I recently attended a one-day conference in Chicago sponsored by Medline Industries called “Prevention Above All.” Focused on patient safety, the conference anticipated the government’s policy (effective Oct. 1) of refusing to reimburse hospitals for 10 so-called “never events”. The keynote speaker was John Nance, a former commercial airline pilot and best-selling paperback author, who also is a founding board member of the National Patient Safety Foundation. As an airline pilot, he grew up in an industry obsessed with safety. Yet he saw lapses. He sees the same thing in healthcare.
Ever since the Industrial Revolution, people have done everything possible to remove the human element from work, he says. Naturally, there have been benefits. But in our zeal to mechanize and systematize work, we have forgotten that humans still play a huge role in it. We ignore that fact at our own peril. Speaking of healthcare, Nance says, “We need to restore looking at this as a human system, filled with people working their hearts out, but who will never be perfect.” By working in teams, healthcare workers can minimize the impact of that imperfection.
To demonstrate the point, Nance showed us a video. Six people are standing in a room, three in white shirts, three in black. We were told that the white team would be tossing a ball amongst themselves, and the black team would be doing the same. Our task was to count the number of tosses by the white team. He turned on the clip. I did as I was told. I counted 16 tosses.
When the clip was over, Nance asked for a show of hands if we counted 15, 16 or 17 tosses. Then he asked us if we had noticed anything else in the clip. Few of us did. So he ran it for us again. About halfway through, a guy in a gorilla suit emerged from the right side of the frame. He walked into the middle of the six people and started thumping his chest. Then he walked off. I hadn’t even seen him the first time.
Nance’s point: We can be so focused on one aspect of our job that we neglect to see other factors that might adversely affect what we are doing. In healthcare, that might lead to a patient injury or worse. By working in teams, we increase the odds that at least one of us will “see the gorilla.” But that strategy works only if team members feel free to point out potential mistakes, even if they are being committed by people who “outrank” them. (Think surgeons and nurses or techs in the OR.) This is as true in the airline industry as in healthcare.
These same principles apply to supply chain management. The best way to combat mistakes is to encourage teamwork – and to encourage those who report to you to speak up if they catch errors being made. It can be a humbling experience. But in the end, it’s the best way to ensure that your team accomplishes its mission of providing high-quality, cost-effective patient care.
