St. Mary's in Madison has undergone a massive nursing training program related to the tragic death of a teenage OB patient.Will what they have done make a difference to prevent other accidents?
I know the leaders and doctors at St. Marys in Madison.They are dedicated,competent,caring people and belong to a great overarching organization lead by a visionary CEO.We all were very sad to learn of the terrible thing that happened a few years ago. How could it be? A great hospital with great doctors and staff.The fact is it happens every day in many American hospitals and everyone feels horrible but usually settles back into the bad practices that allowed it to happen in the first place.
St. Mary's has not done that.They have trained their nurses in something their consultant calls "just culture". All 20000 employees have been trained after this case. According to the consultant the model is designed to "address risky behaviors before they lead to the death of a patient,coaching those who make risky decisions,such as failing to wash hands before touching patients or skipping important checks in administering medications". It's hard to argue with the that. My question is this enough and is the problem fixed not only at St. Marys but for all of us.
Recently John Grout and I published an article on mistake proofing in healthcare (see articles by John Toussaint at the bottom of the page) in which we give concrete examples of how to build a care process that can't fail. In the St. Mary's case there was apparently an error proofing process in place for the medication which ultimately led to the demise of the patient but it didn't work.As the designers of healthcare process we struggle to build quality(and error proofing) into to every patient care process.The reason there are so many mistakes in healthcare is that we haven't done a good job of this.
If a new standard work process is implemented, then it needs to be carefully audited to determine if the process is being followed.If not, training needs to occur and performance measured until leaders are satisfied that the process is in control with little or no variation as the goal.These concepts are basic lean ideas which have been shown to work over and over.
We know St. Mary's went through a training program which presumably has established new behavioral expectations for nursing performance. I assume this also means new standard work for medication delivery. But if this new standard is not being constantly audited and performance feedback given to the staff on a daily basis it's possible the problem could occur again. Of critical importance,the defective medication delivery process must be truly error proofed as described in our article.With the high staff turnover health systems face sustaining an improvement is very difficult and it is one of the reasons we must measure and audit results constantly. Implementing an entire system standard methodology for improvement as I've described in my recent blog series is the only way I know to sustain gains made in point improvement projects like the massive retraining St. Marys has done.
We all hope this mistake never occurs again in any hospital. Hope is not enough, however, we need a methodology which engages every employee to identify defects and then perform plan-do-study-act improvement cycles that create new standard work which is then carefully audited to ensure compliance.This is the only way to break the terrible trend.
http://online.wsj.com/article/SB10001424052748704588404575123500096433436.htmlBUSHOR_798
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