Bureaucratic solutions too-little too late to save lives
Today I read an article in the NP that needs a lean response. Tom Blackwell's article puts light on a serious problem in health care: confusion over similar looking labels has led to mistakes causing death. The tragic deaths of 2 people in Calgary who while undergoing dialysis were given deadly potassium chloride instead of harmless sodium chloride solution; a mistake traced to the extreme similarity of the packaging and labelling. The article quotes pharmacy professor Neil MacKinnon: "If you ask any kind of front line nurse or pharmacist they would say 'Gee, this isn't rocket science, why can't they make labelling clearer- put things in different size fonts and colors?' It's a big problem we've known about for a long time but there doesn't seem like a lot of impetus for change."
The government and industry are working on a standard bar code system for use with scanners - a highly expensive solution that will take "years" to implement. Health Canada is also being asked to vet labels and packaging that may lead to mistakes. They are committing $2 million to a system for REPORTING incidents and developing preventive measures! I am sure the reporting system will comfort the next family that loses a loved one.
This example screams for simple and immediate implementation of lean methods. It is not rocket science. Although the bureaucracy is doing its "best", action on this problem need not be delayed. Error proofing is a basic concept of lean. You simply devise ways to completely prevent common and likely errors. A lean manufacturer would immediately address this issue and market the improved safety. Luckily the Institute for Safe Medicine Practices in Atlanta has begun positive work with drug suppliers but it is clearly not moving as fast as is needed. Interestingly they have a system standard of TALLMAN letters for labels that emphasize the differences between similar medicines right on their label. Why is this not industry standard?
Interested lean leaders would simply ask the front line workers to identify the most likely confused medications. Thereby creating an immediate database of improvements to tackle, heading off mistakes in the short term. I bet there are many simple (and cheap) error proofing ideas on the minds of health care workers waiting to be engaged. Lean is about making improvements right now using the expertise of the front line workers. It is ironic that the bureaucracy has such a hold on "improvement" that even simple changes that save lives can't be made quickly. Isn't saving lives quickly is what health care is all about? I would start with those on the front line, not waste time installing long term costly "solutions" or developing a reporting system that costs more than the solutions to most of this issue would. It is sad that lean in health care at the national level in Canada is not visible at all.
Showing posts with label healthcare. Show all posts
Showing posts with label healthcare. Show all posts
Thursday, September 30, 2010
Friday, September 17, 2010
Elephants, Awards and Lean Health Care
Here are two of my favourite elephant stories that seem apropos to lean transformation of health care:
1) How do you eat an elephant? One bite at a time of course!
2) A king has the blind men of the capital brought to the palace, where an elephant is brought in and they are asked to describe it.
"When the blind men had each felt a part of the elephant, the king went to each of them and said to each: 'Well, blind man, have you seen the elephant? Tell me, what sort of thing is an elephant?"
The men cannot agree with one another and come to blows over the question of what it is like and their dispute delights the king.
The cost of our health care is predicted to completely outstrip our ability to fund it within our lifetimes. Hear that boomers? If any sector in our economy needs to embrace lean quickly and effectively right now, it is our Canadian Health care system. We are in trouble. Recently, right across the country, major initiatives to streamline provincial health care data systems have been tainted by scandals. The public faith is eroded daily by every failure, scandal and personal tale of suffering. I will not turn this into a political debate (you're welcome) but the politicians are our leaders and they must not keep passing the buck by simply cutting services and rationing health care. Can the "blind men"/stakeholders in our health care system do anything to change the downward course of the behemoth that is our medical system? The debate is nothing to fear compared to what is at risk. The time is now to get together, understand what they really have on their hands, and then get eating!
