9. Human Factor Analysis
An error investigative process that goes beyond performing the traditional "root cause analysis" which asks the questions "what" and "who" and then blames the "who," rather than asking "Why"
The idea behind this human factor science is that by understanding basic human behavior, asking the why something happened, one can anticipate where errors in healthcare processes occur and make it difficult or impossible for those same mistakes to occur.
For example, computer lock outs that prevent the ordering of certain medications without several layers of override could prevent drug prescribing and administration mishaps.
At a recent IHI forum, quality and safety experts from the Greenville Hospital System in South Carolina admonished attendees to continue to ask why an event occurred "until all preceding causes are identified." Even factors such as fatigue, or eyesight failures, or hurried decision necessity should be evaluated in order to avoid the next mistake.
10. Innovation That Is Not
Several leading health policy thinkers, including Don Berwick and Ashish Jha of the Harvard School of Public Health, recently said the most common catchword they've heard this past year is "innovation."
But Berwick in his IHI keynote address in Orlando Dec. 12, said that some technologies the word describes merely amount to "another category of greed" such as when a so-called innovative technology is put into practice that "does not help."
The word is "in the title of half the conferences I go to now," Berwick said, adding that many, if not most "of the changes in healthcare equipment, products and services that are called innovations don't help...They give worse care at higher cost...
At a recent convention on new healthcare technology, he said, 6,000 vendors rolled out their products, which he described as "robotic this and fiber optic that. And titanium whatever, ceramics."
"But every instinct I have is whispering to me that most everything I saw isn't just not worth the money, it will add complexity and risk and downstream costs, and yet public policy can do nearly nothing about it."