Confident Voices in Healthcare Blog is gaining a solid reputation for honest, timely, and helpful posts addressing problems and solutions in healthcare. In the last two weeks, it has made “Top 45” (by Concorde Career Colleges) and “Top 30” (by Best Masters of Science in Nursing) lists for Best Nursing Blogs! One major for this is because of unique and high quality posts by guestbloggers like, Bob Latino, CEO of Reliability Center, Inc. Bob has written numerous posts helping us to understand what makes an effective Root Cause Analysis (RCA), and what does not! I thought readers might enjoy learning a little more about these experts and over the next few weeks will include interviews with them starting with Bob!
1. Tell CV readers a little bit about yourself.
My name is Bob Latino and I am CEO of a global Reliability Engineering firm called Reliability Center, Inc. We were established in 1972 as a Research & Development (R&D) group of a company called Allied Chemical (which today is Honeywell).
What is more interesting is that my father, Charles J. Latino, was the founder and director of this group. My father was a Chemical Engineer who was enamored with the success of the U.S. space program. He was amazed at the reliability of the safety systems in NASA and that the creativity of mankind, could put a man on the moon.
As the head of Maintenance & Engineering at a large Chemical plant with 5,000 employees, he wondered why his facility could not be as reliable? He wondered why his facility waited for failure to occur and focused their efforts on being better responders? He was fixated on the need for proaction instead of solely, reaction? But how could he make that a reality at his facility?
My father spent his entire career transitioning the principles of Reliability Engineering from Aviation, Nuclear and Space; and making them practical to apply in his Chemical manufacturing plant(s). He was so successful in doing this in the late 60’s, that Allied corporation funded his own Corporate R&D group to explore this field of Reliability Engineering for the entire corporation, globally. This group existed from 1972 – 1985. In 1985 my father retired from Allied and purchased his Reliability Engineering group to become the independent firm of Reliability Center, Inc. (RCI). We could then apply those principles to any industry we wanted.
Reliability is in my blood! Reliability is not just a job or a role, it is a way of life. How we treat ourselves, our families and our friends involves Reliability. We are proactors and not reactors. We prevent bad outcomes by thinking ahead about of the risks of our decisions and minimizing them. We encourage preventive healthcare to avoid the catastrophic outcomes from not knowing what is going on or not recognizing the symptoms.
My father passed away in 2007, and since that time, his family continues to carry the torch for his Reliability dreams, especially in HC. HC can learn a great deal from our Reliability successes in the past, because all organizations are ‘systems’. Once we understand that fundamental and simple fact, we can start to really understand the ’cause and effect’ that our decisions have on that system.
2. What do you think is the most fundamental problem or concern we face in healthcare?
I have always felt the term ‘patient safety’ was an oxymoron. Patients go into a hospital because of their illness or symptoms, they already have a medical issue. So why should they have to worry about their individual safety when going to the very place they are trusting to successfully treat their medical issues? Why should the patient have to worry the hospital will make their condition worse because of an error. This paradigm is what has to change in Healthcare.
There is too much of a focus on what is best for the organization and not what is best for the patient. We fixate on compliance, budgets, finance, regulations and the like and we seem to overlook our purpose for existence…the patient. The patient is often a number and a means of attaining our financial goals. Providers seem to think they know more about the patient’s body, than the patient. Therefore we don’t listen to the patient.
We focus on being compliant when compliance does not equate to patient safety.
HC is still very silo driven and seems to lack an adequate understanding of ‘systems’ and how they inter-relate with each other. This affects our decision-making and our ability to be proactive because we cannot see beyond our immediate roles. We do not clearly understand our individual role in the big picture.
We never seem to have the time and budget to do things right, but we always seem to have the time and budget to do them again. Why is that?
3. What do you think we need to do to fix it? Or what’s one thing we can do that will help fix it?
A more progressive Leadership has to emerge that understands the fundamental relationship between poor organizational systems, their impact on effective decision-making and the subsequent consequences of our poor decisions.
Leadership has to view the hospital entity as a system, a very integrated system and understand the resonating effects of poor decision-making from well-intentioned, decision-makers. Critical thinking skills and an understanding of human factors can sharply reduce the number of unexpected, undesirable outcomes we have in our facilities. Why do we believe the decisions we make, are correct at the time that we make them? That is worthy of deep exploration!
Leadership has to understand that safe and reliable patient care is good, sound and profitable fiscal policy. This is well-proven in other leading industries, around the world, over and over again. Why is HC lagging and not leading on such indicators?
The government is no longer paying hospitals to make errors, so the errors must stop. This means we have to truly understand why they are happening in the first place. This means that shallow cause analysis will no longer be acceptable, and real Root Cause Analysis (RCA) must be properly implemented.
P.S. I also had the great pleasure of working with Bob on a sample RCA involving a medication error. It is a great teaching tool and available on his website for no cost! Watch as they uncover a variety of factors that contributed to the error i.e. not simply blaming the nurse!