Friday, January 13, 2012

"Every Defect A Treasure"

When you say that your vision is to get it right every time for every patient (because that is what you would want for your own loved one), you realize that you are striving for perfection. Even though we realize that we will never be perfect, we must keep on improving.

We are not improving as fast as we need to at GBMC. I think I know one of the reasons why. I am a very proud man. I believe that I work hard and that I am always trying to do the right thing. When I reflect on my own behavior, I see many instances where I could not learn easily from a mistake because I was too proud and I got defensive. I think that I am not the only one at GBMC that is too proud and is a bit too defensive.

Organizations that strive for perfection, when they don’t get it right, are excited about learning why.  They realize that it is in studying what went wrong that they can redesign the process to get it right the next time.

One of the early leaders of the continuous improvement movement, W. Edwards Deming, worked in Japan in the 1950s and was instrumental in building that country’s industry into an economic world power.  As the Japanese were studying Dr. Deming’s work, they coined a term which translated into English as “every defect a treasure,” meaning that errors and failures are opportunities for learning to generate changes that can improve the system.

I get a lot of wonderful letters, emails, and phone calls from patients who want to make sure that I know about our wonderful staff. But I also get some letters from people who have not gotten the kind of care that I want for my own loved ones. I have been a bit concerned that when I have sent patient complaint letters to staff, our people are like me - way too proud and they immediately want to defend themselves and staff members against the patient complaint.  “Oh the patient didn’t really understand,” “Oh this was somebody you are never going to make happy,” and “Oh that’s not exactly the way it happened” are common responses. I begin by believing that our people are wonderful and are working very hard. When I send a complaint letter to them, I am not indicting them. I am sending it as a learning opportunity. I expect them to be curious about how we might delight the next patient in the same situation as the one who has a complaint. Every reported defect is a treasure, but only if we take the time to learn from the report and redesign our systems!

When I get one of these letters I start from the supposition that there are two sides to every story, but the game is not to defend yourself.  The game is to be self-assured enough to say “Wow, if we didn’t get it right through the eyes of the patient what might I learn from this instance and how can I get it right the next time?”

We need to drop our defenses a little bit and get a little more into the spirit of continuous improvement and look at every report of a failure as an opportunity for learning.  In some instances we will learn a lot, in some instances we won’t learn much.  But either way, we need to make sure our pride doesn’t get in the way of executing change to get closer to our vision.

What did you learn from a patient recently that led to a change in one of our processes? Please share your thoughts below.

On a similar note about striving for perfection but learning from where we don’t quite reach that goal, we are expecting an unannounced triennial visit from the Joint Commission, the accrediting body for hospitals, sometime soon.

While some in healthcare administration believe a Joint Commission survey necessitates a lot of urgent preparation, it really is all about a continual state of readiness.  Our hallways should always be clear of clutter. Our documentation should always be properly filled out.  And we should always strive to give the best care possible to our patients.

If we are really serious about learning, then we should welcome the Joint Commission to GBMC and be excited about the survey because it is a way for us to get feedback about how good our care is and our opportunities for improvement.  When I started in this business decades ago, the Joint Commission was checking things that were too far removed from patient care….like the documentation that staff had been to 50 percent of meetings - even if the staff never listened to anything that was said!  Hospitals would get involved in games, like one that took all the clutter off their units and packed it into a rented tractor trailer that was driven to and parked at a nearby shopping center. When the survey was over, the clutter was right back where it was before. They were obviously missing the point that clutter was about fire safety. Shame on the hospital administrator who authorized that.

Finally, congratulations are due to our Maternal Newborn Health staff.  GBMC was recently recognized with a Breastfeeding-Friendly Workplace Award from the DC / MD Breastfeeding Coalition.  Maternal Newborn Health staff led efforts to provide space, time and other accommodations for staff who choose to breastfeed. It’s always nice when an outside group recognizes your efforts.


  1. As an employee who is breastfeeding her baby... I have to say one of the best benefits of being an employee here is not only is there space provided, but the free use of a hospital pump is wonderful.

  2. Defenses:
    A recent exchange with a patient I think somewhat illustrates why people feel the need for self-defense. I admitted and apologized to a patient for moving his watch to a safer area of the room - I was cleaning, he was sleeping. When he woke he couldn't find it. I explained, apologized. He said that if it was misplaced again, he knew who to point the finger at first - me. (He said he was joking) That finger-pointing is scary; makes it difficult at times to admit where you may have erred because it gives people a scapegoat - you. That's not to say we shouldn't strive to correct whatever patient complaints are out there. But unfortunately, there's alot of the "blame game" among patient staff. No one wants to be singled out as the one who dropped the ball with a patient. On Unit 34 (my unit), CUC's collect comments from patients - letting them name names of staff who are giving good patient care. I think that is helping all of us to strive to give the best patient care we can.


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