Problem Solving: From Reactive to Proactive

Here is an excerpt from my book Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement:

The Heinrich Safety Pyramid

The Alcoa Corporation has built an impressive track record for improving employee safety in what was traditionally considered a dangerous industry. Rather than being resigned to employee injuries and deaths, the company, under the leadership of CEO Paul O’Neill, set out on a quest to become the safest company to work for in the world. Although many in the company felt it was unrealistic, O’Neill set a goal of zero lost workdays as the only acceptable goal—a goal that was set to break the complacency and the idea that accidents were bound to happen. The company reduced its lost work per day rate from 1.87 in 1987 to 0.42 in 199761 and then down to 0.07 in 2013 (compared to an American manufacturing average of 1.0).62 Alcoa posts updated data on its public website and states, “This accomplishment requires the commitment of not only our leaders but also our employees, who are empowered to take personal responsibility for ensuring their safety and that of their coworkers—even if that means stopping work when they feel unsafe or unsure.” O’Neill has, in recent years, focused on spreading these mindsets and results throughout healthcare, including his work with the Pittsburgh Regional Health Initiative and Dr. Shannon.

A key to the safety improvement at Alcoa was the use of the safety triangle or pyramid, created by H. W. Heinrich, as shown in Figure 7.4. Regardless of the exact ratios, the triangle shows that we have many more opportunities to react to minor incidents, solving the underlying problems that might have otherwise later caused a major injury or fatality. Rather than only reacting to employee fatalities or severe injuries, O’Neill and Alcoa management focused on learning from near misses, minor injuries, and unsafe behaviors. Unsafe behaviors might include rushing through one’s work, acceptance that risk is part of the job, being distracted, or being fatigued.

This same idea can apply to hospitals, for both patient care and employee safety. For example, it is estimated that for every drug mistake there are 100 near misses. ThedaCare’s Theresa Moore, formerly a plant manager at Alcoa, recalls that “there was a high sense of urgency around near misses and, if there was an injury in your plant, there was an executive review of your analysis within 24 hours.” ThedaCare is now “working lower on the pyramid,” says Moore, looking for true root causes of injuries in the name of preventing future occurrences.

For every case in which a patient died because a central line was flushed with insulin instead of heparin, there are many more instances when insulin and heparin vials are sitting next to each other in bins at a nurses’ station. For every intravenous administration error, there might have been many instances when intravenous solutions, stored next to each other in overflow bins, fell into the wrong location. Each time a wrong-site brain surgery was performed, there may have been many cases when the “time-out” or “universal protocol” process was not followed. Reacting with root cause problem solving and prevention when unsafe conditions are found can help avoid patient harm and catastrophic situations.

In a Lean culture, leaders have to create an environment in which employees are encouraged or obligated to speak up when they identify unsafe conditions or see a near miss. We must change the culture of workarounds that leads employees to “fix” problems without telling anybody, a culture in which we consider fixing problems as part of our job instead of viewing the problems as waste or process defects that must be prevented. 

Mark Graban is a consultant, author, and speaker. Mark is the author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen. Mark is also the editor of the anthology Practicing Lean. Has recently published his latest book, Measures of Success: React Less, Lead Better, Improve More.

He is also a Senior Advisor to the technology company KaiNexus and is a board member of the Louise M. Batz Patient Safety Foundation. Mark blogs most days at www.LeanBlog.org and has produced over 600 podcast episodes.