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Frederick S. Southwick, MD
Isn’t it time to end the loss of life from preventable medical errors?
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Isn’t it time to end the loss of life from preventable medical errors?
Read more
Isn’t it time to end the loss of life from preventable medical errors?
Each year 100,000 patients die from preventable errors in the U.S. How can you help to change this intractable problem? Knowledge is power, and this course will provide you with a deep understanding of the problems and the solutions. You can become part of the solution.
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Syllabus
Introduction: Who is Caring for Mary?
100,000 patients die annually as a consequence of preventable medical errors, and over 1 million patients suffer life-changing injuries. Despite the calls to action medical errors continue at the rate of 1 out of 10 patients. How can those of us who help to deliver care and those of us that receive care help to prevent harm? There are 5 fundamental areas each of us needs to understand and use to fix healthcare delivery: 1. Apply the principles of high performing manufacturers and athletic teams to continually improve our processes. 2.We all need to learn how lead and be part of multidisciplinary teams that include patients and coordinate the care they receive. 3.The human brain continually makes errors. Certain conditions increase the likelihood of errors, and these need to be avoided. Systems can be designed that force the right behavior, and second checks can help caregivers provide the right care at the right time and in the right place. 4.We all need to become effective leaders. Most importantly we must practice adaptive leadership, that is, leadership that promotes a true change in the way things are done. 5.Finally we all can utilize the campaign methods of successful politicians and advocacy groups to change the attitudes of our fellow caregivers and patients, and thereby change the culture of our healthcare systems. During this 8-module course you will be provided with the tools to accomplish all 5 of these goals, and as an individual you can truly make a difference.
Why do we need to understand about systems? How do we evaluate a system and as a patient or provider what characteristics do you think are important? How does quality relate to safety? These are important questions that we all need to have answers to as we learn how to improve how we deliver and receive healthcare. The personal consequences of distracted physicians and defective systems are illustrated in Mary's frightening hospital experience.
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Syllabus
Introduction: Who is Caring for Mary?
100,000 patients die annually as a consequence of preventable medical errors, and over 1 million patients suffer life-changing injuries. Despite the calls to action medical errors continue at the rate of 1 out of 10 patients. How can those of us who help to deliver care and those of us that receive care help to prevent harm? There are 5 fundamental areas each of us needs to understand and use to fix healthcare delivery: 1. Apply the principles of high performing manufacturers and athletic teams to continually improve our processes. 2.We all need to learn how lead and be part of multidisciplinary teams that include patients and coordinate the care they receive. 3.The human brain continually makes errors. Certain conditions increase the likelihood of errors, and these need to be avoided. Systems can be designed that force the right behavior, and second checks can help caregivers provide the right care at the right time and in the right place. 4.We all need to become effective leaders. Most importantly we must practice adaptive leadership, that is, leadership that promotes a true change in the way things are done. 5.Finally we all can utilize the campaign methods of successful politicians and advocacy groups to change the attitudes of our fellow caregivers and patients, and thereby change the culture of our healthcare systems. During this 8-module course you will be provided with the tools to accomplish all 5 of these goals, and as an individual you can truly make a difference.
Why do we need to understand about systems? How do we evaluate a system and as a patient or provider what characteristics do you think are important? How does quality relate to safety? These are important questions that we all need to have answers to as we learn how to improve how we deliver and receive healthcare. The personal consequences of distracted physicians and defective systems are illustrated in Mary's frightening hospital experience.
Read more
Applying Manufacturing Principles to Improve Healthcare
In this module we will be discussing the manufacturing principles of the Toyota Production System. The concept of value stream or work flow diagrams will be introduced. The well known 80/20 rule in manufacturing will be applied to patient care. The 8 ways waste can be reduced in health care will be explored, and finally the problem of push medicine and how patients can guard against this all too common problem will be covered.
