Medical Errors Report #28
A Four-Year Solution Implementation Study
Solutions to Fixing
Medical Errors is Centered on Process Redesign and Administrative Active Support
Much of this report
indicates that many hospital executives are less responsive to initiatives to reduce
medical errors. Some health-care executives questioned claimed that it was virtually
impossible for them to fix problems identified in various hospital departments. They
expect the department head to be responsible for such intervention. It was further
explained that the hospital operation is big and they cannot be in all places at all
times. How do they know that the system is working? Most of them responded that, as long
as no problem is reported, they believe everything is working out well. According to
Anthony Vecchione’s article, “Fine $1 Million Hospital Installs Narcotic
Tracking” (Drugs Topic, Dec 16, 2002), a hospital was fined for violating the
DEA inventory practice guidelines and failing to report missing narcotics. One nurse
called to help the hospital indicated that the hospital needs a comprehensive team to look
at processes and how they impact hospital operations. She also stated that neither the
hospital policies nor the procedures met government requirements or JCAHO regulations.
Some
conversations with health-care workers including some physicians during this study make it
obvious the present system is not working well in fixing medical errors and systemic
failures. I also gather from these interviews that many of the health-care executives are
as overwhelmed as employees who must do more work with less staffing. To some extent, some
of them created their own administrative problems. Unfortunately, some of them spend more
time and efforts collecting money for the United Ways than the amount of time they spend
on quality improvement. It is also obvious that many of them are interested in improving
quality of patient care because it ties directly to the hospital’s revenue. However,
there is a major problem. Many of them do not know how to fix the problems. They think
their only choice is to delegate. To achieve substantial and ongoing progress in error
reduction, hospital executives must be more involved in quality improvement.
Here is a
rescue. The best way to fix medical errors is to first look at all the systems put in
place to deliver care to patients from all the critical departments of the hospital. An
investigator must keep in mind that most errors are not caused by the complexity of the
system, contrary to what we were being deluded to believe. Most medical errors to-date,
have been cause by simple systemic failures. The process of fixing these failures
may however, be a little more complex because there is a lot involved in redesigning and
implementing a new process. For example, one department may have a very elaborate
collection of procedures. Each procedure has to be evaluated from the perspective of the
process-line workers using these procedures to take care of patients. Most of the time,
disaster turns on the red light. People wait until disaster strikes before igniting a
process to evaluate what went wrong at which time it is too late. Being proactive is to
identify problems before they happen and fix them before disaster strikes.
Another
observation from this study is the replacement of physicians with nurses, techs,
pharmacist or business executives to be administrative heads over clinical departments.
Many hospital administrations resorted to this type of management because they are able to easily influence the techs or nurses more
than physicians regarding financial issues. The impact created disastrous outcome for
quality improvement as many of these physicians washed their hands off quality improvement
issues. For examples, when pathologist were the administrative heads of the lab, they were
not only involved in day-to-day operations of the lab, they were also the lab advocate
with fellow physicians including being directly involved with quality improvement. During
those years, pathologists set a list of tests to be done as STATs. Too many unnecessary
STAT tests are costing hospitals millions of dollars every year in wasteful spending.
Today, some pathologists do not want to get involved with quality improvement because of
the hospital administration’s grip on management power. Since the hospital executive
in charge of the lab does not know anything about the clinical operation of that
department, pathologist must be place back in place of leadership and management. If
quality improvement is to survive in clinical departments especially when it involves
other departments like the nursing, physicians must be more involved in fixing errors.
Removing pathologists or other physicians from presiding over clinical departments is one
of those administrative blunders of the 1970 and the health-care institutions are paying
dearly for it today.
Many times in
this study, we evaluated procedures that people are using and wondered how in the world
they have been delivering services to patients. This situation is like a person sitting on
a time bomb and smiling. What we noted is, when people to do understand a procedure, or
when the procedure is too cumbersome, employees would develop their own personal procedure
leading to variations and increased chances of errors. Most of the time they believe they
are following the normal protocol. They would argue they are following proper procedure.
But, when they are observed carrying out such procedures, variation leads to increase
chances of errors. In some departments like
nursing, errors are often caused by employees in a hurry to get things done either because
of lack of time to double check or because of lack of awareness of the danger of
shortcuts. Other times, errors are caused by carelessness. Once deficiencies are
identified in a process-line, solution is achieved through a process redesign, and
implementation of the new design. People have to be very careful. Such an endeavor to fix
a problem has to be done very carefully and correctly, according to guidelines to assure
effective implementation. Lara Publications has created an answer for that problem with an
in-house seminar to help hospitals achieve this objective. Please visit our website at www.101waystopreventerrors.com
Doing process
redesign correctly is very essential. Many hospitals act as though they do not know
how to effectively conduct process redesign to achieve the intended objective. Rules and
guidelines must be followed, and there is a very important part the hospital
administration must play. An untrained person cannot do this successfully because a lot of
processes are involved including ways to deal with resistance and barriers when they
arise. It is also very essential to understand the techniques for getting employees to
buy-in the new process design. Many quality improvement officers still do not understand
the process of motivating employees to accept, implement and absorb the new redesign. This
is the primary reason why efforts across the nation to fix the problems causing medical
errors have failed. This trend can change if we follow the correct guidelines.
Most
importantly, hospital executives must champion the campaign to improve quality of care in
their respective institutions to help reduce medical errors. Health-care CEOs, medical
directors and nursing vice president must make honest commitment to not only initiate
quality improvement processes but must also be actively involved with various action
groups working to fix errors. The present remote control strategy of the old management
system where the executives dish out orders and expect solutions is becoming obsolete as a
management policy or technique. Employees need to be motivated to take ownership, identify
problems on the process-line and work with the system to fix them. This cannot happen in
the absence of hospital executives championing the process. No amount of training, efforts
or workshop programs will work to fix medical errors in the absence of administrative
active commitment and involvement.
The outcome of
this report so far has both a bad and a good news. The bad new is the continuation of
medical errors will continue to kill patients until health-care executives start listening
to us – who are working on the process-line. Celebrity researchers who have no idea
about what is happening on the process-line except for a few of them have no answers.
Those researchers with big titles do not push patients to X-ray or to surgery. They
neither draw blood, perform blood tests, take patient x-rays, dispense medication from
pharmacy, receive telephone orders from physicians, give medications or transfuse blood to
patients. Those researchers only based their assumptions of the problems on the data
provided to them. The celebrity researchers have no answers, that is why after spending
over half a billion dollars since 1999, medical errors are still killing patients due to
simple systemic failures. The solutions lie with us who are not only working on the
process-line but also studying systemic failures while taking care of patients. The good
news is, reduction in medical errors increases when hospital executives are motivated and
enchanted by incentives to champion the efforts to improve quality of care. Hospital
executives must make quality improvement their number one priority just like they look out
for the financial picture of the hospital.
The rest of the story
and the detailed chronicle of war on medical errors during the implementation phase of
solutions and the obstacles encountered are featured in the book: Managing Crises on
the Job – Reported for Working on Duty and Reprimanded for Working too Hard
– An Interminable Journey of Fixing Medical Errors, by Yinka Vidal
published by Lara Publications, due for release in Summer 2004.
Reports (books) on
the ongoing medical error reduction project
1. Process
Redesign – An Effective Way of Fixing Medical Errors and Systemic Failures –
(publication date to be announced)
2. Managing
Crises on the Job – An Interminable Journey of Fixing Medical Errors - 2004
3. 101
Ways to Prevent Medical Errors – A 24-year Odyssey - 2002
4. Overcoming
the Invisible Crime - 1993
www.101waystopreventerrors.com
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