Universal health care was a populist initiative that set us apart from the rest of North America. Canadians are rightly proud of their system, and also rightly wary of US style health care. Perhaps to a fault. Universal health care access is right up there with hockey as a Canadian cultural icon. Federal elections have been swayed by the mere suggestion of "two tiered health care". I know we have excellent arguments about why universal health care is better for society, but why can't our public system rival the best privately run operations? Why should the Canadian public accept less value-for-money as a condition for a universal system? I have spoken to a number of health care workers and virtually all are unsatisfied with the system somehow (some to the point of despair). I am told things are dysfunctional and the future is bleak. I understand there is much to discuss and my point here is that it is clearly time for us to act differently and face our elephant.
Advocating the American style solution is "not on" in Canada. That is a political reality. But, (putting aside cultural biases) if the US system is so bad why were so many US citizens opposed to health care reform? In that recent and divisive debate down south, our Canadian system was demonized for having a lower standard of care and huge waiting times that cause unnecessary suffering and death. Hmmm...let me ask you Canadians in your heart-of-hearts; are our wait times for treatment and level of care all that you would like them to be? I know the US debate was ill informed and hysterical/comical when referencing our Canadian system, but I believe the anti-reform forces in the US had a point underpinning their arguments. The opponents did not want any system that reduced standards of available care. Nor did they want care rationed or limited. They wanted high standards of health care. That desire for quality is one of the best attributes of the consumer and it forms a key motivator for a transformation to Lean. It is extremely important to understand that the Canadian public is doubly empowered compared to Americans because we own the system as well as being its customers. We are in the better position to demand both quality and efficiency in our health care.
A great example of Lean in health care is at Virginia Mason Medical. Virginia Mason has transformed itself such that it now offers training and consulting to other hospitals using their own "production system". They went and took the best of lean from manufacturing and applied techniques like kaikaku (rapid change) successfully to health care. Why haven't our institutions gotten that far on the lean journey?
I understand there are efforts to go lean in most health jurisdictions in Canada. A good place to measure the state of Lean Health care in Canada is at the 3rd Annual Lean in Health Care conference being held this month in Vancouver. This conference represents a good bite from the elephant. Private health care support services are among those presenting lean success stories to the conference and that is a very good sign. All these good efforts must be leveraged and we must raise our collective expectations in order to aggressively pursue excellence in health care quality.
In the US there is a Baldridge Award for excellence in health care quality that we in Canada would be wise to shamelessly emulate. The recognition of excellence on a national basis is long overdue. (There is an emerging award CHEQA Canadian Healthcare Excellence in Quality Award that is taking steps in the right direction, but it doesn't have the profile or the criteria to compete with the impact of a Baldridge Award). If we had a prestigious national award of excellence I believe we could better inspire the stakeholders to take on root cause solutions, and to fan the sparks of innovation.
Awards create focus and focus usually creates discussion. Let's get the "blind men" talking seriously. In this case the "blind men" on the health care elephant are: the Public, Government, Doctors, Nurses, Management, Support Industries, and Politicians. Of all the "blind men", the Canadian public have the most potential influence on the pace of improvement. If we could just allow the politicians to fully debate the challenges faced by our system there is a chance we could steer away from the bleakest vision of our health care future. Let's not fry the next intrepid politician that wants to jump start the debate!
Healthcare leadership in governments must be pressed to promote recognition of innovation and quality. Everyone should know who in the country delivers the best care. The public needs to open their ears to the debate, and get used to the fact that change must happen or the great Canadian social accomplishment of the last century will wither away in our lifetimes.
1) How do you eat an elephant? One bite at a time of course!
2) A king has the blind men of the capital brought to the palace, where an elephant is brought in and they are asked to describe it.
"When the blind men had each felt a part of the elephant, the king went to each of them and said to each: 'Well, blind man, have you seen the elephant? Tell me, what sort of thing is an elephant?"
The men cannot agree with one another and come to blows over the question of what it is like and their dispute delights the king.
