There has been no shortage of blame for the poisoning of Flint, Michigan's water supply. In March, a governor-appointed task force issued a report that rebuked local, state and federal authorities for their actions — and inactions — that created the public health crisis. Then, in late April, state prosecutors announced the first charges in the(...)
Organizational and Cultural Change
It’s Not All About the Checklist: The Power of Believing and Belonging
Posted by | Organizational and Cultural Change, Preventing Patient HarmTrine Engebretsen was clinging to life. It was the early 1980s, and the girl had a genetic liver disorder that would kill her if she did not get a transplant. Yet, as she waited for a matching liver, some providers called her parents and urged them not to allow the surgery. They cautioned them that(...)
Patient Care: What’s Love Got to Do with It?
Posted by | Organizational and Cultural Change, Patient-Centered CareTalking to health care professionals about the importance of loving your patients and colleagues — as I often do — might raise eyebrows. How can we be expected to love our patients during a 15-minute clinic visit? How can love form among hospital teams coming together for a surgical procedure but then moving on to other work?(...)
Seeking the Right Stuff for Teams: In the Hospital or Distant Space
Posted by | Designing Safer Systems, Measurement of Safety and Quality, Organizational and Cultural ChangeWanted: Talented, highly driven individuals to take on multiyear work assignment with potential for benefiting humankind. Requires the highest levels of technical skill, teamwork and adaptability. Must be able to tolerate social isolation, mental and physical fatigue, demanding and uneven work schedules, days and nights away from home. Risk of depression and burnout. Must be(...)
Patient Safety at 15: How Much Have We Grown?
Posted by | Designing Safer Systems, Measurement of Safety and Quality, Organizational and Cultural Change, Preventing Patient HarmFifteen-year anniversaries often come and go without fuss, overlooked in favor of those we can mark in full decades. Yet recently, at Johns Hopkins and nationally, we've crossed that mark for a couple of events in patient safety that merit both celebration and reflection. In January 2001, a series of lapses at Johns Hopkins led(...)
Turning Health Care Improvement Training into Results
Posted by | Organizational and Cultural ChangeMaybe you've had this experience: You attend a workshop or conference to build your skill set, you pick up new strategies and tools, and you leave energized and excited to put them to use in your hospital or clinic. Yet when you return to work, you find it hard to get the ball rolling. Colleagues(...)
To Engage Physicians in Cost Savings, Start with Quality
Posted by | Organizational and Cultural ChangeLike a pro golfer swears by a certain brand of clubs or a marathon runner has a chosen make of shoes, surgeons can form strong loyalties to the tools of their craft. Preferences for these items — such as artificial hips and knees, surgical screws, stents, pacemakers and other implants — develop over time, perhaps out of habit(...)
Walking in Another Caregiver’s Shoes
Posted by | Organizational and Cultural Change, Preventing Patient HarmHow many of our conflicts could be handled better or averted if we had the opportunity to spend some time in the shoes of the person on "the other side"? When we experience a situation through another's eyes, and when we understand their work and world, true empathy, understanding and trust can emerge. This is(...)
Learning from the Leaders in Patient Experience
Posted by | Organizational and Cultural Change, Patient-Centered CareHospitals across the country are searching for ways to create the "always positive" patient experience. For example, we want our patients to tell us that their pain was always addressed, that clinicians were always responsive to their needs and that our communications at discharge time always helped prepare them to take care of themselves once(...)
What Any Caregiver Can Do to Support a ‘Second Victim’
Posted by | Organizational and Cultural Change, Preventing Patient HarmLet's say that you're a nurse on a hospital unit, and a colleague has recently been involved in a medication error. It was a mistake that anyone might make — a tenfold overdose that occurred when she wrote down an order and accidentally moved a decimal point one space to the right. Luckily, it didn't lead(...)