Medical Errors Report #4

A Four-Year Solution Implementation Study

To Achieve Continuous Quality Improvement, Hospital Administration Needs to Listen to Those Working on the Frontline

For many years, hospitals have been in the habit of not listening to health-care workers on the frontline. A majority of health-care workers interviewed complained that hospital administrations are either unreachable or never listen to them. Each time there is a problem, hospitals hire a generic consultant from outside who knows nothing about the inner workings of the hospital. After being paid huge amounts of money, consultants spend a couple of days within the institution and design solutions without asking for the opinions of the frontline workers who are supposed to work with the solutions. What people are failing to realize is that there is a big difference between evaluating a problem as an outsider and as a person actually working on the process-line. This is the reason why some celebrity CEOs have failed to turn a company around while people who know the inner working of the system succeed. Sometimes, generic consultants can be useful for giving ideas about what may be wrong with the system and for suggesting solutions. But, the solutions have to be designed and implemented by those working on the frontline. The multi-tasking idea previously discussed of removing phlebotomy from the hospital laboratory and placing that task with nursing was one of those ill-advised strategies by consultants. This has now created a serious problem for hospitals across the nation. Cross-training of employees has been helpful in some cases if done within limitations.   Overdoing multitasking not only reduces efficiency, but also reduces quality of patient care. Did the hospital administration listen to health-care workers before implementing these changes?

 A sentinel event at a Michigan hospital resulted in the tragic death of a patient after a nurse accidentally administered a bolus dose of regular insulin to a nondiabetic patient through the arterial line, “Sentinel Event Leads to Safety Checklists: Quality Project Stresses Input From Frontline Staff,” (Hospital Peer Review, July 2002). This incident prompted the nursing staff of this hospital to develop a safety checklist suggested by Dr. Daniel B. Hinshaw, chief of staff at the Veteran Affair Healthcare System. After going through many twists and turns, the success of the checklist was associated with the involvement of everyone working in the unit in suggesting solutions. Hinshaw indicates that overcoming the hierarchy of a health care system can be very difficult but very vital to improving safety. He stresses that to achieve the objective of reducing errors, everyone in the unit should be able to speak up about conditions that could threaten a patient’s life.

 Effective communication of problems to hospital executive remains difficult as long as many of them are willing to stay in their offices and not talk to their employees. Instead of intervening when there is any problem on the process-line of quality improvement, many of them remained in their offices still pushing pens. Unfortunately, many of these hospital executives are suffering from the “infra-dignitatem syndrome” where they refused to talk to regular employees because those employees are said to be below their dignity.


Better Results Can be Attained from Those Who Work on the Process-line

Redesigning the process of fixing medical errors and systemic failures is more effectively achieved with direct input from workers on the process-line. Detachment from the front-line makes manager ineffective in fixing problems on the process-line. Based on this study, it appears that when frontliners are involved in designing and implementing corrective actions, success is easier to attain as compared to when only managers are involved. Those who work on the process-line as part of the corrective action team are more able to place non-aggressive pressure on their peers to conform to the new design than are managers.

 Those who work directly on the process-line are better at redesigning their work environment than are managers or supervisors. One of our three-year studies compared the performance of a group made of managers with a group made of frontline workers in solving process-line problems. Managers were constantly calling for more data to be collected and more studies to be conducted while frontline workers asked for very little data. The group of frontline workers was able to make more progress within six months than was the managers’ group which ran for over three years