It was in this module that I realized that something I had always mistook as ‘consistency’ was actually ‘reliability’. I share this because ever since I started with the health region I’ve heard my leaders talking about consistency – particularly from the patient perspective. This was to be achieved by being able to offer the same standard of care to patients, no matter who the day of the week/year, nor who the pharmacist was. This has been met with mixed reviews by staff because their impression of consistency came from having one or a few pharmacists cover an area. Both groups wanted to achieve the same thing – improved patient outcomes – but there was a disconnect in how to get there, perhaps partly due to terminology. Learning so much about reliability, I realized that it was consistency that was desired, per say. Perhaps it is all semantics, but when you shift the focus to reliability (from consistency) you sure are confronted with a lot more resources to help navigate the waters. The Chassin paper, for example, or the AHRQ toolkit on enhancing patient safety (just to name a few).
Other key learnings include those on push vs pull, Six Sigma and Lean, and why transformation efforts fail. On this last point, I would like to highlight the most important paper in all of PLA – for me, it’s Kotter’s paper, ‘Why transformation efforts fail”. I must referenced this paper a dozen times throughout PLA because it so concisely wrote about the diagnoses for so many missed attempts at success. I use it as the quintessential guide on what not to do, and I truly believe the sequence explains so much in our world. Because of this paper, I now know that before I attempt any change effort, I need to create a sense of urgency… otherwise failure is inevitable.
Memorable Resources: Hospital Survey on Patient Safety