Friday, June 2, 2017

Things did not go as they should. What did we learn?

We have been using the technique of  Lean Daily Management (LDM) now for four years. We started using LDM to accelerate improvement toward our vision of being the healthcare system where every patient, every time, gets the best health outcome and the best care experience with the least waste of resources and the most joy for those providing the care. LDM is designed to create a family of focused problem solvers. LDM, therefore, requires curiosity – the desire to know what actually happened. 

Thanks to the hard work of our pharmacists and nurses, we have much fewer “missing” medications than we used to. Our nurses and pharmacists work so hard and it is frustrating to them when a nurse goes to give a medication to a patient and the medication can’t be found on the unit. The nurse must then alert the pharmacy that he or she doesn’t have the medication and the pharmacy must stop what they are doing and send the missing dose to the floor.

We use the term defect to describe this situation. What should happen is the nurse goes to give a medication ordered by the physician or advanced practitioner and verified by the pharmacist and finds it where it should be and then administers it. If the nurse doesn’t find it on the unit, it’s a defect. We record defects in red on the LDM chart. When a defect occurs, the learner says to himself or herself: “That’s interesting, I wonder how this happened?” This is where the curiosity comes in and the learning starts. The learner must think like a detective or engineer and go and see what happened. The learner knows that the more time that passes the harder it will be for him or her to get the facts right. (By the way, as we have said in the past: red is not bad. Red is an opportunity for learning in order to get it right the next time. If we do not learn, the defect will come back. Not learning is what should be thought of as bad!)

When I started in healthcare, the prevalent thought was: “The medication should be here but it isn’t …who screwed up?” This approach to defects assumes that there is someone who doesn’t know what they are doing or doesn’t care to do their job right. This rarely is the reason behind a defect in a big complex system like the modern American hospital. The answer to the, ‘how did this happen?’, question is almost always that there were multiple system failures. The person trying to figure it out will only do so by asking a number of questions of those involved and/or by trying to reproduce the problem. It is in the study of the defect that we find opportunities to fix the problem. We can then test our fixes to see if they make the system more reliable. Our pharmacists and nurses have done this so well that we have many fewer calls to the pharmacy for missing medications. Let’s all become more curious about defects in whatever our work is to drive GBMC towards its vision faster!

Get some exercise on Father’s Day for a great cause!
Another fundraiser for the GBMC HealthCare system is coming up in a few weeks – on Sunday, June 18th, we’re holding the 29th Annual GBMC Annual Father’s Day 5K & 1 Mile Fun Walk on our GBMC campus to benefit the hospital’s Neonatal Intensive Care Unit (NICU).  This is a wonderful event where former NICU babies, families, staff members, community supporters and friends come out to have some fun and support our NICU.

Over the past 28 years, the annual Father’s Day 5K & 1 Mile Fun Walk has raised more than $1.75 million for the NICU. We operate a strong NICU with excellent clinicians, great care, and the latest equipment. With 12 rooms in the NICU, there is always equipment that needs updating, new technologies to incorporate and resources critical for these more fragile babies, who require 24/7 care. But again this fundraising effort helps a great deal.

There’s still time to register and support this wonderful event. Click here for all the information. I’ll be out there running, so please come join me! Remember that your support will touch more than 500 critically ill and premature babies cared for annually in GBMC’s NICU.

If you’re planning to participate in the Father’s Day 5K & 1 Mile Fun Walk, please feel free to share your story of why you help fundraise for GBMC.


  1. I wonder if an LDM metric for more joy would be # of employees completing a full year's employment after being hired (or you could select a different time period.) Health care has a high turnover rate and it would be enlightening to see the reasons for leaving. This would entail careful exit interviews to elicit honest reasons for leaving within the first year, but it seems like it would be well worth it, for the organization, the leaders and the staff. Just a thought. Joanne Timmel

    1. Thanks, Joanne. A high level metric on why employees leave sounds like a good idea. We already collect the data, but this might be a good way to generate change. I am going to run this by our new Vice President for Human Resources, Anna Maria Palmer.


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