Healthcare Requires Teamwork
Teamwork is critical in modern healthcare. We will explore the state of healthcare teamwork in most healthcare systems. The 5 resources required for effective teams will be reviewed, and we will discuss how athletic principles can be used to encourage teamwork, improve efficiency and increase the quality of patient care. We will review how to launch and coach a team, and how to manage the complex dynamics of teams. Finally we will discuss how to create a self-improving team.
Understanding and Preventing Human Error Part I
This module will be discussing the consequences of medical errors, and you will learn from Sorrel King's loss of her daughter, Josie, and from my personal experience that preventable injuries not only cause death but also can lead to permanent life changing injuries. Sitting around and doing nothing is not an option. However we all need to understand and use three key tools to determine the causes of medical errors and to fix them, Root cause analysis, Driver Diagrams, and PDSA cycles. Finally we will discuss the issue of small errors and our tendency to ignore and workaround them. Unfortunately this approach to small problems is one of leading causes for the continued high rate of preventable injuries and deaths in our hospitals and clinics. It is time to fix the little things.
Understanding and Preventing Human Error Part II
This module introduces you to the famous W. Edwards Deming red bead experiment that illustrates the tyranny of random variation, and introduce the use of run charts to differentiate random or common cause from specific cause variation. Next we will introduce you the concept of reliability and will illustrate why we need to dramatically improve the reliability in health care. Strategies for reducing human errors are reviewed, and the effectiveness hierarchy of different interventions discussed. We end with a discussion of how health systems and providers should be treating patients and families who they have inadvertently harmed.
We All Can Lead: Becoming an Adaptive Leader
In this module, we will be discussing the need in healthcare for distributive leadership that is adaptive. The complexity of healthcare prevents one leader from micromanaging a healthcare system, and leadership must be encouraged on the front lines of care. Effective leaders are good listeners, empathetic, follow their principles (North Star) and are courageous. Adaptive or innovative leaders are a necessity for improving the quality and safety of healthcare. The strategies for controlling emotional disequilbrium will be addressed, and specific analogies presented to assist students in understanding how to practice leadership that will bring about change.
How Organizing People can Drive Change in Healthcare Delivery
Change requires those on the front lines to embrace new approaches to care and to work across department barriers. This session will use our Founding Father Samuel Adams to exemplify the approaches that have been used for decades to encourage others to come together to bring about change. Samuel Adams campaign led to United States independence from Great Britain and these methods if applied throughout the world can lead to a revolution in healthcare delivery. One-one techniques, personal narrative, creation of leadership teams, and the creation of effective strategies and tactics to bring about action will all be covered. You can make a difference.
Immunity to Change, Examples of Successful Patient Care Initiatives, and Final Summary
In this final module we will review why many of us fail to change our viewpoints and behavior. We will discuss how you can overcome your natural immunity to change. Next we will review the key points from each of the past 7 module, and then outline a general plan of action that will allow you to create your personal plan to fix one component of your healthcare system. Your learning has just begun. Now you will be able to apply what you learned, you will achieve greater and greater understanding by doing.
Final Exam
This is the final exam.
Good to know
Good to know
Know what's good ,
what to watch for , and
possible dealbreakers
Develops a deep understanding of the problems and solutions to medical errors, empowering learners to be part of the solution
Taught by Frederick S. Southwick, MD, a renowned expert in preventing medical errors
Examines the consequences of medical errors, focusing on the human toll they take and the need for understanding and reducing them
Introduces the Toyota Production System and its principles for improving healthcare, promoting efficiency and waste reduction
Emphasizes the importance of teamwork in modern healthcare, exploring strategies and techniques for effective collaboration
Provides tools for understanding and preventing human error, including root cause analysis, driver diagrams, and PDSA cycles
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Save Fixing Healthcare Delivery to your list so you can find it easily later:
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Reviews summary
Healthcare delivery solutions
Learners say this quick and easy course is an excellent introduction to health improvement efforts. It teaches how errors occur in medicine and how to develop solutions. Although responses are limited, all reviews are largely positive.
