Medical Errors Report #17

A Four-Year Solution Implementation Study

 Avoid Using the Power of Office to Make Committee Decisions

Some managers love to nurse problems instead of fixing them. This study indicates that some managers have a very tough time transforming the managing of people to managing of problems. Stagnation occurred many times because some managers would not let go their authority during group sessions. The primary rule in a CQI committee is for people to remove their titles when attending problem-solving meeting. This is important to attaining an objective evaluation of the problem instead of being biased by the opinions of managers with no idea what is happening on the process-line. It may be suggested that when managers cannot remain quiet during a meeting or want their opinions to dominate the committee or the agenda, subsequent meetings should exclude such managers. In one committee, it was observed that when a physician was present, committee members tended to cling to his opinion and go along with his ideas rather than from an objective evaluation of the problem. To solve that problem, the committee was redesigned as it entered the next phase of intervention and the physician was excluded from the group. He was occasionally called when his ideas were needed and his opinions could no longer dominate the group. A committee needs the collective brainpower of its members, not the monolithic idea of one person.

 Managers Need More Education About Using Team to Solve Problems

Health-care industry managers need elaborate training to help them manage problem-solving groups. According to Patrice L. Spath’s article; “CQI Business as Usual? Not For Patient Safety: Traditional Approach Weak on Cultural Change,” (Brown-Spath Associates, March 2002), lack of training combined with an inherent flawed approach creates a formula for failure when it comes to process improvement. She explains that most of the managers are people who moved-up the ladder of management without getting the training they need to improve the process.

 Spath’s observation supports what we found in this study while interviewing heath-care workers. Many managers are either under-trained for the job they are doing or lack the emotional intelligence to function in the capacity of their office. Most of these managers are still used to the old idea of one person dishing out rules and regulations. This style has failed in the past to solve problems, and in some situations has made problems worse. People should ask themselves before creating a committee what they want from the people who are going to be serving on the committee. Without clear-cut pre-set expectations from the group, it is very difficult for a group to accomplish quality improvement. For example, if a group is designed to brainstorm about problems on the process-line, the objective of the group is to be used to identify problems along the process-line instead of staging personal attacks. Those working on the process-line must be well represented within the committee. Otherwise, the group will not achieve its intended objectives.

Hospital Managers Need to Develop Organizational Skills

This study makes it evident that some health-care managers lack the organizational skills needed to make things happen, especially when implementing a solution. For example, when trying to implement a new procedure or a new program, many implementations failed because of inadequate planning and preparation. One pilot study failed not because the solution implementation would not work, but because those who put the solution to work did not make adequate preparation for coverage of the shift for the 24-hour period of the study. A year later, somebody else did the study with better planning and obtained a much better result. The first one failed because of inadequate planning. Some people have the impression that programs are not to be planned because things will just fall into place. This is a fallacy! Nothing falls into place when implementing a program. Everything has to be carefully planned to attain success.

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