Stumbling blocks or stepping stones?

Hello All,

I wish I knew the name of the person who provided this great quote:

“The difference between stumbling blocks and stepping stones is how you use them.”

As a leader, there were times I should have used them as stepping stones versus stumbling blocks. (In fact, I may not have just stumbled, I fell flat!)  I am sure that there were times when I could have helped my staff use those stones better too! This leads me to what we can do as leaders when errors occur. I am going to share some personal thoughts; and I am also going to share information that I have recently gotten from a very interesting and thought-provoking book I read.

In almost every error, there is a system issue that needs to be tweaked or outright fixed too. If we assume it is only the employee’s fault and stop looking further – and unfortunately this does happen – then we will have missed the opportunity to fix a system issue and prevent other employees from making errors and potentially harming our customers! Here are some of my thoughts:

1. Listen to what the employee would do to correct an error . This often demonstrates where a system issue may be. The employee is working hands-on in the system every day and has a very different perspective from those who episodically access.

2. Re-evaluate policies and procedures. Sometimes our practices have outpaced the changes needed in policies and procedures.

3. Examine the circumstances around the issue – level of expertise, staffing (not just whether the number of employees needed were available, but skill mix), the activities of the shift (for nursing – admissions, discharges, transfers, codes, etc.) and level of support available (for example – day shift vs. night shift). Do these findings point out an opportunity for improvement?

4. Evaluate whether there is a technological fix (from electronic records to technology/equipment) that could have prevented the error.

The other thing we need to explore is the creation of support systemS. I capitalized the last “s” on purpose. There are efforts across our country to develop support mechanisms for the staff. There is one almost in our backyard. In 2011, a multidisciplinary group at John Hopkins developed a new peer/staff support system called R.I.S.E – Resilience in Stressful Events. In 2014 the staff at John Hopkins partnered with the Maryland Patient Safety Center to develop and distribute a program called Caring for the Caregiver – Implementing R.I.S.E. Perhaps this could be explored.

About that second “S”. This work is also difficult for the leader. Talking to the patient, his/her family, the staff…..evaluating the issues ….implementing solutions…..providing follow up…are all emotionally draining. It is equally important that the leaders have a support system too. Peer support is just as critical for the leaders. Human Resources is an important ally. Don’t forget that leaders are humans too.

Those are some of the things that are within our immediate purview. Having noted that, the book I just read – Still Not Safe: Patient Safety and the Middle Managing of American Medicine – co-authored by Robert L. Wears and Kathleen Sutcliff – has made me realize we must look at errors from a much, much broader perspective…..and with help from people outside of the healthcare arena.

This book is rich with the history of the patient safety movement from the days of Florence Nightingale through today. It is not a book to read all at one time! The information provided is so dense, I had to stop and think about what was said. Here are just a few of the notes and ideas that resonated with me.

“Patient safety can be tricky to define, because it’s essentially a nonevent. When things are going well, no one wonders why. When a mistake occurs that threatens the unrealistic ‘getting to zero’ goal of many health care mangers, then it becomes an event that demands reaction. And the reaction is to assign blame to people further down the organizational ladder.”

“This focus on who did wrong and how they did wrong is misplaced. It should be on what’s going right and what lessons can be learned from successes.”

“We live in an error of multifaceted problems that call for multidisciplinary approaches. Advances in anesthesia safety, for example, would not have come without input of engineers. Experts from outside medicine should be welcomes to any serious discussion of how to improve patient safety, and their insights heeded.”

The authors note it will take people from a “broad variety of disciplines (medicine, psychology, organizational behavior, human factors engineering and others)” to address patient safety issues. They also noted that patient safety would not only “involve activity at the level of practitioners or care delivery organizations. There are large classes of hazards that are deep, structural challenges within healthcare as a whole, far beyond the scope of even large, multihospital systems and must be addressed at higher social-political levels of authority.” (They used as examples of this look alike- sound alike drugs and Luer locks! These changes would also need to include drug companies and manufacturing companies!)

We must continue to do what can to make things safer for our customers and staff. And we must determine ways to reach out to others with different skill sets and different mindsets to help us learn and change. We do not have to shoulder these changes by ourselves. Nor should we.

Let me end on a positive note. You show up every day. You work hard every day. You care every day. In Laura Dern’s acceptance for her Academy Award, she stated “Some say never meet your heroes. I say if you’re really blessed, you get them as parents.” I agree with that. I am lucky with my parents. I would also add that if you’re really blessed your heroes are also your colleagues, your partners…..all who are working to make the world better.

I am blessed to call all of you my heroes.

Phyl