Studying Defects to Learn and Improve at GBMC

I and other members of the senior team have really been impressed with what Kendrick Wiggins and Kevin Edwards and the materials management team have done to improve their work and make sure that our nursing units always have everything that they need to care for our patients. They have significantly reduced calls from nursing units for all types of supplies. Our nurses are spending much less time looking for supplies and calling to get things that they need that should already be present on the floor. At the same time Kendrick, Kevin and their colleagues have reduced the waste of having too much supply on the unit that can then expire and have to be discarded or reprocessed. Kendrick and Kevin have made their processes much more reliable.

This Tuesday morning on LDM rounds, Kendrick presented the learning on calls for missing linen from the day before. Kendrick had received a call that Unit 36 needed more linen. After directing the delivery of the needed things, he began to investigate. He asked the first why: Why did the unit run out of linen? He learned that the daily cart that replenishes the supply according to the predicted usage had not been delivered to the unit. He then asked the second why: Why had the cart not been delivered? And he learned that the vendor had not delivered the cart for that unit to GBMC. He then asked the third why: Why had the vendor not delivered the cart to GBMC to be brought to that unit? Kendrick called the vendor and found that they had not followed their standard delivery work. He asked them to problem solve and to create a final check of their delivery and to alert materials management when they did not deliver what was needed. The process that Kendrick followed is called the 5 Why process because it frequently takes asking the why question 5 times before you get to the fixable cause of the defect. Kendrick got all of the information that he needed in this case by asking just 3 why’s.

For LDM to be of value, the local leader must have a curiosity about how things are actually working. He or she must avoid the trap of assuming that they already “know” before going to study the actual event. On rounds when we hear people responding to the “what happened” question with “usually” or “sometimes” we know that the person has not actually investigated the event and done a 5 why’s. Tests of change that come from someone assuming what went wrong are not likely to be helpful. Engineers that are trying to improve something always start by going and watching the existing process. Only when they have observed and learned as much as they can about how a process fails do they test a change.

Another point that the leader must understand is to not stop the 5 why process too soon. On rounds we often hear “the chair alarm was not on.” The first ‘’Why was the chair alarm not on?” results in the answer, The nurse did not turn it on.” At this point we often hear that the leader has assumed education is the answer and that he or she is going to reeducate the nurse about the importance of turning on the chair alarm. If the leader had asked the second why, “Why didn’t the nurse turn on the chair alarm?” he or she may have gotten the answer that the nurse forgot. Very hard working and well trained people forget things from time to time, especially when they are under pressure and have many things to get done. Forgetfulness is better fixed by some kind of reminder in the moment (like a sign) or by some kind of constraint to make it impossible to get to the next step without completing the preceding step (you can’t order anything online until you have put in all of your credit card information) or by eliminating the step (like having the chair alarm reset itself). Leaders who stop the why process too soon don’t make as much improvement as those who learn as deeply as they can.

So the next time you see Kendrick, Kevin or anyone from the materials management team, thank them for being excellent learners and for helping us move closer to our vision faster!