Enthusiastic professor.
"professor is very enthusiastic!"
"Quick, easy class and professor is very enthusiastic!"
"Useful for anyone wanting to understand how errors happen in medicine as well as how to look at those errors in a way to come up with solutions."
Teaches how errors happen and how to develop solutions.
"Excellent introduction to Health Improvement efforts "
"Quick, easy class and professor is very enthusiastic!"
"Useful for anyone wanting to understand how errors happen in medicine as well as how to look at those errors in a way to come up with solutions."
Activities
Be better prepared
before
your course. Deepen your understanding
during
and
after
it. Supplement your coursework and achieve mastery of the topics covered
in Fixing Healthcare Delivery with these
activities:
Organize a team launch and simulate a clinical case
Show steps
Practice team-based approaches through role-playing and case simulations.
Browse courses on
Teamwork
Show steps
-
Assemble a study group
-
Select a clinical case
-
Assign roles and responsibilities within the team
-
Conduct a team launch meeting
-
Simulate the clinical case
Run the Toyota Production System through the paces
Show steps
Review the Toyota Production System and apply it to different healthcare scenarios
Browse courses on
Toyota Production System
Show steps
-
Read 'The Toyota Production System'
-
Create a value stream map of your favorite fast food
-
Identify areas where healthcare can improve efficiency
Review 'Getting to Yes: Negotiating Agreement Without Giving In'
Show steps
Learn negotiation techniques to facilitate change in healthcare
View
Getting to Yes: Negotiating Agreement Without...
on Amazon
Show steps
-
Read chapters 1-3
-
Identify negotiation principles
-
Analyze case studies
Three other activities
Expand to see all activities and additional details
Show all six activities
Conduct a root cause analysis and corrective action plan
Show steps
Apply root cause analysis methods to identify and address medical errors
Browse courses on
Root Cause Analysis
Show steps
-
Select a medical error case
-
Conduct a root cause analysis using the 5 Whys method
-
Develop a corrective action plan
Calculate the reliability and failure rate of different healthcare systems
Show steps
Quantify and compare the reliability of healthcare systems
Browse courses on
Reliability
Show steps
-
Gather data on healthcare system performance
-
Calculate the reliability using different metrics
-
Compare the failure rates of different systems
Form an improvement group and tackle a quality improvement project
Show steps
Collaborate with peers to implement a healthcare improvement initiative
Browse courses on
Quality Improvement
Show steps
-
Identify a quality improvement need
-
Form an improvement group
-
Develop an improvement plan
-
Implement the plan
-
Evaluate the results
Organize a team launch and simulate a clinical case
Show steps
Practice team-based approaches through role-playing and case simulations.
Browse courses on
Teamwork
Show steps
Show steps
Show steps
- Assemble a study group
- Select a clinical case
- Assign roles and responsibilities within the team
- Conduct a team launch meeting
- Simulate the clinical case
Run the Toyota Production System through the paces
Show steps
Review the Toyota Production System and apply it to different healthcare scenarios
Browse courses on
Toyota Production System
Show steps
Show steps
Show steps
- Read 'The Toyota Production System'
- Create a value stream map of your favorite fast food
- Identify areas where healthcare can improve efficiency
Review 'Getting to Yes: Negotiating Agreement Without Giving In'
Show steps
Learn negotiation techniques to facilitate change in healthcare
View
Getting to Yes: Negotiating Agreement Without...