The cost of our health care is predicted to completely outstrip our ability to fund it within our lifetimes. Hear that boomers? If any sector in our economy needs to embrace lean quickly and effectively right now, it is our Canadian Health care system. We are in trouble. Recently, right across the country, major initiatives to streamline provincial health care data systems have been tainted by scandals. The public faith is eroded daily by every failure, scandal and personal tale of suffering. I will not turn this into a political debate (you're welcome) but the politicians are our leaders and they must not keep passing the buck by simply cutting services and rationing health care. Can the "blind men"/stakeholders in our health care system do anything to change the downward course of the behemoth that is our medical system? The debate is nothing to fear compared to what is at risk. The time is now to get together, understand what they really have on their hands, and then get eating!
Universal health care was a populist initiative that set us apart from the rest of North America. Canadians are rightly proud of their system, and also rightly wary of US style health care. Perhaps to a fault. Universal health care access is right up there with hockey as a Canadian cultural icon. Federal elections have been swayed by the mere suggestion of "two tiered health care". I know we have excellent arguments about why universal health care is better for society, but why can't our public system rival the best privately run operations? Why should the Canadian public accept less value-for-money as a condition for a universal system? I have spoken to a number of health care workers and virtually all are unsatisfied with the system somehow (some to the point of despair). I am told things are dysfunctional and the future is bleak. I understand there is much to discuss and my point here is that it is clearly time for us to act differently and face our elephant.
Advocating the American style solution is "not on" in Canada. That is a political reality. But, (putting aside cultural biases) if the US system is so bad why were so many US citizens opposed to health care reform? In that recent and divisive debate down south, our Canadian system was demonized for having a lower standard of care and huge waiting times that cause unnecessary suffering and death. Hmmm...let me ask you Canadians in your heart-of-hearts; are our wait times for treatment and level of care all that you would like them to be? I know the US debate was ill informed and hysterical/comical when referencing our Canadian system, but I believe the anti-reform forces in the US had a point underpinning their arguments. The opponents did not want any system that reduced standards of available care. Nor did they want care rationed or limited. They wanted high standards of health care. That desire for quality is one of the best attributes of the consumer and it forms a key motivator for a transformation to Lean. It is extremely important to understand that the Canadian public is doubly empowered compared to Americans because we own the system as well as being its customers. We are in the better position to demand both quality and efficiency in our health care.
A great example of Lean in health care is at Virginia Mason Medical. Virginia Mason has transformed itself such that it now offers training and consulting to other hospitals using their own "production system". They went and took the best of lean from manufacturing and applied techniques like kaikaku (rapid change) successfully to health care. Why haven't our institutions gotten that far on the lean journey?
I understand there are efforts to go lean in most health jurisdictions in Canada. A good place to measure the state of Lean Health care in Canada is at the 3rd Annual Lean in Health Care conference being held this month in Vancouver. This conference represents a good bite from the elephant. Private health care support services are among those presenting lean success stories to the conference and that is a very good sign. All these good efforts must be leveraged and we must raise our collective expectations in order to aggressively pursue excellence in health care quality.
In the US there is a Baldridge Award for excellence in health care quality that we in Canada would be wise to shamelessly emulate. The recognition of excellence on a national basis is long overdue. (There is an emerging award CHEQA Canadian Healthcare Excellence in Quality Award that is taking steps in the right direction, but it doesn't have the profile or the criteria to compete with the impact of a Baldridge Award). If we had a prestigious national award of excellence I believe we could better inspire the stakeholders to take on root cause solutions, and to fan the sparks of innovation.
Awards create focus and focus usually creates discussion. Let's get the "blind men" talking seriously. In this case the "blind men" on the health care elephant are: the Public, Government, Doctors, Nurses, Management, Support Industries, and Politicians. Of all the "blind men", the Canadian public have the most potential influence on the pace of improvement. If we could just allow the politicians to fully debate the challenges faced by our system there is a chance we could steer away from the bleakest vision of our health care future. Let's not fry the next intrepid politician that wants to jump start the debate!
Healthcare leadership in governments must be pressed to promote recognition of innovation and quality. Everyone should know who in the country delivers the best care. The public needs to open their ears to the debate, and get used to the fact that change must happen or the great Canadian social accomplishment of the last century will wither away in our lifetimes.
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