Assuming and Speculating vs. Observing and Learning
Throughout the GBMC HealthCare System, excellent improvement work is being done to move us closer to our four Aims and our Vision. Where our teams have made the most progress is in letting go of behavior that proud people like me have a hard time getting rid of. We “learned professionals” have studied hard and have been trained to voice our opinion when confronted with a problem. We hear a few facts and quickly give our belief on a cause without really knowing. We assume many factors and then speculate on how these have contributed to the problem.
Engineers, as a group, do things differently. They are trained to observe things in action, to take things apart and to see how things really work or don’t work. Engineers are taught how to investigate; to get as deep as possible an understanding of an element or a process before thinking that they have a solution. When they believe that they have thoroughly studied a process only then do they test changes, one at a time, so they can see if their change is responsible for an improvement.
Engineers know that the best incident investigation is done immediately after the event with the people actually involved so that the steps can be recreated with as much fidelity to the true story as possible. Getting as deep an understanding of what happened by asking a series of “why’s” is the best way to generate tests of change to prevent the incident from happening again.
On a bad day in healthcare when we ask someone how defective care occurred (like a nurse going to give a medicine to a patient only to find that the medicine is not available to give) we get responses that begin with “Well, usually….” or “Sometimes….” Beginning the response with these words shows that the speaker has not investigated the occurrence, but, is merely speculating on the basis of his or her personal assumptions.
At GBMC, we are making great progress as our people work to investigate defects in close to real time to better come up with improvements. The learning from studying individual cases deeply is much more helpful than a perfunctory review of many cases. We leaders must give our people the time and resource to investigate defects as they occur. I look forward to hearing your thoughts on this.
I want to congratulate both Clair Francomano, M.D., Director of Adult Genetics at the Harvey Institute of Human Genetics and Janet S. Sunness, M.D., Medical Director of the Richard E. Hoover Low Vision Rehabilitation Services for their recent achievements.
Last month, we celebrated a monumental event, attended by Ehlers-Danlos Syndrome (EDS) patients and families from throughout the U.S., members of The Ehlers-Danlos National Foundation (EDNF) and GBMC leadership, to announce the official opening of The EDNF Center for Clinical Care and Research. The major goals of the EDNF center are to expand treatment options for patients diagnosed with Ehlers-Danlos Syndrome (EDS), an inherited condition, which negatively affects the connective tissue that binds together skin, ligaments and bone. EDS affects one in approximately 5,000 people in the US. Ours is the first center anywhere or at any time dedicated to helping EDS patients. The center is being funded by EDNF which will give $250,000 a year over the next five years. The funding will go toward providing comprehensive clinical care for patients, professional education , and cutting-edge research. Dr. Francomano will serve as the center’s Director.
Dr. Sunness has been selected to receive the 2014 Envision Award in Low Vision Research. She is being recognized for her expert work and as a prolific clinician-researcher in the area of maculopathy and for her significant contributions, most specifically in the understanding of and defining the parameters in clinical trials for the “dry” form of advanced age related macular degeneration. The Envision Oculus Award is presented to individuals or organizations whose efforts in professional collaboration, advocacy, research or education have had a significant national or international impact on people who are blind or have low vision. The Envision Award in Low Vision Research recipient is chosen by peers and selected from among nominations submitted by the Envision Research Peer Review Committee.