This the story of two hospitals. Looking at the buildings from the parking lot, they looked very similar. Walking into the emergency room or riding the elevators and there were no big differences. But the outcomes for patients , in these two hospitals, were as different as day is to night.
Hospital A was lead by a dynamic leader who was passionate about his work. He had kept up to date with both medicine and management. He was obsessed with providing quality outcomes for his patients. He had introduced a BIG IDEA.
If anyone working at the hospital noticed a mistake or an error or a broken process, then they were rewarded for entering it into the hospital’s knowledge sharing system. And the person responsible for the mistake was not needlessly shamed or punished. The big idea was to educate every one at the hospital about mistakes so that they would not happen again. It worked. Patient outcomes were superb.
Hospital B was lead by an academic who was engaged in research. He kept up to date with his fellow researchers around the world. He traveled extensively. He left the management of the hospital to others.
In hospital B, if a mistake was noted by someone in the hospital or by a patient or family member, the hospital leader would ask one his medical staff persons to investigate. No one except the person complaining learned of the outcome. The process seemed to be secretive. Mistakes were considered a reason to shame and punish. So, obviously, no one talked about them or admitted to them.
Unfortunately, this was bad news for patients. Mistakes proliferated. Outcomes continued to degrade. The hospital drifted into failure. The parking lot was empty. Weeds grew up through the pavement. A very sad outcome for hospital B.
So the two hospitals might look the same from the parking lot, but the outcomes were dramatically different all because of the BIG IDEA about learning from mistakes at hospital A.
The important lesson for patients is to ask their hospital CEO or head of the foundation or the head of clinical staff about how mistakes are handled ( because we know that they occur) and if they are a source of learning or if they are swept under the rug.