“gemba walk” (lean thinking term) to go to the actual place where value is added + “walkabout” (Australian aborigine) a short period of wandering bush life engaged as an occasional interruption of regular work
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I had a chance to attend a meeting where Steven Spear led a discussion about systems, complexity, problem identification and problem-solving. He used a video that I had seen before, but this time in a new way.
The video is the “First, do no harm” video that shows problems that occur with woman (Mrs. Romanov) and the bad things that happen to her and baby Romanov. I had seen the video before and it seemed to make some useful points, but I saw new things this time. The main reason (I think) is that we watched it backwards (and also, had Dr. Spear pointing out some important things.
The typical way the video is shown (forward) starts off with Scene #1 - initial OB appointment and scheduling of follow-up. The “Partnership For Patient Safety” organization has some discussion guidelines that they provide for organizations to use to get the most out of watching the video. These are the kinds of discussion questions that suggested: “do you have a policy that could help to create this particular set of circumstances in your office?” ”how would you hand the situation that confronted this support person?” etc.
When we watched the video backwards, there was a lot more to see. Things that were not even touched upon in the discussion document. In particular, a receptionist made a note on a post-it note and that post-it note was then (inadvertently) picked up (and lost) by a stray chart. Having the information on that note could have prevented a lot of bad stuff from happening down stream.
There were many other examples - too numerous to mention. So, I need to read and re-read some of Dr. Spear’s books on this topic and also need to think about how our systems need to better identify unusual conditions and problem-solving for small things before they turn into big things.
