Healthcare - A journey to High Reliability by eliminating Never Events

By Check-6


 The Institute of Medicine estimated that up to 98,000 people a year die [in the US] because of mistakes in hospitals; subsequent reports have said the number is much higher as reported by the Joint Commission Center for Transforming Healthcare.

High-consequence industries often have red flags before an incident occurs. The industry needs to know what these flags look like.

"Never Events" are defined as the type of mistake that should never happen in the healthcare system.   A deficiency of safety and process in a culture that is not transparent is what contributes to this flawed system. Developing a culture of planning, briefing, executing and de-briefing from leadership to the front-line build a culture of transparency, turning any high-risk organization into a high reliability organization. The healthcare industry is far from this level and will continue to struggle without the necessary intervention of those who have successfully implemented a culture of operational excellence.

Is it a stretch to say that Never Events can be completely eliminated from the healthcare industry? We don't think so. If your goal is perfection, then safety and efficiency fall under that strategic framework. Tracking of healthcare products as well as procedures can be done to eliminate errors in medication, surgery, devices, etc...Today, there is no scalable system to provide the tracking and metrics necessary for healthcare to become transparent as well as enter the ranks of high reliability organizations such as oil & gas, manufacturing, construction, transportation and others. There may be many software solutions but technology is only part of the solution. Without human performance at the core of any strategic objective, software solutions and process fail.



Transparency and Compliance


Communication and transparency are key to eradicating Never Events. Many healthcare organizations utilize manual procedures to log and communicate critical  process steps. There is so much lost in translation with the back and forth emails and voice mails. With the reality of a patient death stemming from failure to communicate cardiology, radiology or laboratory  results, it is imperative that there be a culture of communication and process to prevent these situations. According to the Joint Commission, 71% of Never Events over the past 12 years have led to fatality and are a red flag pointing to the safety problem within an organization. With Never Events being preventable as well as devastating, healthcare organizations are under pressure to eradicate them. 

In 2002 the NQF released its Never Events list and 11 states have mandated reporting of these incidents. An additional 16 states mandate reporting of the Never Events along with more serious adverse events. All healthcare organizations are accountable for correcting problems that have contributed to any Never Event. 

Safety and efficiency are typically linked in the sense that if you increase one, the other will directly suffer. Understanding that both are not mutually exclusive frees leaders from this mindset and allows organizations in high-risk industries to incorporate a culture where both operational excellence and safety complement one another. Moving beyond the mindset of "safety" and into the mindset and lifestyle of perfection will not only bring safety and compliance but also save the healthcare organization money and discover new streams of revenue. 

Check-6 coaches have well over 200 years at sea leading and operating in high consequence environments.  To learn more about how Check-6 can help your organization make Operational Excellence a true part of its culture, please contact us or continue on to view case studies and white papers across high consequence industries.