Never in my wildest dreams (nightmares?) did I ever hope to receive an honorary membership in the plaintiff bar, but I think the disclosure I'm about to make would make such an induction the very least that the litigation lobby might have in mind for me.
To set the stage: We'd probably all agree that prescriptions--the medical kind--are a very serious matter, where quality control should be an absolute top priority. If a short-order cook misinterprets the scribble on an order sheet and serves you wheat toast rather than white with your breakfast, well, that's an error we can all deal with: Eat the wheat or send it back. But what happens when the error occurs not in some trivial situation like that, but with prescribed medicine? And what if the error is introduced by, of all things, indecipherable handwriting that a pharmacist misinterprets?
How frequently do you think this happens: One time out of a million? One time out of a thousand? More? Less? Well, according to Dr. John Halamka, CIO at a network of six Boston-area hospitals called CareGroup Healthcare System, misread handwriting--across the entire country, not just with this particular system--contributes to 7% of all patients having some sort of medication error. Halamka's organization has launched a $2 million Web-based prescription system to replace handwritten slips of paper sent to pharmacists, according to last week's InformationWeek cover story by senior writer Marianne Kolbasuk McGee ("Get Well, Fast," informationweek.com/864/well.htm.)
But the bad news is that most healthcare organizations are still relying on 3,000-year-old technology that contributes to an astonishing error rate of 7% in what I think could be called a highly nontrivial application: prescriptions. Now, the people in the health-care business in this country are anything but dumb--well, most of them--so there must be some fairly massive complications acting to preserve this dangerous inertia. Or do the people involved look at that giant, pulsing number and think, "Well, it could be worse--better 7% than 10%."
|After the service, [38-year-old NYPD Officer John] Perrys
friends and relatives couldnt stop telling stories of his unsolicited
gifts and favors.
He was at Police Headquarters, off duty, when the
first plane hit the World Trade Center. His retirement was promptly postponed.
He bought a golf shirt with the NYPD logo and rushed to the lobby of the
north tower next to the plaza. As office workers came down the stairs, he
and other officers steered them away from the plaza, to an exit safe from
the debris and bodies that were falling outside.
come out and freeze when they looked at the plaza, said Keith Morse,
a police officer working with Mr. Perry. There was one body lying
right next to the window. A burning foot bounced off the glass at one point.
We had to grab them and keep them moving.
It was just
part of John's nature to be there, his mother said. This big
man standing there, directing people to safety. It was the culmination of
a lifetime of wanting to help. I was very glad we had the Good Samaritan
New York Times columnist John Tierney, Nov. 16, 2001
This isn't a rant advocating a return to Total Quality Management in every pot as the ultimate in corporate strategy. On the contrary, it's a question about what happens when processes, systems, and behavior patterns are carried forward not necessarily because they're the right way to go but rather because they're what was used or bought or practiced yesterday and the day before that and last year and three years ago and 25 years ago.
I think more than anything else, these are vestigial sixth fingers of an outmoded view of the world that puts our companies, our organizations, and our processes at the center of things, and the customer somewhere out on the fringe. A view where priorities continue to be set by least common denominators, internally driven thinking, risk-averse reward systems, and a cultural mind-set that honors, reveres, and ultimately fights for preservation of the status quo. And a view whose proponents will sooner or later find themselves spiraling into irresponsibility and then irrelevancy and finally insolvency.
The opposite view is to look inside--not to preserve the status quo, but rather to unleash the ideas, knowledge, innovation, and commitment of our people in building a customer-centric organization with zero tolerance for utterly inexcusable and truly pathetic outcomes like 7% of all patients having some sort of medication error. What if you were to ask everyone in your company to send you three ideas for putting the customer first and tearing down the walls of shame that isolate archaic systems and behavior that isn't just inefficient but also probably dangerous to your customers' health--and certainly to yours?