Evaluate how a culture of learning and error reporting can give the organization a structure where lessons learned from mistakes and substandard care can provide system solutions for the healthcare facility.
As I sat in multiple meetings learning about the Air Force clinic I would be running on Lewis-McChord, I kept hearing process improvements and lessons learned. It seemed like a foreign language while I began my journey of taking on all the challenges of running a clinic. As time progressed we forged a culture of learning from mistakes and reporting errors. It was not easy, but as time progressed it became woven into our daily operations. As we strived to become a High Reliability Organization (HRO), it became evident that it was important for every employee at all levels to have some buy in to the progression of the organization. One thing that stuck out that was different from many other places I worked previously was the encouragement of employees to voice ideas to improve their specific work areas. Doing so catapulted the speed of change we wanted. I found that this article had it right in saying “change is not only embraced but exploited, while employees develop growth mindsets and seek out new opportunities to learn and to share knowledge with their colleagues.” The buy in to change alleviated a lot of the headache and friction especially for those employees that resist change to no end.
With change comes set backs and flat out processes that do not work. Utilizing lessons learned to cultivate quality improvement is genius in healthcare. Once we had a shared mental model and true buy in we could conquer anything. The first true test was building a system that attacked substandard practices and care at its core. We didn’t set out to place blame or shun those that just didn’t know better. The organization used those as models and speaking points on how to improve from here. Pulling some joint commission reports from years prior helped facilitate the system solutions that helped self heal the healthcare facility. I often wondered how lawyers who handled malpractice cases expressed standard of care. Surprisingly it’s not too far off from how we as medical professionals express it. What I found was this “ In general, the standard of care for those who provide medical services is higher than a normal standard of care. This is because the job of a medical professional requires substantial expertise and preparation. Accordingly, medical professionals have a duty to carefully and professionally provide adequate care in treating patients.” As we understand the level of care we must provide the better we understand why the bar must be continuously elevated.