Can We Mistake-Proof Hospice and Palliative Care?

by Lizzy Miles

On a recent road trip, I was distracted. I stopped to get gas and accidentally picked up the diesel nozzle. I tried to put it in my gas tank, but it wouldn’t fit. The opening to the tank and the nozzle were incompatible. This is one example of the Japanese concept of Poka-Yoke (mistake-proofing).  While most Westerners are not familiar with the term, we all have benefitted by the design practice. The automobile industry does what it can to design cars in a way to prevent consumers from making mistakes. You cannot put the car in “Drive” unless you have your foot on the brake. Modern cars now remind you if you forget your keys or if you leave your headlights on.

On this particular road trip, I was on my way to visit my Uncle Paul who is a retired Union Carbide scientist. I asked him about mistake-proofing and how it works. There are several components to successful mistake-proofing:

1. Examine “what if?” – Wonder what could go wrong
2. Analyze all the steps in a process
3. Never underestimate the users’ ingenuity to bypass safeguards
4. When mistakes do happen, examine why they happen and contemplate how to prevent

I believe there are opportunities for hospice and palliative care organizations to integrate a Poka-Yoke approach.

Poka-Yoke is not new to healthcare, but is more prevalent in hospital environments. A friend who worked as a career med-flight nurse practitioner told me about several examples used in the hospital:

• Patients are asked multiple times for information confirming their identity
• Morbidity and Mortality Conference to review process and/or clinical errors
• Critical Incident Stress Debriefing (CISD) process after particularly rough cases

The difficulty with integrating a Poka-Yoke approach in hospice and palliative care would be that it requires an organization or industry to admit that it makes mistakes. In order to improve, we would have to admit that we are not as good as we could be. The challenge with that reflection is that our industry is having a hard enough time as it is right now. We do not always get positive press for what we do. A few years ago it was Sarah Palin and Death Panels. Now it’s inaccurate newspaper articles about hospices admitting non-dying patients just for profit.

I did an informal content analysis of the complaints about hospice in the comments section of one of the less favorable newspaper articles. There were caregivers who felt their loved one received too much medication and others who said there wasn’t enough attention to symptoms. Some commenters felt there wasn’t enough emotional support, and others felt it was “forced” on them. Coupled with what’s going on in the media with the “right to die” advocates, and the groups who are afraid they’re being pushed into hospice, there is clearly a theme here.

People want control of their own life and death. Right now, they don’t feel in control.

Yes, we have to acknowledge there is room for improvement. It is easy for us to point upstream and say that it is the hospitalists or the oncologists that are not making referrals, and that’s are number one problem with hospice, at least.  But is it? I challenge the #hpm community to brainstorm.

What is our responsibility as end of life professionals for the referral process?

How do we give patients and families a feeling of control?

What could hospice and palliative care professionals be doing better?

I have one suggestion for the answers: Community. This is what we are trying to do with Pallimed is to bring together the hospice and palliative care community to share ideas so that we can become better. But also, I believe (at least in my hometown) the hospices and palliative care organizations are not out in the community enough.  We need to step out of the shadows. We don’t have to talk about death all the time. Community engagement builds trust. Look at the events at St. Christopher’s in England. They have plays and art and curry night. They are integrated into the community so that when people need hospice, they are not afraid.

“Oh, hospice, I went to a potluck there last month.”