Operational Excellence and the Rest of the House
Current thinking in healthcare to date has been very directly focused on clinical services, operations, processes, tools and practitioners. All very obviously crucial to establish and maintain objectively robust standards of care. How do physical facility, nonclinical staff practices, supply choices and other “environmental factors” support or challenge clinical operations and patient outcomes.
Are nonclinical staff and operating practices designed, trained and measured to sustain clinical performance? Can decisions about physical plant, equipment and supply choices make patient safety and clinical execution less burdensome or dependent on clinician vigilance and discipline for reliable performance?
The Studer Group points out that the US Navy nuclear submarine service has never had a safety event in over 40 years of service. There are two schools of thought on the origins of accidents and reliability. The Normal Accident Theory and High Reliability Theory was compared by Jos Rijpma in the Journal of Contingencies and Crisis Management in 19971. Normal Accident Theory holds that, no matter what organizations do, accidents are inevitable in a complex and tightly coupled system. High Reliably Theory asserts that organizations can contribute significantly to the prevention of accidents[i].
There is certainly little margin for error in the nuclear Navy. The Navy has earned its’ safety record by creating a culture and environment of high reliability. Every Navy crewman is thoroughly drilled and trained on safety procedures, proactive maintenance schedules and understanding of what “sound operating condition” looks like so that an aberration gets noticed and reported. Checklists are rigorous, used formally and documented. Time outs happen as scheduled to verify that any complex procedure is being correctly executed by all crewmen. Every engineering fitting is designed so that a mistaken connection or a faulty connection is not physically possible. However,There is a general culture of responsibility for safe operations drilled into every crewman, from a Captain to a cook. Mistakes cannot happen but controls are not taken for granted with everyone staying vigilant.
Hospital can learn from the Navy experience. Feeding tubes, medication tubes and similar items can be purchased color coded with unique couplers that make inappropriate use physically impossible. Beds, transport items (gurneys, wheel chairs) and diagnostic equipment should be selected with both staff and patient safety in mind. All staff: housekeeping, facility maintenance, office workers, volunteers, dietary, should be trained in CPR. Training should include infectious disease control, recognition of physical distress and fall prevention. Checklists and timeouts can be incorporated in every clinical procedure. Moreover, everyone involved in a clinical process should know what “unsound operating conditions” look like in a patient. However, If you see something, SAY something as quality patient outcomes should be everyone’s mission in your facility on hospital.
Nonclinical Service Team-
Nonclinical service teams in a hospital should be provided with processes, training, tools and metrics which support the same levels of accountability, transparency and compliance with high standards that will reduce the chances of accidents and move the organization into a highly reliable organization. A hospital should operate like a Swiss watch, every element meticulously crafted to fit into a frame which assures robust alignment and consistent execution irrespective of the stresses imposed upon it and well designed and engineered tools can provide much of this frame. Sound decisions about organization, workflows, standards, training, metrics, supplies, physical plant. Also, equipment can provide the gear, bearings, and spindles that make up a functioning mechanism. Especially, A highly reliable organization has leadership that focus on quality, soundly crafted standards and performance goals.
1 Rijpma, J.A. (1997), Complexity, Tight-Coupling and Reliability: Connecting Normal Accidents Theory and High Reliability Theory. Journal of Contingencies and Crisis Management.
Gary Seay is Principal of BrightWork Advisory,LLC., a practice focused on enabling innovative healthcare solution success. Mr. Seay is an author, speaker and advisor possessing extensive executive experience with major healthcare provider systems, managed care organizations, venture capital firms, and academic programs. He can be reached at josephgseay@BrightWorkAdvisory.com.