Healthcare Failures – Opportunities to Learn

Yep its broken - Bruce DenisBlog post by Colin Hung

Last week I had the privilege to attend the Society for Healthcare Strategy & Market Development conference (#SHSMD14) in sunny San Diego. It was my first time at a conference that blends marketing and healthcare. I have no idea why I waited to so long to attend.

The keynotes from Simon T Bailey (@SimonTBailey), Earvin “Magic” Johnson (@MagicJohnson) and Eric Topol (@EricTopol) were amazing. The exhibit hall was filled with interesting companies and well-designed booths. Even the food was tasty. But what was truly memorable about the conference were the breakout sessions. They were educational, had excellent presenters and most of all – refreshingly honest.

One breakout session in particular stood out and is the inspiration for this week’s #hcldr discussion. Jamey Shiels (@jameyshiels), Senior Director eBusiness and Cindy Moon-Mogush, SVP Communications from Aurora Healthcare blew the audience away by presenting their work on a mobile health (#mHealth) app that ultimate failed to catch on with their patients. Their honest retelling of their failed foray into the #mHealth world was remarkable.

I’ll never forget this statement from Shiels (paraphrased):

After looking at the use data and soliciting feedback from actual end-users we came to the conclusion that our mobile app had missed the mark. Although it was easy-to-use, well put together and was fun – it ultimately did not catch on with users who abandoned it after only a few uses. In the end we decided to shut it down. But now we have a very clear understanding of what our patients want/need in a mobile health app – something that will be valuable in future initiatives.

The audience had a lot of questions for Shiels and Moon-Mogush after their presentation and as each one stepped up to the microphone, they started by thanking the presenters for being so open, honest and courageous to present their failure. Many also commented on how much they learned in the session.

The Aurora Health presentation got me thinking about failures in healthcare – more specifically what we can learn from failures if people were more willing to discuss them openly. There are valuable lessons that can be learned from failures, but only if we are willing to treat failures as opportunities to improve instead of errors to be swept under the rug.

Now when I say discussion, I don’t mean public criticism of failures – like what’s happening now with everyone under the sun commenting on the Texas Health Resources Ebola situation in Dallas. What I’m referring to is sitting down with all the stakeholders and having an open dialog on what went wrong, why it went wrong and what measures could be employed the next time so that the same failures don’t happen again.

Why is it so hard for us to discuss our failures? Is it because in healthcare we fear being seen as not-having-all-the-answers? Or is it out of fear of litigation? Debriefing in healthcare has long been touted as an effective way to improve quality and safety, yet I do not believe this has been widely adopted by healthcare organizations.

Vaithilingam, Jain and Davies published an article in 2011 entitled “Clinical governance. Helping the helpers: debriefing following an adverse incident”. In it they commented on how important it is to learn from failures through standard “debriefings” after an adverse event has happened:

A debriefing process that is an integral component of an adverse event-reporting protocol, as is the case in other high-risk industries such as aviation and nuclear power, could potentially improve both the quality of incident reporting and support the staff involved. It could help to ameliorate the stress related reactions and illness that occur all too often in the aftermath.

I’m in 100% agreement with Vaithilingam et al. Many years ago, when I was an IT consultant, I was involved in an implementation that went horribly wrong. The project started off well, but things began to go sour about 2 months into the 8 month engagement. The environment had gotten so toxic that the client team, vendor team and consulting team were no longer speaking with one another. By month 7 the project was cancelled and lawsuits were threatened.

One of the project managers decided to hold a full 2-day debriefing meeting. Everyone felt awkward and uncomfortable at the start, but as people began opening up the conversation became more and more meaningful. There was certainly lots of finger-pointing and blaming at first, but the facilitator did a good job cutting that off and focusing the group back on the core issue rather than the emotions.

I have never forgotten the lessons I learned from this debriefing. I learned that in my exuberance to get the project started, I had used only the best-case-scenario estimates for the initial project ROI calculations. By the 3rd month it was clear to all (except me) that the projected savings would never materialize.

I also learned that several key members of the team (including myself) had known as early as the second month that the chosen technology would not support the designed workflow or anticipated workload, yet none of us raised this as an issue.

