By: Dr Rajaram Govindarajan, Professor in the Department of Operations Management, Innovation and Data Sciences at the prestigious ESADE Business School, Barcelona.
Abstract Of the Talk: A recent study published by researchers at the Johns Hopkins University in the British Medical Journal estimates that 250,000 people die every year due to medical errors in the U.S., making it the third greatest cause of death. These errors are systemic and often do not relate to the attitudes or skills of care providers. Rather, they relate to the skills of those who organize and manage healthcare. It is surprising to note how the third greatest cause of human death can receive such low public and political attention, especially considering that: 1. most errors are preventable through better system design and management, 2. the elimination of these errors will not only save hundreds of thousands of lives but will also reduce the morbidity rate in millions of patients, and 3. healthcare cost can be reduced significantly (estimated at 20%) because we will save resources currently spent on patients who are harmed but not killed, due to re-interventions, repeated medical treatments, prolonged hospital stays, payment of damage claims, and other legal structural costs. A reactive mechanism is really necessary to learn lessons from mistakes, but it is not sufficient. When the level of systemic errors is so high, we cannot just do correction without addressing prevention. Hence, lean thinking is utilized as a mechanism to address this problem. Tools such as Failure Mode and Effects Analysis (FMEA), the resulting preventive actions such as poka-yokes, checklists, cross-checks, improved protocols, improved employee training, and better quality of information reaching operators, among others are commonly used in healthcare. They were also discussed the universal 6M factors causing variability in any process.