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Lean Thinking: Applications for Patient Safety Goals
Southern California Patient Safety Collaborative
David Munch M.D. SVP, Chief Clinical Officer
Healthcare Performance Partners
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Lean can help you with:
Providing Value to the
Customer (Patient)
Improving Reliability and Safety
Eliminating Waste
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Driving Incentives to Focus on Patient Safety
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Improving Patient Safety
Designing Reliable Process – The Reliability Design Triad
Establishing Management Systems to support and sustain them – Visual Management – Development of People
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Pyramid for Quality, Safety, Reliability, -
Process: 1. Prevent 2. Mitigate 3. Redesign
Clinical Technology: Work Flow Ideal Use
Safety Culture: 5 Subcultures +
Elements of HROs
People: Management
Systems, People
Development
Process 1. Prevent
1. Standard Work 2. Simplify 3. Total Productive Maintenance
2. Identify and Mitigation 1. Visual Management 2. Mistake Proofing 3. Identify and Respond Immediately
3. Redesign 1. Ideal design, 2. Root Cause problem-solving, 3. By those doing the work, using Scientific
Method, with a Coach
Safety Culture -A Just Culture -Mindfulness -Communication & teamwork
People -Development -Management systems -Leadership standard work
Clinical Technology Work Flow-technology interface
• 3P, Skills and Fit • Appropriate IT application
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Unnecessary Variation is the Enemy
Creates Waste Hides Problems Counter to Professional
Culture
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Fundamental to Safety and Reliability: Prevention, Detection and Response based upon Understood Standards
You cannot see the abnormal until you have established the normal.
Time
Harm or Damage
Determining Cause
High
Low
Defect: E.g.. Adverse Event
Prob
abili
ty
Adapted from slide by John Shook: U. Michigan
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Qualities of High Reliability Weick and Sutcliffe: Managing the Unexpected
Preoccupation with Failure Reluctance to (Over) Simplify Sensitivity to Operations Commitment to Resilience Deference to Expertise
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Preoccupation with Failure: Root Cause Problem Solving: “A3” Thinking
This image cannot currently be displayed.This image cannot currently be displayed.
Problem Cause Solution Action Measurement
A3 Process Follows
Scientific Method
Similar To Healthcare
Familiar PDCA
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Sensitivity to Operations
Status at a
Glance
Standards or Norms
Observation
Data & Analysis
Visual Mgmt. & Coaching
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What Does this Look Like in a Hospital?
Imaging Department
Andon Board – “I need help”
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Visual Controls
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Patient Status at a glance
Pt + Dr name Sched time
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History/Pareto/Problem Solving
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5S Score
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/07
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/07
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WeekHistory Pareto Principle
Problem Solving
Extra Pt Lift keeps coming back to this floor 1 2 Clean Pain pump not available from Central Equipment 3 Weekend shift not putting equipment back
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Visual Management Example: Backdrop for Dialogue
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Helping People Through Change: The First I.T. Coaching Session
The Development of People
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Cascading Team Structure: Extensive Support and Coaching at the Front Line
Director
Manager
Team Lead
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Coaching Example 410 Bed Hospital in the Denver Area
The Problem: Could not get hand washing compliance above 70% despite DMAIC and effort
The Countermeasure: Coaching – Who are the Coaches? – What are the barriers and support needed?
The Objective: – Wash or gel in and out of patient room, everyone, every time. – Barriers, support and accountability: The Red Rule
The Presence: Within the flow of your other work every day
Timeliness: Immediate intervention The Interaction: Understanding and Action
– “What prevented you from washing your hands this time?” – “What will you do such that this doesn’t happen again?”
The Follow-up: Visual management, ongoing conversations
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Stop when there is a Quality problem Hand Washing
Understanding The Problem
Manager Coach Training
Manager Coaching
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Rat
e of
Com
plia
nce
Weekly Hand Hygiene Rates October 2008-December 2010
P UCL Average LCL
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Outcome Measures Does all this washing make a difference?
HAI Prevalence Correlated with Hand Hygiene Compliance
0.00
0.50
1.00
1.50
2.00
2.50
3.00
1/1/082/1
/083/1
/084/8
/085/8
/086/8
/087/8
/088/8
/089/8
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10/8/
08
11/8/
08
12/8/
081/1
/092/1
/093/1
/094/1
/095/1
/096/1
/097/1
/098/1
/099/1
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10/1/
09
11/1/
09
12/1/
091/1
/102/1
/103/1
/104/1
/105/1
/106/1
/107/1
/108/1
/109/1
/10
10/1/
10
11/1/
10
12/1/
10
HAI P
reva
lenc
e
0
20
40
60
80
100
120
Hand
Hyg
iene
Com
plia
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HAI Prevelance per 1,000 pt days Hand hygiene percent compliance
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The Management System for Patient Safety
• Do the Standard Work • Surface and Solve Problems • Improve the Standard Work
Staff
• Observe, Measure, Analyze, Action
• Immediate Response to Errors • Develop and Coach the Front
Line • Support and Lead the
Improvements
Management • Align to Strategy: Safety as the
Highest Priority • System and Structures • Develop the Middle • Deeply Understand your
Organization: Go See
Executive
Performance Improvement, Decision Support, HR, I.T. Facilities
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“We are Leaders in an industry that we are not sure we understand” Timothy Porter O’Grady
Healthcare has become so complex that “command and control” no longer works.
We have the most educated staff of all industry yet we do not take advantage of their wisdom. – Timothy Porter-O’Grady
Leaders must develop those for whom they are responsible so that the organizational capacity to be self-correcting, self-improving, and self-innovating is distributed and practiced widely and consistently – Steven Spear
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The Method 3 attributes of lean leadership at every level:
Go see: Visit the point where value is actually being created; verify the situation
Ask why: What is the problem? What are possible solutions?
Show respect: Assign clear responsibility for every process and problem; ask questions about people’s work.
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James Womack: Lean Enterprise Institute