Accident

From HMCwiki

Accidents are like pain to a quality system. They highlight a problem that, if left alone, grows bigger over time and erodes both service and safety the organization. If one looks at accidents as a treasure found, something can be done with them.

Here are ways to have great accidents

1. Grow a dissatisfaction with its loss. A satisfied mind won’t grow anywhere.
2. Grow what you don’t know about it. What it is, what it isn't, when it happens. Better yet, find something profound about it.
3. Make it part of your learning organization. Make it a formula for success.

• Cycle time to detect + Cycle time to correct = Organizational Cycle time to learn.
• g x g = how fast you can generate ideas times how well you can generalize them.

4. Understand how different people understand. It’s an accident to use how you think as the measuring stick of what’s common sense. The first step in solving a problem is clarifying what is not understood.
5. Turn it into a learning lesson. Don’t waste the accident. Let pain of the dent motivate you to prevent. Create a blooper book, one that exposes boo-boos and celebrates that we will NEVER do this again.
6. Expose where rules have become a substitute for thinking. Safety director at NASA said: There are two extremes you can make. Only follow the rules. And Never follow the rules.
7. Share its prevention with all who might gain. It’s called knowledge management (sharing). Collective sharing. It's the system of connecting need-to-know with need-to-share. Hewlett Packard Quote: If HP all knew what Hp knew, we would have far fewer problems. How do you learn intra and inter-organizationally?
8. Look externally. Use its pain to push you to the non-traditional to learn from. Grow what you know from what’s different. What have you learn lately from another field or culture? How did it get adapted into a healthcare application? What other healthcare organizations know about it.
9. Leverage its learning to apply universally. Know-how is situational (procedures). Know-why is universal (similar applications). Understand the puppet strings that created the accidents behavior and it can be applied to a host of potential problems.
10. Transform it into a Poka Yoke. Mistake-proof it. Design it so that it’s intuitive to do it the right way. So many times, errors are made because the choice between the right and wrong way are so similar. Parts or procedures have such symmetry that they can be installed/performed backwards and not know it. Mechanically design it so there is only one way to choose: the right way. That way staff aren't relying on the variability of human judgment. The Toyota Production system employed this concept and reduced previous errors that plagued them to zero.

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