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Safer Hospital Care: Strategies for Continuous Innovation Elaborates on the Steps Required to Make That Paradigm Shift a Reality Raheja Healthcare / Hospital Safety / Healthcare Quality Assurance Medical Errors May Be Unpreventable, but Preventing Harm Is Often an Option From newborns switched in the nursery and never events in the operating room to medication mix-ups and hospital-acquired infections, we are all familiar with the horror stories about hospital safety, and unfortunately, the statistics say we aren’t exaggerating. The safety issue in U.S. hospitals has become so profound and Safer Hospital Care embedded, that we cannot hope to fix it without a paradigm shift in our approach. After defining and demonstrating the true depth of this dangerous concern, Safer Hospital Care: Strategies for Continuous Innovation elaborates on the steps required to make that paradigm shift a reality. A respected and sought out expert on hospital safety, author Dev Raheja draws on his 25 years of experience as a risk management and quality assurance consultant to provide hospital stakeholders with a systematic way to learn the science of safe care. Supported by case studies as well as input from such paradigm pioneers as Johns Hopkins and Seattle Children’s, he explains how to: • Adapt evidence-based safety theories and tools taken from the aerospace, nuclear, and chemical industries • Identify the combination of root causes that result in an adverse event • Apply analytical tools that can effectively measure hospital efficiency • Establish evidence between Lean strategies and patient satisfaction • Make use of various types of innovation including accidental, incremental, strategic, and radical, and establish a culture conducive to innovation This practical guide shows how to find elegant solutions that are simple and comprehensive, and can produce a high ROI. To reform hospitals, we must recognize that they are highly dynamic systems that must be fixed systemically. Instead of thinking in terms of continuous improvement, we need to think in terms of continuous innovation. Safe hospital care is not just about doing things right; it is also about breaking old habits, finding new tools and doing the right things. K11114 ISBN: 978-1-4398-2102-2 90000 www.crcpress.com 9 781439 821022 www.productivitypress.com Safer Hospital Care Strategies for Continuous Innovation Safer Hospital Care Strategies for Continuous Innovation Dev Raheja CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2011 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20110726 International Standard Book Number-13: 978-1-4398-2103-9 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material repro- duced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copy- right.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifica- tion and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Dedicated to all physicians, nurses, and caregivers who are doing their best to prevent adverse and “never” events. Contents Acknowledgment............................................................................. xiii About.the.Author...............................................................................xv Introduction................................................................................... xvii 1 The.Etiologies.of.Unsafe.Healthcare.............................................1 Introduction .................................................................................................1 Failure Is Not an Option .............................................................................3 An Unconventional Way to Manage Risks .................................................3 Defining Unsafe Work ................................................................................4 How Unsafe Work Propagates Unknowingly .....................................5 How Does Unsafe Work Originate? ..................................................10 So, Why Do We Unknowingly Sustain Unsafe Work? .....................11 Using Best Practices Is Insufficient ...................................................13 There Is Hope ...................................................................................14 The Lessons Learned .........................................................................15 Summary ...................................................................................................16 References .................................................................................................16 2 Sufficient.Understanding.Is.a.Prerequisite.to.Safe.Care............19 Introduction ...............................................................................................19 Insufficient Understanding of System Vulnerability .........................20 Insufficient Understanding of What Is Preventable .........................22 Insufficient Understanding from Myopia ..........................................23 Insufficient Understanding of Oversights and Omissions ...............25 Insufficient Understanding of Variation ............................................27 Some Remedies .................................................................................28 Summary ...................................................................................................33 References .................................................................................................33 vii viii ◾ Contents 3 Preventing.“Indifferencity”.to.Enhance.Patient.Safety..............35 Introduction ...............................................................................................35 Performance without Passion ...................................................................36 Not Learning from Mistakes ..............................................................36 Inattention to the Voice of the Patient ..............................................37 Making Premature Judgments without Critical Thinking ................38 Lack of Teamwork .............................................................................39 Lack of Feedback and Follow-Up .....................................................40 Performance without Due Concern ..........................................................41 Lack of Accountability .......................................................................41 Encouraging Substandard Work .......................................................42 Reacting to Unsafe Incidences Instead of Proactively Seeking Them ..................................................................................................42 Inattention to Clinical Systems ..........................................................44 Difference in Mindset between Management and Employees ........45 Poor Risk Management .....................................................................46 Performance Diligently Done in a Substandard Manner .........................46 Continuing to Do Substandard Work, Knowing It Is Substandard .......................................................................................46 Ignoring Bad Behavior ......................................................................47 Inattention to Quality ........................................................................51 Summary ...................................................................................................52 References .................................................................................................52 4 Continuous.Innovation.Is.Better.Than.Continuous. Improvement...............................................................................55 Introduction ...............................................................................................55 Why Continuous Innovation? ...................................................................56 Types of Innovations ................................................................................58 Marginal Innovation ..........................................................................58
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