DailyKaizen

Thank you to Group Health patient Donna Kerr for writing down her experience. Please let us know what you think. I think I would like to continue to see patients involved in every event.

Day4: Transforming the Commonplace

We are in our last day of the work of this Quality Improvement Support Team. The changes in the system have gone live in this medical center (to enthusiastic applause); now reports are beginning to walk in the door. During the first three days, I characterized and tried to figure out how this improvement process works. Today I want to tell a small story. It is about something that just happened here in Conference Room C.

10:22 a.m. Nurse S walks into the QIST room to report to the system builders that the SmartSet (here, information for the patient) did not appear with the blood pressure alert (BPA) that fired for a hypertensive, diabetic patient. The builders took down the information necessary to investigate the case and thanked the nurse for letting them know.

11:17 a.m. The EMR support staff confirmed that the builders’ correction in response to Nurse S was up and working.

Commentary: That is precisely what we hoped would happen. A member of the clinical flow staff spotted a problem and made the effort to report it. Though predictable in this context, what just happened is remarkable!
The organizational commonplace would be for a change to be instituted, for the staff member to observe the glitch and then remark to a colleague that the failure was so predictable. Further comments in private might excoriate the very improvement effort, for example: “How dare they think that they know how to improve upon what we do!” That is, a mistake would occasion finger-pointing. Instead, because the process values perspectives of the flow staff, treats errors as important sources of information, and makes it clear that the system builders’ role is to help the flow staff, Nurse S came to the QIST room with her report. In organizational life, this represents a transformation of the commonplace.

This QIST is finishing its business, as is my participation. Ted, thank you for your invitation to share my experience as a member participant. Writing my observations has helped me see. I hope that I have done this laudable improvement process justice. Congratulations to you all and thank you for taking care of my healthcare system.

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