on Amazon
Show steps
Show steps
Show steps
- Read chapters 1-3
- Identify negotiation principles
- Analyze case studies
Three other activities
Expand to see all activities and additional details
Show all six activities
Conduct a root cause analysis and corrective action plan
Show steps
Apply root cause analysis methods to identify and address medical errors
Browse courses on
Root Cause Analysis
Show steps
Show steps
Show steps
- Select a medical error case
- Conduct a root cause analysis using the 5 Whys method
- Develop a corrective action plan
Calculate the reliability and failure rate of different healthcare systems
Show steps
Quantify and compare the reliability of healthcare systems
Browse courses on
Reliability
Show steps
Show steps
Show steps
- Gather data on healthcare system performance
- Calculate the reliability using different metrics
- Compare the failure rates of different systems
Form an improvement group and tackle a quality improvement project
Show steps
Collaborate with peers to implement a healthcare improvement initiative
Browse courses on
Quality Improvement
Show steps
Show steps
Show steps
- Identify a quality improvement need
- Form an improvement group
- Develop an improvement plan
- Implement the plan
- Evaluate the results
Career center
Learners who complete Fixing Healthcare Delivery will develop knowledge and skills
that may be useful to these careers:
Patient Safety Officer
Patient Safety Officer
Patient safety officers are responsible for developing and implementing programs and policies to prevent and reduce patient errors. They work with healthcare providers to identify and mitigate risks to patient safety. This course can help individuals who want to become patient safety officers by providing them with a deep understanding of the challenges facing healthcare providers and the strategies that can be used to improve the quality and safety of healthcare services. Additionally, this course has a strong focus on understanding and preventing human error, which is a major cause of patient safety incidents.
Risk Manager
Risk Manager
Risk managers are responsible for identifying and mitigating risks to an organization. They work with healthcare providers to develop and implement policies and procedures to reduce the likelihood of patient safety incidents. This course can help individuals who want to become risk managers by providing them with a deep understanding of the challenges facing healthcare providers and the strategies that can be used to improve the quality and safety of healthcare services. Additionally, this course has a strong focus on understanding and preventing human error, which is a major cause of patient safety incidents.
Compliance Officer
Compliance Officer
Compliance officers ensure that healthcare organizations comply with all applicable laws and regulations. They work with healthcare providers to identify and mitigate risks, improve the quality of care, and reduce costs. This course can help individuals who want to become compliance officers by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services.
Healthcare Administrator
Healthcare Administrator
Healthcare administrators are individuals who manage the operations of healthcare facilities such as hospitals, clinics, and nursing homes. They are responsible for overseeing the day-to-day operations of these facilities, including patient care, staffing, and financial management. This course can help individuals who want to become healthcare administrators by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services. This course may also be useful for healthcare administrators who wish to advance their careers.
Health Policy Analyst
Health Policy Analyst
Health policy analysts analyze and evaluate health policies and programs. They make recommendations to policymakers on how to improve the quality and efficiency of healthcare services. This course can help individuals who want to become health policy analysts by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services. This course also discusses how health systems and providers should be treating patients and families who have been inadvertently harmed.
Healthcare Consultant
Healthcare Consultant
Healthcare consultants provide advice to healthcare organizations on how to improve their operations and performance. They work with healthcare providers to identify and mitigate risks, improve the quality of care, and reduce costs. This course can help individuals who want to become healthcare consultants by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services.
Healthcare Project Manager
Healthcare Project Manager
Healthcare project managers plan and manage projects to improve healthcare services. They work with healthcare providers to identify and mitigate risks, improve the quality of care, and reduce costs. This course can help individuals who want to become healthcare project managers by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services. This course also discusses how to launch and coach a team; both key skills for project managers.
Health Informatics Specialist
Health Informatics Specialist
Health informatics specialists use technology to improve the quality and efficiency of healthcare services. They work with healthcare providers to design and implement information systems, manage data, and conduct research. This course can help individuals who want to become health informatics specialists by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services. This course also provides an introduction to how data can be used to increase reliability in health care.
Medical Director
Medical Director
Medical directors are physicians who oversee the medical care provided by a healthcare facility. They are responsible for developing and implementing policies and procedures to ensure the quality and safety of patient care. This course can help individuals who want to become medical directors by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services. This course may also be useful for medical directors who wish to advance their careers.
