Identify, Specify and Create Value for the Users
Kristin Bentz, RN, BSN, CPHQ
Lean Transformation Specialist, LeeHealth
I am a registered nurse by trade. I spent the first 18 years of my career career caring for critically ill and injured patients in large healthcare institutions nationwide. Before the turn of the century, the words ‘quality’ and ‘performance improvement’ were not commonly used in the clinical environment. Policies and procedures were typically drafted by senior leaders who were far removed from current state front line. This operational disconnect resulted in functional barriers to performance, and these barriers were often addressed by the creation of process workarounds. These workarounds then evolved into practices of normalized deviance and unfortunately surfaced as root causes for many medical errors.
When the Institute of Medicine released To Err is Human in 1999, the US health care system had a rude awakening. We were a human services industry who contributed to more fatalities per year than car crashes and firearms. We were informed that as many as 98,000 Americans die every year at the hands of health care professionals. After 16 years of quality and safety initiatives from the Institute of Healthcare Improvement, The Joint Commission, and a trillion dollars in federal health care legislation, the British Journal of Medicine now cites that the third leading cause of death in the United States is attributed to medical negligence. It is estimated that over 250,000 patients per year enter our health care facilities and die because of errors in care delivery. The initial root cause analysis blamed system failures in health care communication and collaboration for the accidental death of patients, and these systemic failures continue to plague our health care institutions today.