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Six Steps for Evaluating Broken Processes


By William T. Choctaw, MD, JD, CSSBB
Physician Advisor
The Joint Commission Center for Transforming Healthcare   

Since the 1999 Institute of Medicine report “To Err is Human”, many books have been read and conferences attended, all to learn ways to eliminate mistakes and improve quality.

The magnitude of nosocomial errors to patients has had a major effect on the healthcare industry and its providers. Mistakes occur every single day in our hospitals and have a devastating impact on our patients and their families. Our patients deserve better because they have a fundamental right to quality care and patient safety.

I have been involved in healthcare for over 30 years, as both a physician and hospital executive, and I have learned our hospitals are very hierarchical and isolated, both internally and externally. Our healthcare culture rewards success and punishes failure.  Therefore, when a mistake occurs, instinctively, we look for someone to blame or fire. Usually, it’s a lower-level employee with minimal support. We call it holding staff “accountable”. Hospital leadership then feels collectively absolved of responsibility from the issue and then moves on to the next agenda item. Actually, we are all responsible, including leaders, because when errors occur, they are caused by the underlying process defect that is directly or indirectly responsible, not the person. 

Identifying Process Problems

When errors occur, it is usually due to broken or even absent processes rather than a person. Absent processes tend to be a collection of individual workarounds with little to no systematic connection. Thus when bad things happen- it’s the process, not the people. Systems and their processes create results, either good or bad. Admittedly, processes may be hard to initially identify but, if they are not addressed and improved, the same mistakes will occur again and again. 

Even if the error did not result in patient harm, it is still just as serious. Errors without harm are flashing red lights signaling a future serious patient injury. We don’t want to passively improve our processes; we want to proactively make all our processes sustainably excellent.

To mitigate and investigate health care mistakes, consider implementing the following seven steps when evaluating an identified broken process:

6 Steps to Evaluate Bad Processes

  1. Do not fire the employee – you need the valuable event information from them about the event. Observing staff will never trust you again, regardless what you say.

  2. Suspend judgment. 

  3. Define the process – get all the facts, step by step. Is there a policy?

  4. Define the error/defect in the process – what was the exact problem?

  5. Engage employees who made error in the solution process.  Engagement sends a positive message.

  6. Develop a monitoring system to continually evaluate the improved process.

If we successfully make our processes excellent, our staff will be more engaged. More importantly, patient quality care and safety will increase in a potentially statistically significant manner. Excellence begets excellence.

Culture change and change management are the requisite vehicles for every sustained step toward process excellence. Excellence requires transformational change, fundamental and irreversible. 

We, as leaders, must commit ourselves to excellence, with every single process within the system, every single time. It is not easy. Mark Chassin, MD, president of The Joint Commission, in his revolutionary Milbank Quarterly paper “High Reliability Health Care: Getting There from Here”, noted healthcare is nothing if not complicated.  We must be relentless because our patients deserve no less!

ChoctawBill Choctaw, MD, JD, CSSBB is Physician Advisor for the Joint Commission Center for Transforming Healthcare, where he contributes on a variety of topics. Previously, he was Chief Transformation Officer at Citrus Valley Health Partners (CVHP) where he practiced surgery and was a member of the hospital executive team for seven years. In 2013, Dr. Choctaw launched a Robust Process Improvement/Lean Six Sigma program at CVHP, in partnership with the Joint Commission Center for Transforming Healthcare.