Robservation # 13 – Leader Knowledge of Error Reduction Tools

Last week I found myself in a lot of pain and exhibiting some of the symptoms that I saw my mom go through the day she died. It scared me, and when I went to the hospital, they confirmed that my gallbladder needed to be removed immediately. I want to thank all the individuals involved in my care at Atrium Health in Concord, NC. You were awesome!

As we at FIT have moved our Advanced Error Reduction in Organizations (AERO) technology further into the medical industry, we have started noticing some things that organizations do well, and some that aren’t done well). As the staff prepared me for surgery, I became increasingly aware of them using some of the tools very intentionally to ensure things went well. And that’s when the Robservation hit me.

I started taking a moment to ensure that they KNEW that I understood that they were properly and intentionally using effective tools for minimizing the probability of an error or incident. By starting a discussion with thanking them for being so diligent at using the tool I discovered two things. First, it seems that not many people recognize them for effectively utilizing the tools that they use to reduce the probability of patient harm, and second, they not only knew what tool to use, but WHY to use it in most cases. It could be something as simple as a nurse sanitizing their hands when they enter the room (which they described as being needed because they didn’t know whether they would have to make contact or not, so better safe than sorry!). Or even when I tried to fool them a bit (I know I couldn’t resist) and gave them a different name when they checked to see if they were delivering the food to the right person. In this case, the attendant somewhat admonished me for giving a wrong name and said, “now sir, you know that’s not right! If the name doesn’t match, we can’t deliver the food to the right person, but imagine if we didn’t check and someone got the wrong medicine. Now let’s try again… what Is your name and date of birth?”

I thanked her for both her intentionality, but also her explanation of WHY she was using the tool of patient verification.

My Robservation is, in many organizations, the leaders don’t really know enough about the tools for reducing or mitigating errors and incidents to have effective engagement with the workforce. Do the leaders know what GOOD looks like regarding tool usage? Do they know good or bad tool usage when they see it, enough to identify the positives and have an engagement on the things the workforce is doing WELL?

The leaders in an organization that is trying to integrate the concepts of human and organizational performance into the day to day work to create sustainable outcomes need to establish leader knowledge, language and behavior standards that ensure they know what good looks like, so they can engage the workforce on the positives of error and incident reduction. If management response to failure matters as Todd Conklin stated in his book, then management’s response to success REALLY matters!

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