Patient Limbo – We Don’t Know What We Don’t Know
This is what happened at a major Victorian hospital last week; a medical-instrument washing machine broke, and subsequently impacted 500 surgeries (The Age). Such an innocuous and seemingly disconnected piece of equipment failing caused a raft of surgeries to be cancelled, leaving hundreds of patients seemingly dancing their way under a horizontal bar.
“An investigation into how the crisis unfolded at the hospital is under way”.
We don’t know what we don’t know
It will be interesting to see the outcomes of this investigation. Often, a root cause analysis will take place centred around the particular failed device, or around the maintenance department and their schedule. Perhaps even through to the manufacturer of the equipment to banner understand their processes in how the machine was built, in order to get to the bottom of ‘what broke’.
It is often the case that we end up missing the big picture.
Could it be that 5 months ago, a maintenance worker had to stay home to care for their child that came down with a cold, and missed the inspection of this machine that ended up failing?
Could it be that when the machine was made, a millilitre too much grease was put into a particular bearing, which increased mechanical resistance and over the life of the machine, caused wear ever so slightly above expectations?
We could theorise as to what went wrong all day long – and the truth about it all is that we simply don’t know yet.
It’s not impossible to get to the truth, though. It’s easier than most people think.
A needle in a haystack of needles
In situations that involve technology, for some reason we have a tendency to blame or fault the technology when something goes wrong, and can easily miss what might be staring us in the face. Technology is only ever as good as the organisation it’s being inserted into.
Over the years, I have seen many attempts at automation or industrialisation of otherwise ‘manual’ or human-based functions, only for the business to discover that the process itself was actually wasteful to begin with. Not only have they then invested in the solution, they have also invested in the support mechanisms that must also surround the solution in order for it to function.
I am not suggesting that in this example – medical instrument washing machines – are a waste. On the contrary, I believe that such equipment can help a medical facility become more efficient and help service patient needs faster.
This is however not true for all technical, digital, and mechanical solutions.
In order to know you’re doing the right thing when implementing any solution, it’s always best to go back to the core purpose of the entire organisation to better understand if what is being built is valuable for the patients, or actually detracting. This is also true for all of the support services that are needed for the new solution, too. Anything that does not contribute to the delivery of these services that provide patient value can be considered wasteful, and avoided.
It will be interesting to see if this example is able to look outside of the small realm of the machine to see where the failure occurred. I have no doubt of the capabilities of the staff at The Austin, so I am sure that they will look at the widest picture possible.
Would you do the same in your organisation – take a wide view in order to better understand where things went wrong and left patients in limbo?