PDCA in a Zen Perspective

The gamekeeper of the never (events) land

My job is maintaining the most negative database in New Zealand storing what (sometimes almost) went wrong and what did not (occasionally positively) go as patients expected in healthcare, to learn from them and improve quality and safety of care.

In recent dialog with other HL7 New Zealand executives, I called myself the gamekeeper of the never (events) land. The quarries under my administration are captured in tertiary care facilities and kept for shooting out systemic problems.

We would need to greatly extend the scope and range of this never (events) land as regional and national shared care initiatives are being rolled out. But there is a catch.

When patients, family members and other people within the community are taking more active roles in healthcare, it would be unlikely that they are naturally more motivated than health professionals to share unwanted results.

Thus we have got to build user friendly information systems and the culture of non-blaming discourse for collecting bad lucks to turn them into good practices which would be utilised by everyone in the community.

This is a quite a challenge.