THURSDAY, NOVEMBER 27, 2014
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Community Blogs Plane Crashes…Medical Error

Plane Crashes…Medical Error

As it’s put, “the airline industry doesn’t need a plane crash to learn how to crash planes.” The great majority of learning is extracted from incidents which had the potential to result in accidents, not from accidents themselves. So why does healthcare feel that it must make an error to learn from an error? For the quality of healthcare to improve, it must be willing to identify and eliminate the opportunities for error.

For every 1 major death or injury, there are literally thousands of unsafe practices and working conditions. The irony in this is that we spend all of our time trying to figure out who is to blame for this death or injury. While the combination of individual mistakes that causes a sentinnel event may be unique, the individual mistakes rarely are. With that said, why do we strive to learn as much as we can about this one death or injury so that we can create new ways to prevent this sentinnel event from happening again? Why don’t we ever bother to take a look at all of the contributing factors that lead up to this one event – those thousands of unsafe practices and working conditions. If we only could just admit that healthcare is a wealth of highly intelligent people who are working in a broken system.

We need to improve the working conditions and eliminate unsafe practices in order to prevent near misses, minor injuries, and sentinnel events. Lean Six Sigma is the combination of tools necessary to identify opportunities for error, and eliminate them. Further, using Lean Six Sigma to improve working conditions will lead to improved employee satisfaction. Improving working conditions involves putting systems in place that nearly eliminate the chance of making a mistake. Studies have shown that there is a direct correlation between improved employee satisfaction and quality of care (perhaps this is why Southwest Airlines has such great employee loyalty). There is a natural progression towards the elimination of error when the employee is not pressured to perform perfectly in a flawed system. Most importantly, it cannot be forgotten that interacting with the employee when implementing Lean Six Sigma will success and sustainability. Be sure to involve the employees and ask for opinions and suggestions. After all, they are the one’s working in broken system every day. They know best what aspects of their job lead them to feel overwhelmed and pressured to perform perfectly.

Once the employee is satisafied and they are working in a quality system, the customer satisfaction will improve. Common knowledge, again, says that a delighted customer also contributes to a successful, sustainable business. For healthcare, a delighted customer/patient improves the patient outcome as well. A patient who is less concerned about their care, who feels more comfortable in the hands of experts, is proven to have improved outcomes in regards to their treatments. With this in mind, why aren’t we doing more to improve the current conditions?

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