Are we following the standard work…the design?

Earlier this week, at the executive Lean Daily Management board, we learned of three cases of patient falls at GBMC where the individual sustained minor injuries. Our people, especially our nurses and nursing support technicians, have done a remarkable job at reducing falls within our system. I believe that frail elders are now safer at GBMC than they are in their homes. Let me make the statement that I don’t think we will ever get to zero falls because to do this we would have to rob patients of their freedom and we will not do that. But as smart, caring professionals we need to always be learning from falls and changing our systems to move closer to zero.

So when three falls get reported what should our first question be? Our first question should be “did we follow our standard falls prevention work?” That standard work includes assessing the patient’s falls risk, educating high falls risk patients about how we will act and how they should act to protect themselves, and then implementing measures, like red socks, to alert others to the high falls risk, and using the bed and chair alarms.

The Swiss Cheese Model of error informs us that we should not expect to find one cause of a fall. In large complex systems, it is usually a series of factors that result in the bad event. One category of “holes” in the Swiss Cheese is that leaders need to be aware of managerial failure. One type of managerial failure is knowing that the standard work (in the case of falls prevention it is standard safety work) is not being followed and not doing anything about it.

If you are a very busy nurse on a medicine unit caring for a number of sick elderly patients, you have a lot to do. Setting up the bed alarm and making sure that it is turned on is one of your tasks. It should come as no surprise that a very busy nurse will sometimes get called away to urgently help another patient and forget to turn on a bed alarm. At GBMC we have, as part of our every two-hour rounds, a safety checklist that is done in part to check that the appropriate safety measures are in place and turned on. But what if we are not doing the safety checks as designed? If we are not, then that is a hole in the Swiss Cheese that is waiting to line up with a busy nurse getting distracted and forgetting to turn it on that might then lead to a patient fall.

So, as leaders at GBMC, we owe it to our patients, our staff and ourselves to assure that those safety checks are being done correctly. As we work to improve our care and get to even higher levels of reliability, we accept the fact that people will make mistakes and we must be preoccupied in catching the mistakes before they might result in harm.  So, we set up audits or checklists, but if we don’t follow the standard work of the check itself we miss our opportunity to find the mistake and fix it.

All leaders at GBMC have to unite NOT on ‘re-educating’ our staff on the importance of not forgetting, but, unite on ways of making sure that the standard work is followed when we are doing the safety checklist.  Only after enrolling all of their team members in the standard work should leaders decide how to hold their people accountable.  Leaders must take ownership as well.  If we know that the standard work is not taking place, as leaders we can’t wait until there’s an event, we must immediately work to close the hole in the Swiss Cheese and prevent the event from happening.

Please share your thoughts with me.