Originally published by Mark Graban on LinkedIn: A Fire Captain on Lean, Quality, Post-Event Reviews, Avoiding Blame, and Improving Firefighting and EMS
My guest for the 278th episode of the Lean Blog Podcast is Tom Bouthillet, a Fire Captain / Paramedic in Hilton Head Island, South Carolina where he is the Cardiac Care Program Manager (STEMI and CARES Site Coordinator) for his department.
Fire captains are responsible for on-scene management of any emergency that is not related to law enforcement, Tom explained. This includes fire and medical incidents, as well as the upkeep of the captain’s assigned fire station and equipment.
“But in reality, what I’ve come to understand is what we really do is manage people,” Tom added.
Though he doesn’t remember when he was first exposed to Lean and process improvement, Tom explained that for those interested in quality and researching the topic, an understanding of the central role of culture in an organization starts to take hold.
He learned from the work of W. Edwards Deming, especially the emphasis on building quality into the product upfront and being less reliant on inspection after the fact spoke to him.
“It’s too late to help that patient, that call’s over, and we can nit-pick what the opportunities for improvement were, but on some level you think, ‘Well, maybe our time would have been better spent perfecting our craft and training to the point where our on-scene performance is much, much better,’” Tom explained. “We have a very finite amount of time that we can get the guys together for not actually running calls, either to do training or to do post-event review, which we consider training.”
“I can’t get enough of it when he loves to remind us that 94 percent of problems in an organization are system problems. And systems are the purview of management. Clearly, it is human nature to assign blame and it’s completely ineffective,” Tom said.
“Conducting a post-event review is a skill, and it requires a lot of diplomacy. I would not encourage someone who hasn’t thought long and hard about it from rushing headlong into it because post-event critiques can do more harm than good if they devolve into finger-pointing.”
As Tom said, it’s important to recognize there are nascent causes of failure that had lay dormant for a long time. While it’s easy to fixate on the last domino that fell, as Tom put it, and assign blame to the person on the frontline, upon further reflection, there’s almost always underlying system factors that allowed the opportunity for the error to occur.
“Almost always.” Tom said. “These things are complicated, and, if you have a culture of blame, no one is going to report problems to you. They’re going to hide them, and then you’re never going to improve."
"I think they need to know that you’re there to help support them because you can get compliance with a whip, but you can’t get quality.”
Variation may be important for safety in some circumstances however. Tom brought up how the field of aviation has come to understand that to err is human, and highlighted one example he had come across of frontline improvement work.
“One of the stories I love from aviation is in World War II, when some of their fighter airplanes would taxi after a battle. There were two levers – one was for flaps, and one was to retract the landing gear. The two levers were side-by-side and looked identical. If you pulled the wrong one when you were trying to put the flaps back to neutral, you would drop the landing gear and drop the plane on its belly and it would damage the propeller. You’re out in the middle of the Pacific and that’s an aircraft that’s not combat effective anymore, not because it was shot down but because the pilot had a 50-50 chance of pulling the wrong lever,” Tom explained.
“On their own, the pilots mocked up a little wheel and put it on top of the one for the landing gear, and a little triangle for the one for the flaps to make it more difficult for them to get confused. So, when you think about things like that, there are a lot of engineering solutions to help limit, or at least modify the effect of human error.”
Today, the field of aviation generally understands pilots are going to be tired, have personal issues, etc., which mean they are going to pull the wrong knob, so they’ve designed systems to catch mistakes before it causes a catastrophic accident.
I asked Tom about checklists, and if they were something that is something that EMS and fire services personnel are embracing, and he said yes.
“I think checklists are being adopted more so, or at least more rapidly, than anything that they’re consciously calling Lean, Tom said. “Definitely, we’ve embraced checklists, and I think there’s a growing awareness that they have real value in medicine.”
Thanks to Tom for being my guest!
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Mark Graban (@MarkGraban) is a consultant, author, and speaker in the “Lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. Mark is also editor of the book Practicing Lean.
He is also theVP of improvement and innovation services for the technology company KaiNexus and is a board member for the Louise M. Batz Patient Safety Foundation. Mark blogs most days at www.LeanBlog.org.