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QI 202: Addressing Small Problems to Build Safer, More Reliable Systems
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If an organization is to avoid catastrophic failure, staff members need to call out small problems as they arise in daily work. In this lesson, you’ll learn that organizations that successfully manage complexity have a deliberate approach to escalating the small concerns and suggestions of employees. Staff members know how to recognize problems, whom to contact, and how to get that person’s attention immediately. The leaders, in turn, avoid blame and provide the resources necessary to solve problems.
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If an organization is to avoid catastrophic failure, staff members need to call out small problems as they arise in daily work. In this lesson, you’ll learn that organizations that successfully manage complexity have a deliberate approach to escalating the small concerns and suggestions of employees. Staff members know how to recognize problems, whom to contact, and how to get that person’s attention immediately. The leaders, in turn, avoid blame and provide the resources necessary to solve problems.

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Objectives

After completing this course, you will be able to:

  1. Explain why system complexity requires us to take a methodical approach to system design, operation, and improvement.
  2. Describe the connection between the effective escalation of staff members’ concerns and the prevention of catastrophic events.
  3. List the conditions under which it’s possible for organizations to see and solve small problems quickly.
  4. Give an example of a health care organization that achieved a significant clinical improvement through the deliberate and widespread escalation of staff concerns.

Contributors

Authors
Steven Spear, DBA, MS, MS, Senior Lecturer, Massachusetts Institute Of Technology  
Tom Downes, MD, MRCP, MBA, MPH, Clinical Lead for Quality Improvement, Sheffield Teaching Hospitals 
Editors
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement  
Reviewers
Eugene Litvak, PhD, President and CEO, Institute for Healthcare Optimization  
Jonathan Finkelstein, MD, MPH, Professor, Harvard University Medical School  
Sean O'Neill, MD, PhD, Resident Physician, UCLA Health System  

  • Training Hours: 1.75
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