Healthcare Researcher
Healthcare Researcher
Healthcare researchers conduct research to improve the quality and efficiency of healthcare services. They work with healthcare providers to identify and mitigate risks, improve the quality of care, and reduce costs. This course can help individuals who want to become healthcare researchers by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services.
Quality Improvement Manager
Quality Improvement Manager
Quality improvement managers are responsible for developing and implementing programs and policies to improve the quality of healthcare services. They work with healthcare providers to identify and mitigate risks to patient safety. This course can help individuals who want to become quality improvement managers by providing them with a deep understanding of the challenges facing healthcare providers and the strategies that can be used to improve the quality and safety of healthcare services.
Healthcare Educator
Healthcare Educator
Healthcare educators develop and deliver educational programs to healthcare professionals. They work with healthcare providers to identify and mitigate risks, improve the quality of care, and reduce costs. This course can help individuals who want to become healthcare educators by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services.
Medical Writer
Medical Writer
Medical writers develop and deliver educational programs to healthcare professionals. They work with healthcare providers to identify and mitigate risks, improve the quality of care, and reduce costs. This course can help individuals who want to become healthcare educators by providing them with a deep understanding of the healthcare system, the challenges facing healthcare providers, and the strategies that can be used to improve the quality and safety of healthcare services.
Physical Therapist
Physical Therapist
Physical therapists help people who have been injured or disabled to regain function and independence. They work with patients to develop and implement treatment plans that may include exercises, activities, and assistive devices. This course may be useful for physical therapists who want to improve their understanding of the healthcare system and the challenges facing healthcare providers.
Occupational Therapist
Occupational Therapist
Occupational therapists help people who have been injured or disabled to regain function and independence. They work with patients to develop and implement treatment plans that may include exercises, activities, and assistive devices. This course may be useful for occupational therapists who want to improve their understanding of the healthcare system and the challenges facing healthcare providers.
For more career information including salaries, visit:
OpenCourser.com/course/mmdt45/fixing
Reading list
We've selected seven books
that we think will supplement your
learning. Use these to
develop background knowledge, enrich your coursework, and gain a
deeper understanding of the topics covered in
Fixing Healthcare Delivery.
Provides a practical guide to implementing the Toyota Production System in healthcare. It valuable resource for anyone who wants to improve the quality and efficiency of healthcare delivery.
Provides a practical guide to adaptive leadership. It covers the principles of adaptive leadership, the challenges to adaptive leadership, and strategies for becoming an adaptive leader.
Save
Provides a practical guide to overcoming immunity to change. It covers the principles of immunity to change, the challenges to overcoming immunity to change, and strategies for overcoming immunity to change.
Provides a framework for understanding why successful companies often fail to innovate. It covers the principles of the innovator's dilemma, the challenges to overcoming the innovator's dilemma, and strategies for overcoming the innovator's dilemma.
Provides a practical guide to the lean startup methodology. It covers the principles of the lean startup methodology, the challenges to the lean startup methodology, and strategies for implementing the lean startup methodology.
Provides a comprehensive overview of the performance of health systems around the world. It covers the indicators of health system performance, the challenges to improving health system performance, and strategies for improving health system performance.
Save
Provides a comprehensive overview of healthcare reform. It covers the history of healthcare reform, the different approaches to healthcare reform, and the challenges to healthcare reform.
For more information about how these books relate to this course, visit:
OpenCourser.com/course/mmdt45/fixing
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University of Florida
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Frederick S. Southwick, MD
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Good to know
Develops a deep understanding of the problems and solutions to medical errors, empowering learners to be part of the solution
Taught by Frederick S. Southwick, MD, a renowned expert in preventing medical errors
Examines the consequences of medical errors, focusing on the human toll they take and the need for understanding and reducing them
Introduces the Toyota Production System and its principles for improving healthcare, promoting efficiency and waste reduction
Emphasizes the importance of teamwork in modern healthcare, exploring strategies and techniques for effective collaboration
Provides tools for understanding and preventing human error, including root cause analysis, driver diagrams, and PDSA cycles
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