An error only happens if measured

Most people do not listen with the intent to understand; they listen with the intent to reply. The Seven Habits Of Highly Effective People (1989) p. 239

Every doctor I encountered was intelligent, knowledgeable, and trust worthy. Every nurse caring, competent and friendly. I am left with an incredible sense of gratitude and feel cared for. I was treated with compassion. The hospital did exactly as its vision dictated “

To provide each patient with the world-class care, exceptional service and compassion we would want for our loved ones.

The hospitals vision references platitudes that cannot be measured. Who is to say I did not receive an “exceptional”, “world class”, kidney. I was certainly treated with compassion. In fact that was not the issue, the issue was how does a sero negative patient receive a sero positive kidney when anyone informed on kidney transplantation should know better. The reason is because the value statement does not sound like this.

Our treatments are based upon scientifically derived processes designed to make treatments safer with improved outcomes for our patients. We continuously improve our processes and care standards through rigorous public evaluation of metrics.”

If treatments are not based upon process, mistakes are made, if measurements are not made, no one knows. If the actions of staff are heroic, they are always making “saves”, its because they are “winging” it. Outcomes are not predictable as management does not measure and success is independent of the patients outcome and no one improves or fail. As fate would have it, organizational process is something I practiced and studied.

Courage is not the absence of fear but the awareness that something else is more important.
Viktor Frankl’s Principles at Work (2004)

Back to Kidney Transplant

Back to Capability Maturity