It’s hard to believe it’s been five months since a group of us (from Five Hills Health Region and HQC) did our mistake proofing tour – with stops at Virginia Mason Institute, Virginia Mason Medical Center, Seattle Children’s Hospital, and Autoliv. Each of these organizations has embraced Lean principles and methodology and is unwavering in their commitment to zero defects.
The trip (which I blogged about in an earlier post) was the easy part; it was fun to be part of a group of individuals curious and committed to learning how to make our health organizations safer. However, when we landed back in Saskatchewan in mid-May, fear quickly replaced the exuberance and hope I felt while I was away.
Each of our teams had to begin applying the ideas and concepts we’d learned, then report out to leadership five months later about the improvements we made since the trip. Could we really achieve any improvements in patient safety in such a short time? We’d never done this before. And what if we did it wrong?
One of the liberating things I’m learning as part of Lean training is that time (or lack thereof) is actually your friend — not your enemy. Before, we would have built in lots of extra time to ensure our improvement plan was rock solid. We wouldn’t actually DO anything until we had the perfect plan.
The great thing about having a fixed amount of time to make improvements is that it forces everyone on the team to just “go do it.”: come up with some ideas, try them, collect data on these ideas, then try some more.
Are you going to make mistakes? Yep. Are you going to wish you had more data? Probably. We’re still hardwired to think ‘just in case’ rather than ‘just enough.’ I’ve come to realize though, that our teachers from John Black and Associates are more focused on helping us change our behaviors than on changing our mindset. Initially, I was kinda ticked off with this. Now I see that we learn a lot more from doing than from thinking.
The project I was assigned to looked at the number of medication defects for patients on the Mental Health Unit at Moose Jaw Union Hospital. A defect included the wrong drug, wrong dosage, wrong time, wrong person, or medications not given.
In 2011-12 there were 17 instances of one of these defects. During the time we tested some of our improvement ideas, there were just three. If we keep on this same path, our team estimates we should be able to achieve a 33% reduction in defects over the longer term.
We’re not at zero yet. But my colleagues in Five Hills are committed to hitting that target.
If you were to ask my mistake proofing colleagues, fun is probably not the first word they’d use to describe their experience thus far. But words like curious, hopeful, and humble just might be. It’s these words — and the behaviours that come with them — that make me think we’re on the right path with our improvement journey in Saskatchewan.
What did you think of this post? Did it affirm your view on the topic? Change your thinking? Let us know, using the Inspire-o-meter below.