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At the Heart of Health Care – Part I

July 23, 2012

By Cathy O’Neill, Director of Quality Improvement and Patient Safety, Quinte Health Care

Cathy O’Neill works in a health network of four hospitals with a plethora of patient services.  She has a passion for ensuring patient safety and a determination to find the root cause of problems in order to fix them once and for all.  Cathy has worked in Health Care for 15 years and believes that continuous learning and improvement are the keys to providing a positive patient experience.

As a Director of Quality Improvement and Patient Safety in the healthcare sector I provide advice and direction on how to tackle various challenges related to delivering high quality and safe care to our patients. Recently, I was sitting at with a group of intelligent and well intentioned colleagues who were concerned about the number of blood specimens being mislabelled in our emergency department. As I inquired a bit further I learned that this was a historical issue that many had attempted to solve before; albeit unsuccessfully. Throughout the discussion many seemingly logical solutions were suggested, however my challenge to them was whether or not they had asked frontline staff what was contributing to these errors and had we isolated the true root cause(s). The response to both was that we had not yet done so. I knew that if they continued down this path we would once again fail in trying to correct this issue. Therefore I urged the group to work with the frontline staff to uncover the authentic causes of failure and that this must be their next crucial step before going any further. One might ask how in such a short time I knew they were on the wrong path, besides the history of failed solutions? It was actually by drawing on my experience at Boot Camp with the Tatham Group.

My experience at Boot Camp was transformational in that it provided a whole new way of looking at how to solve failing systems and getting to the heart of many cultural issues inherent in health care. Below are some examples of how the Tatham Method achieves this:

  • Healthcare is full of complex systems that make it difficult for well-intentioned health care providers to provide high quality and safe care.We are continuously challenged to care for higher volumes of patients in an efficient and timely manner. Performance indicators such as emergency department and surgical wait times constantly tell us that we are not succeeding in delivering efficient and timely care. I propose this is likely due to the fact that many of our systems push our patients versus pulling them.  The concept of push versus pull is a critical component of the Tatham Approach and one which health care should take stalk of. Creating systems that pull our patients through the system to the care they need when they need is far more efficient and creates a better patient experience. Boot Camp provides the opportunity to experience first-hand the difference between working in a push versus a pull system and will make you a champion for pull versus push systems in your organization.
  • In health care we are fearful of failure and remain adverse or unsure of how to learn from failure. This is to be expected since inherent in every health care provider is the notion that we have to be perfect and doesn’t allow for errors. I, along with many others, challenge this notion as health care providers are in their most natural state human and humans err regardless of their profession. In order to reduce the likelihood of errors it is imperative that we take every opportunity to learn from failures so they are not repeated. In healthcare we are afforded many opportunities to learn from near misses or almost events where there hasn’t been an error that led to harm. What better environment to learn in when staff aren’t burdened with knowing they harmed a patient? Despite this opportunity we have yet to take advantage and build our capacity for accepting failure and applying our learning’s from failure to the systems and processes we create. TheTatham Method empowers you to see how accepting and learning from failures are central to creating highly productive systems. It also assists you in seeing that not learning from failure is no longer an acceptable option for you.

Next week I will talk more about how to solve these problems and make sure to keep the framework flexible and responsive to change.

  • Cathleen Colehour

    Great insight…what a novel idea to “ask the front line” for input into solutions. All too often, we forget that management information is filtered many times. It is the eyss and hands of those who work with the challenges daily that lie at “the heart of health care”. Thanks for the reminder!

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