Investigating Healthcare Events: Do We Want to Learn? Are We Committed to Listening?
When we investigate events in healthcare, we are looking for the systemic causes of failures, both human performance based and equipment based. When looking at individual events we cannot exclude other related or similar events in our data gathering process as we should be learning from those as well. So if it takes research to see that staffing levels are affecting patient care, then we need to look at our long standing RCA programs and ask are we doing everything we can to understand the bigger picture?
A recent article highlighted this issue with true clarity. The research told us that there is a link between Nurse staffing levels and the quality of care provided. Now, I could go through and show you how TapRooT® helps you find the “Scheduling NI” root cause or the “SPAC NI-> Confusing or Incomplete” root cause and how it fits these types of events. Looking at this I see it in the bigger context of an organization and the bigger picture is understanding and “listening” to the data and what our process is communicating to the organization.
Looking back at the original research and tying things back to RCA it became clear that we have some larger systemic issues that we are not addressing. These may include Trending of RCA data, communication of issue within our hospitals, and data collection during event analyses. Any of these three puzzle pieces could lead us towards the same conclusions found in the above article. So why does it take us so long to see “Generic Issues”? Well here are a couple of my ideas or hunches, if you will, on this issue:
1. Do we truly want to learn or are we satisfying a “requirement”?
Regulation is a necessary evil in our society… many times it seems that doing the “right” things are not as commonplace as it once was. So through regulation we “require” diligence, we require analysis, we legislate what should be done anyway. With this there truly are two trains of thought, compliance mentality and improvement mentality. The compliance mentality is what I highlight here. If we have the compliance mentality we only do because we have to, which usually means meeting the letter of the law and no more. Checking a box does not mean we listen to the data or what our systems are telling us and many times it leads to only the corrective measures we can get away with at a minimum. Is this acceptable when adverse outcomes can cost the lives of the ones we commit to serve, aid and protect?
How do we change this mentality? Understand the value of the use of Root Cause Analysis within the organization and work to make it part of the everyday job of each employee to improve their jobs, their productivity, and empowering them to bring about change in an organization. This means tackling the everyday issues with RCA and not waiting to fulfill a requirement. Expand the scope through empowerment for change.
2. What is our commitment to “listening” versus “hearing”?
Confronted with my own personal family issues around this very issue has brought this to the forefront of my mind. When people are recovering from traumatic injuries and are being helped by others there is a tendency to be overwhelmed by the “claustrophobic” nature of personal care from a loved one. The feeling is that they are complaining at me so much that I am overwhelmed, and am listening but can’t take all this information. When in fact they are “hearing” everything said, but truly are not listening to the messages for various reasons.
This can be like a corporate culture, are they “hearing” or “listening”. There is a huge difference in these two things that many people simply don’t get. Too many times we have people report issues or problems or near-misses because we say “We are Listening to you”, but we truly are only “Hearing you” in the absence of acting on the data. Generic issues (which I have written about before) are something that you have to be willing to “listen” for through your RCA and Report data. Data provided to your organization will tell you a story, it will provide you with indicators or precursors that help you predict the future. Now is it an exact science, no, but it doesn’t have to be if you “listen”. In my opinion too many organizations want to make their employees and clients feel “heard” but are not willing to actually listen and act upon what they are being told.
Changing this behavior is not as simple as it may sound. It is truly a change in the corporate culture of an organization, the “walk the walk” versus “talk the talk” mentality. This can be started simply by the communication from management through to the folks on the front lines of how RCA data and corrective actions are handled. Allowing people to see that they have the ability to enact change. Then making sure that the proper trending and “listening” tools are in place to understand what the reported data is telling you. These two pieces can paint a very cohesive picture of how the organization is performing. Process Behavior Charts, Pareto Charting, and other basic data analysis tools are built into the TapRooT application to aid in doing this.
Within this discussion there are probably many other reasons why we can’t or won’t see the bigger picture and I would love to hear your theories and thoughts on this issue. The two issues I raise above are two good starting points to making your organization more efficient. But improvement opportunities abound throughout your organization, but they can only be found if you are “listening” and heed the messages being sent to you from your employees and from your systems. Don’t wait for research to tell you where your problems are, listen and act upon what you already know and bring your organization ahead of the curve.
If you would like more information about the Trending tools recommended and provided by TapRooT® please feel free to contact me directly at firstname.lastname@example.org or plan to attend our 2-day Trending Course held before our TapRooT® Summit this August in San Antonio TX.