Get To the Bottom of It

In life, we have many expressions like, “oh well what else do you expect?” Expressions like those are limiting, make us believe that we have a problem, and that the problem can’t be solved. We could replace these types of expressions with better ones like, “we just haven’t figured that one out yet.” If we’re being honest, we may also need to admit we “haven’t gotten around to it” yet.

Medication errors in health care are widely discussed, documented, and in many cases — accepted as unavoidable. Accidents will happen, but what if we looked deeply at them, could these be avoided? Let’s think about what happens when we measure something and can easily count the mistakes. This is what our Delaware residential team did, they counted; and at that point, they grabbed onto one of the better expressions — “let’s get to the bottom of this.”

The team conducted a root cause analysis. When you think of roots, you can make the connection; which is the “bottom” or cause of the problem. Here are some of the smart things they did:

1. They looked critically at the data and found the homes where the errors occurred.
2. They brought together team members who work within the residences — to think together about the skills needed to successfully administer meds, and the right environment needed to do so correctly.
3. They created a plan which did not place blame on individual people or roles! In their plan they used all of the best learning points from the book Turn the Ship Around.
4. They made sure that staff were certified; that they were not only capable but also confident in passing medication. This process included reviewing requirements and making careful observations of the medication distribution.
5. They created an inspection process to make sure the work was being done well.
6. They conducted audits throughout all the homes to ensure that our team members had the competence and confidence to conduct medication administration successfully.

They stayed vigilant throughout — making sure there were no new factors, lighting, noise, or other factors which could result in mistakes. Their data was widely shared with the rest of the leadership team, which was a smart move! Sharing results helps everyone develop a deeper understanding of the work performed by others; and how managers can support staff members to be their best, and deliver the quality we’re committed to achieving.

Throughout the root cause analysis and problem solving the Delaware residential team stuck together as a team to help staff do their best work. Let’s be honest, no one comes to work saying “I want to make as many mistakes as possible today!” In taking all these steps, they applied their learning from one site to the rest; and gained a great new skill in conducting a root cause analysis, which can be applied to all kinds of challenges. In twelve months, the number of medication errors made by staff is down to ZERO; or you can look at it the other way, we had 100% success!

The lessons in this story are HUGE:

ü We can improve performance

ü We need to engage the staff who do the work in the problem solving

ü We need to have truly certified staff

ü We need to embrace inspection as good

ü We need to widely share the results.

Let’s measure what matters, and when we see numbers that are not good — dig in! We can always improve. For this and other ideas on enhancing quality, follow this blog series and read Turn the Ship Around by David Marquet.