My training is in manufacturing management specifically organization and process control. Mistakes are investigated, outcomes are measured and improvements striven for across the organization where I come from. To do that you need to measure, to measure you need a process to adjust when the outcomes are less than 99.999% positive.
The process control in the hospital, the way they deal with non compliant treatments, the lack of consistency is frightening to anyone trained in process control.
The depth of the problem is obvious when looking at the mission statement of the hospital. For more go here.
Every doctor I encountered was competent, intelligent and caring. Heroics on their part the norm. The mistakes in my treatment exposed to me a lack of capability maturity in the organization of the hospital not in the individuals working in the hospital.
A famous quote from the autour of “The seven habits of highly effective people” Steven Covey
“The leader is the one who climbs the tallest tree, surveys the entire situation, and yells, ‘Wrong jungle!’ …
Busy, efficient producers and managers often respond … ‘Shut up! We’re making progress!’
Stephen Covey (1932 – 2012) Author & Consultant
Making a large organization responsive to the needs of the customers is usually accomplished thru a quality management program based upon a deep understanding of capability maturity. This is lacking in the Ottawa General Hospital.
Follow this link to learn more about capability maturity.
An error is only an error if it is measured.
When looking at any organization it is possible to overlay observed behaviors against a rubric of characteristics. From that you can determine the capability maturity of that organization. The objective of management should be to use metrics to build a body of best practices; outcomes over time will improve as processes are adjusted based on decisions founded on sound scientifically derived metrics.
This study found most doctor mistakes were like everyone else’s mistakes. The result of faulty reasoning attributed to cognitive biases. Physicians generate diagnostic hypotheses based on recognition of similarities between a case at hand and scripts of diseases or examples of previous patients stored in memory. This “pattern recognition” is largely dependent on the doctors attention to detail and is an open door for confirmation bias (i.e., a tendency to search for evidence that confirms rather than refutes initial hypotheses), or the availability bias, which leads physicians to overestimate the likelihood of a diagnosis when it comes to mind easily.
Sadly what doctors do not do is use a process driven predictive algorithm with a feedback loop and a multi billion point data set that is constantly updated as new knowledge is discovered. Read about new tools here.
For a person trained in auditing against a CMM the nature of the organization is obvious, the path to correct it is arduous but well understood, supported by scientific research.
Follow this link in regards to studies
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