Inside Healthcare Computing has graciously agreed to make previous Mr. HIStalk editorials available from its newsletter as a weekly “Best Of” series for HIStalk. This editorial originally appeared in the newsletter in June 2006. Inside Healthcare Computing subscribers receive a new editorial every week in their Electronic Update.
Hospitals realized several years ago that medication errors are rarely the simple screw-up of a single nurse, pharmacist, or physician. They occur because an organizational system of assumptions, processes, and communication fails, the so-called “Swiss cheese effect” whereby a number of usually self-correcting practices sometime line up unfavorably like the holes in Swiss cheese. That alignment of individually unusual circumstances causes errors.
Knowing that’s the case, it doesn’t make sense to fire someone involved in a medication error. The underlying system is still broken. Disciplinary action also discourages others from reporting their own mistakes and near-misses, thereby depriving the organization and industry of the opportunity to learn from them.
Maybe we should think that way in hospital IT. We’re still stuck in the old “fire everyone involved” mindset when projects fail, which is disturbingly often. Software implementation is simply business change with a technology component. Therefore, when a project deviates from expectations, it doesn’t make sense to have a knee-jerk firing of the IT project manager, the CIO, or even the vendor. Supporting cast changes won’t improve the flawed underlying system that allowed them to fail.
A non-punitive IT culture would acknowledge that all executives, not just those in IT, bear responsibility for the success of business changes involving technology. It’s their job to support process change, contribute resources, and participate in project decisions. The kickoff meeting doesn’t happen until they’re on board and they don’t get to go incognito when the project blows up and the CIO lynch party is being formed.
Some of the worst CIO and vendor behavior involves rationalization and ass-covering once projects have failed spectacularly, much like the nurse who kills a patient through a mistake not entirely under his or her control. We’ve built incentives for people to keep quiet, to dodge blame, to avoid risk, and to criticize others. Eventually everyone gets tired of the finger-pointing, so the only remaining task is to ban mention of the project in polite conversation, at least until the same mistakes doom the next one.
When it comes to IT projects, hospitals are more like surgeons than internists. Cutting is the cure: the vendor, employee, or consultant must be removed and publicly blamed to provide closure. Everyone must believe that lessons have been learned and the chances for future success increased. To admit otherwise would require a lot more self-analysis and work, and after all, Men of Action believe in their keen ability to simplify complex problems and fix them with quick, skilled incisions.
We make a lot of mistakes, many of them eminently preventable if we could just learn collectively. Most of them are quietly buried away, often taking a few careers or contracts with them.
Hospitals are mostly non-profit and non-competitive. Maybe we could improve our odds of IT success by sharing our misses and near-misses just like we do for medication errors.
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