Fair warning: This is one of those articles you read that makes you think twice about checking into an emergency room.

I’m still reeling from a recent New York Times article on a Department of Health and Human Services study that found hospital employees note and report only one in seven errors and other incidents of harm to hospitalized Medicare patients. One in seven: That’s an F in a classroom and includes instances that range from bedsores, acquired infections and other mishaps that could even result in death.

Medical error

This x-ray, courtesy BigHealthReport.com, illustrates a much-feared medical error.

The point here isn’t to encourage you to hit the Advil next time you fall off a roof. Read deeper and the lean alarm bells start sounding. According to the article, federal researchers say it isn’t shame or embarrassment that’s keeping these instances from being reported. Rather, it’s hospital employees not recognizing what constitutes patient harm or realizing a procedure has harmed a patient. In lean-speak, researchers hint the root cause lies deep within the procedures and training that line the backbone of hospitals’ operations.

The most staggering sentence in the article comes later: “In some cases … employees assumed someone else would report the episode, or they thought it was so common that it not need to be reported, or ‘suspected that the events were isolated incidents unlikely to recur.’”

This is a shining example of how a finger-pointing, siloed approach to daily work and problem-solving can infect an organization. On a shop floor, this could mean a malfunctioning widget. In a hospital, this could mean one less vacancy in the basement morgue.

The report is mostly, but not all, bad news. Medicare officials told the Times they’ll develop a list of “reportable events” to clear up confusion, a sure sign of progress. But much work remains to be done – a major problem in the system these days, the report states, is that once problems are recognized they very rarely lead to changes in policy or procedure. It’s a good start, though, to define what a problem is, design processes so they expose problems and then have a process in place to address them.

Reading the article, I’m reminded of a chat I had with lean guru Steven Spear when he visited Fisher to coach our Master of Business Operational Excellence cohort in November. Spear has loudly advocated that health-care providers should focus less on problems in the market and more on reforms in specific processes to effect meaningful change.

“I’m not sure that’s caught on in health care in a broad-based way,” he told me.

Unfortunately, he’s right.



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