For the past week I have been reading a book entitled, The Nun and the Bureaucrat - How They Found an Unlikely Cure for America's Sick Hospitals by Louis M. Savary and Clare Crawford-Mason and I have to tell you that it's quite a good book. The primary themes of this book are systems thinking and the Toyota Production System and how both were applied to two separate healthcare organizations. The book's format is sort of unique in that it is full of quotes about what they did to improve their organizations by employees of both these two organizations.
I haven't finished the book yet, but I wanted to share one of the lessons both of these organizations learned during their transformation to systems thinking. In Chapter 5, The Most Disabling Challenge We Faced: Removing Blame. Kevin Kast, President, SSM St. Joseph's Health Center said, "Before we shifted to systems thinking, we were always looking for the bad apple. We believed that somewhere among the employees was a bad apple. If we could just get those employees out of here that weren't good employees this would be a great place. So, when we identified anybody likely to mke a mistake or close to making a mistake, that was the person that we should fire. Often we did fire them, believing that by getting rid of them everything would get better. But what happened was that everything didn't get better."
If you're a fan of W. Edwards Deming and his 14 Points of Quality Management like I am, you will remember that he advocated removing fear from the workplace. Most workers fear being blamed when something goes wrong and this is especially true in many healthcare environments. Blaming others for mistakes that happen on the job is a major symptom of a fear-based working environment. But what these two healthcare organizations learned was that blaming generates feelings of opposition, secrecy, mistrust and resentment and that fear stifles creativity. They learned that fear curtails the improvement of processes and procedures which is a key to successful systems management. The staffs at both organizations discovered that it was the system or process within the system that allowed errors to occur and that it was paramount to stop blaming people if they wanted true and lasting improvements to happen.
They also learned that as long as people fear that they will be blamed and held personally responsible for medical mistakes or pharmaceutical errors, they will simply stop reporting them. As long as errors go unreported, faulty processes cannot be changed or improved. Knowing this, the staffs at both organizations knew they had to create a blame-free environment and it had to start with the belief that it's ok to make mistakes as long as they were reported. In addition, these same staffs recognized that near misses must be brought out into the open as well. Both organizations realized that each mistake and/or near miss is an opportunity for real improvement.
The key points from this chapter are:
1. Blaming an individual is the direct opposite of systems thinking, it is unproductive and raises fear.
2. Blame says the outcome is due to the individual rather than the result of the system.
3. In systems thinking there are no bad people, only bad processes that need to be improved.
4. Blame, a radical form of waste, creates fear, stops creativity and causes people to hide mistakes.
5. A culture of blame will ruin any attempt at healing the organization.
As I continue reading this book, if I think something might be of interest to my readers, I'll pass it along. And for the record, I highly recommend this book.