One Patient, One Lesson by Maryann McBean

At Studer Group, we start team meetings with a “connect to purpose” story—reminding us why we do what we do. These stories highlight the impact of healthcare experiences and reinforce our belief that N=1: every individual’s experience and outcome matter. Through this lens, we work with our partners to make healthcare safer, more effective, and compassionate.

Building a culture of quality and safety takes more than policies—it requires leadership, engagement, and continuous learning. We asked our coach, 𝗠𝗮𝗿𝘆𝗮𝗻𝗻 𝗠𝗰𝗕𝗲𝗮𝗻, who brings extensive experience in 𝗘𝘅𝗲𝗰𝘂𝘁𝗶𝘃𝗲 𝗡𝘂𝗿𝘀𝗶𝗻𝗴, 𝗢𝗿𝗴𝗮𝗻𝗶𝘀𝗮𝘁𝗶𝗼𝗻𝗮𝗹 𝗦𝘂𝗿𝘃𝗲𝘆𝘀, and 𝗤𝘂𝗮𝗹𝗶𝘁𝘆 𝗮𝗻𝗱 𝗦𝗮𝗳𝗲𝘁𝘆, to share her insights on fostering excellence in healthcare.

𝗠𝗮𝗿𝘆𝗮𝗻𝗻, 𝗵𝗼𝘄 𝗱𝗼 𝘄𝗲 𝗰𝗿𝗲𝗮𝘁𝗲 𝗮𝗻 𝗲𝗻𝘃𝗶𝗿𝗼𝗻𝗺𝗲𝗻𝘁 𝘄𝗵𝗲𝗿𝗲 𝗹𝗲𝗮𝗿𝗻𝗶𝗻𝗴 𝗳𝗿𝗼𝗺 𝗲𝗿𝗿𝗼𝗿𝘀 𝗶𝘀 𝗲𝗺𝗯𝗿𝗮𝗰𝗲𝗱 𝘄𝗶𝘁𝗵𝗼𝘂𝘁 𝗯𝗹𝗮𝗺𝗲?

I’ve always found that shifting the conversation from “Who made the mistake?” to “What did we miss?” or “How can we reduce the likelihood of this happening again?” makes a huge difference. It moves us from a reactive mindset to a proactive one—focusing on solutions rather than fault.

One thing I’ve consistently encouraged in my teams is a culture of reporting. In my experience, near misses are some of our greatest learning opportunities. They give us a chance to identify and fix gaps before they escalate into incidents that could cause real harm to patients or staff.

𝗪𝗵𝗮𝘁 𝗮𝗰𝘁𝗶𝗼𝗻𝘀 𝗼𝗿 𝘁𝗼𝗼𝗹𝘀 𝗵𝗮𝘃𝗲 𝘆𝗼𝘂𝗿 𝗽𝗮𝗿𝘁𝗻𝗲𝗿𝘀 𝗳𝗼𝘂𝗻𝗱 𝗲𝗳𝗳𝗲𝗰𝘁𝗶𝘃𝗲 𝗶𝗻 𝗱𝗿𝗶𝘃𝗶𝗻𝗴 𝗾𝘂𝗮𝗹𝗶𝘁𝘆 𝗼𝘂𝘁𝗰𝗼𝗺𝗲𝘀?

For me, objectively measuring progress is key. Data helps facilitate meaningful discussions about what’s working, what needs to change, and where we should focus next. I’ve found that using 90-day action plans keeps us accountable and ensures that improvements aren’t just talked about but actually implemented within a clear timeframe.

𝗛𝗼𝘄 𝗱𝗼 𝘆𝗼𝘂 𝗺𝗮𝗸𝗲 𝘀𝘂𝗿𝗲 𝗾𝘂𝗮𝗹𝗶𝘁𝘆 𝗮𝗻𝗱 𝘀𝗮𝗳𝗲𝘁𝘆 𝗲𝗳𝗳𝗼𝗿𝘁𝘀 𝘀𝘁𝗮𝘆 𝗽𝗿𝗼𝗮𝗰𝘁𝗶𝘃𝗲 𝗿𝗮𝘁𝗵𝗲𝗿 𝘁𝗵𝗮𝗻 𝗿𝗲𝗮𝗰𝘁𝗶𝘃𝗲?

One approach I’ve seen work well is using audit tools to measure compliance with high-risk policies or known gaps. Another simple but powerful practice is for managers to have regular check-ins with their teams—asking questions like, “What’s not working well right now?” and “How can we improve it?” These conversations help catch small issues early, before they snowball into major problems. I think of these moments as “good catches”—opportunities to fine-tune our processes before errors occur.

𝘈𝘵 𝘵𝘩𝘦 𝘩𝘦𝘢𝘳𝘵 𝘰𝘧 𝘲𝘶𝘢𝘭𝘪𝘵𝘺 𝘢𝘯𝘥 𝘴𝘢𝘧𝘦𝘵𝘺 𝘪𝘴 𝘭𝘦𝘢𝘥𝘦𝘳𝘴𝘩𝘪𝘱 𝘵𝘩𝘢𝘵 𝘭𝘪𝘴𝘵𝘦𝘯𝘴, 𝘵𝘦𝘢𝘮𝘴 𝘵𝘩𝘢𝘵 𝘧𝘦𝘦𝘭 𝘦𝘮𝘱𝘰𝘸𝘦𝘳𝘦𝘥, 𝘢𝘯𝘥 𝘢 𝘤𝘶𝘭𝘵𝘶𝘳𝘦 𝘵𝘩𝘢𝘵 𝘷𝘪𝘦𝘸𝘴 𝘪𝘮𝘱𝘳𝘰𝘷𝘦𝘮𝘦𝘯𝘵 𝘢𝘴 𝘢𝘯 𝘰𝘯𝘨𝘰𝘪𝘯𝘨 𝘫𝘰𝘶𝘳𝘯𝘦𝘺.