Defining A Defect


Originally published on [Not] Running A Hospital

From Charles Kenney’s book Transforming Health Care, about Virginia Mason Medical Center’s journey:

Implementing the program was not a simple matter. Defining a defect in a medical setting presented a challenge…. [D]octors pushed back. The argued that many instances of harm — ventilator-acquired pneumonia, for example — should not be considered an error because these things happened in medicine. Complications, they argued, were inevitable.

This is a typical assertion, based on a belief that there is a statistically irreducible amount of harm that must occur in medical settings. There may be such a statistically irreducible amount, but most hospitals are not close to the potential minimum. As Gary Kaplan and his team showed, and as shown at BIDMC, setting an audacious target of zero defects and organizing work to reach that target can enable the people in a organization to reach or get mighty close to that target.

Joseph Gavin strived for such a goal in space flight. Others are doing so in medicine.

Real transparency is a concomitant of success in such a transformation. You cannot improve what you do not acknowledge to be flaws. That is why I pound away below as to its importance and as to why misuse of transparency is unethical.

This is deadly serious. Those who stand in the way are causing death and injury as clearly and directly as those who wield weapons.

Paul Levy, the soon-to-be former CEO of Beth Israel Deaconess Medical Center in Boston, writes at [Not] Running a Hospital.

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