Since then I have conducted a few debriefings over the years with similar results. People have come up to me afterwards (sometimes years afterwards) and told me how valuable those sessions were. I believe that failures are truly an opportunity to learn.

Join us Tuesday October 21st at 8:30pm Eastern (for your local time click here) for the weekly #hcldr tweetchat where we will be discussing the following questions:

  • T1 What lessons have you learned from your own failures?
  • T2 Should debriefings be mandatory after a healthcare failure/incident? Who should be there?
  • T3 How can leaders encourage more discussion about failures/mistakes?
  • T4 When we look back at 2014, what healthcare failures will we be talking about? Ebola? WHO? HIEs? MU?

Resourses

“Clinical governance. Helping the helpers: debriefing following an adverse incident”, Nirmala Vaithilingam et al, The Obstetrician & Gynaecologist, January 24 2011, http://onlinelibrary.wiley.com/doi/10.1576/toag.10.4.251.27442/pdf, accessed October 18 2014

“Importance of debriefing following critical incidents”, Sonya Healy and Mark Tyrell, Emergency Nurse, March 2013, http://rcnpublishing.com/doi/pdfplus/10.7748/en2013.03.20.10.32.s8, accessed October 18 2014

“The benefits of debriefing as formative feedback in nurse education”, Robyn P Cant, Australian Journal of Advanced Nursing, http://www.ajan.com.au/vol29/29-1_cant.pdf, accessed October 18 2014

“Why Learning from Mistakes is Overrated”, Stephen J Meyer, Forbes, August 29 2014, http://www.forbes.com/sites/stevemeyer/2014/08/29/why-learning-from-mistakes-is-overrated/, accessed October 18 2014

“Dissecting a health care IT failure”, Michael Krigsman, ZD Net, March 17 2010, http://www.zdnet.com/blog/projectfailures/dissecting-a-health-care-it-failure/8932, accessed October 18 2014

“Using failure as motivation for medical residents”, Mary L Brandt MD, KevinMD.com, January 14 2011, http://www.kevinmd.com/blog/2011/01/medical-residents-deal-failure.html, accessed October 18 2014

“Debriefing for Patient Safety”, Scott H Turner and Walter D Kurtz, Patient Safety & Quality Healthcare, June 11 2009, http://psqh.com/debriefing-for-patient-safety, accessed October 18 2014

“Dallas mishandling of Ebola patients an object lesson for nation’s hospitals”, Kelly Gilblom et al, Chicago Tribune, October 10 2014, http://www.chicagotribune.com/news/sns-wp-blm-news-bc-ebola-prepare10-20141010-story.html#page=1, accessed October 18 2014

“Dallas hospital stumbles in early response to Ebola”, Rick Jervis, USA Today, October 15 2014, http://www.usatoday.com/story/news/nation/2014/10/14/ebola-dallas-hospital-mistakes/17204527/, accessed October 18 2014

“Dallas hospital leader: ‘We are deeply sorry’ for our mistakes”, Advisory Board, October 16 2014, http://www.advisory.com/daily-briefing/2014/10/16/dallas-hospital-leader-we-are-deeply-sorry-for-our-mistakes, accessed October 18 2014

Image Credit

Yep – It’s Broken by Bruce Denis

https://www.flickr.com/photos/f2point8/5361206376/in/photolist-9aKzSG-5rZFdc-4nPo3M-b97BVx-TuxEQ-916giA-32Ys36-8B3zrH-8iXrRm-Hb6x-63VRfz-7tSwut-duAKED-duATyx-duGmP7-dupNVP-duGoDu-dupPuV-duGnpd-duvqJJ-duGnZw-8tRA2S-duAND6-duAPR6-duAPdn-duAQoH-duAR1H-duARDp-dupE4F-dupGtv-duvm7E-duvjkf-duvopU-duvmEq-dupMd4-duvneE-dupH6r-duvgXS-nDMva2-bBH3D3-4Jjifx-6nUCGr-aeEQeP-6sQoy7-8Quaba-2y7cV-ba67YV-3YKLS6-8SUZj4-a6aESH

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