Physicians have an important role in reducing and eliminating this violence, and we have an obligation to ourselves and others to do so.

Taking a stand against falls

May 01, 2014 | Comments (0) | 30282 Views

erin_dupreeBy Erin DuPree, M.D.
Chief Medical Officer and Vice President
The Joint Commission Center for Transforming Healthcare

"Why do we fall? So we can learn to pick ourselves back up."

While this quote from the movie "Batman" might apply to children and superheroes, we in health care know that falls can be deadly or lead to a general decline in health for the ill or elderly. That’s why earlier this week, the Joint Commission Center for Transforming Healthcare announced its Preventing Falls with Injury project.  With patient falls accounting for approximately 11,000 deaths in U.S. hospitals annually, the Center began working on new measurement systems and solutions to try and combat this problem.

The result? The number of patients injured in a fall was reduced by 62 percent, and the number of patients falling was reduced by 35 percent. These are exciting numbers not only for us, but for patients and health care organizations. These numbers mean if the Center’s approach is translated to a typical 200-bed hospital, the number of patients injured in a fall could be reduced from 117 to 45 and save approximately $1 million annually through fall prevention efforts.

Working with the Center, seven participating hospitals were able to significantly reduce the total number of falls and falls with injury by using targeted solutions, such as creating awareness among staff, empowering patients to take an active role in their own safety, and utilizing a "validated" fall risk assessment tool. 

The targeted solutions, which were thoroughly tested and proven effective during the project, are strategies developed to mitigate contributing factors. In all, the hospitals and the Center created a total of 21 targeted solutions during the course of the project. As solutions were developed, the hospitals discovered that fall prevention was not a set of disparate and unrelated activities. Instead, preventing falls was a key strategy in preventing or minimizing patient harm.

With a death rate of 11,000 annually from patient falls, we "fell" as a health system. Now, through efforts like the Preventing Falls with Injury project, we’re picking ourselves back up so we can tackle this challenging patient safety issue.