According to a September 19th article in the Wall Street Journal (http://blogs.wsj.com/health/2007/09/18/more-hospitals-lag-than-leap-on-quality/), just over 1/3rd of the hospitals they surveyed have adequate hand-washing policies to prevent the spread of antibiotic-resistant infections. This should be frightening. You would hope the results would be better coming from hospitals that volunteered to be surveyed on the topic. With the recent push from hospital quality experts to utilize LEAN methods and the attention of IHI, AHA, CMS and others on the topic, why do so many hospitals struggle with Safety? Answer: they still need the Oversight, Accountability, and Support offered by a balanced scorecard framework.
LEAN thinking in healthcare is not new. I recall reading a 2004 IHI Innovation Series white paper called “Improving the Reliability of Health Care.” (www.ihi.org), where Thomas Nolan discussed many LEAN topics. For those of you who would like a quick, high level LEAN overview, see the "high level overview of LEAN methods in hospitals" section of this post.
Informed Executive Oversight– the Hospital executive team will know their business, but they may not know what role they play in a LEAN Hospital. When the Executive team looks at their balanced scorecard and sees a LEAN initiative aligned to a top level safety measure, they need coaching to know what to expect. For example, if they spot a LEAN initiative on their scorecard that is expected to improve results, they need to expect to see information regarding the current and future state value streams. Without informed executive oversight, Hospital executives often hear best guesses during scorecard reviews rather than systematic Root Cause Analysis.
Accountability - for LEAN to work, it requires CHANGE. There will be changes to processes across the silos of the hospital. Only through repeated, structured reviews with each impacted scorecard team can you ensure that those accountable don't escape. Without executive visibility to who's accountable and how they are performing, the status quo will likely continue and NOTHING WILL CHANGE.
Support - to make the new processes stick (i.e. sustainability), the departments need training, time, and continued encouragement. Consistent scorecard reviews with department leaders offer a channel of encouragement and are an ideal way for hospital executives to communicate how important the new process is. The LEAN initiative’s place on the department scorecard helps department leaders prioritize resources and time spent on the new process.
Here is a high level overview of LEAN methods in hospitals:
- Reducing waste
- Standard work
- Error proofing
Waste: think of waste as the time a nurse might spend not providing "value added" care to patients. Examples might be searching for supplies, searching for medications, getting the wrong drugs from pharmacy, or solving problems. Hospital LEAN expert, Mark Graban, sites in a recent article a world-renowned cancer treatment center with nurses spending 70% of their time on waste. (How Toyota Can Save Your Life (http://changethis.com/32.02.HowToyotaCanSave). A LEAN improvement team identifies and reduces waste in their processes, which allows nurses to spend more time caring for patients. The immediate impacts of waste reduction can be proper staffing levels, cost reduction, and nurse engagement.
Standard work: standard work represents a hospital taking advantage of what science has proven to be the "best practice". To be sure, following best practices (tools, processes, training, targets) will be a culture change for any hospital.
Error proofing: error proofing goes beyond fixing problems; it looks at why errors COULD happen. Most hospitals will have a Root Cause Analysis methodology which analyzes past errors. This is very important, so mistakes are not repeated. LEAN methods utilize FMEA (failure mode effects analysis) to identify where errors COULD happen. FMEA is used to expose near misses and unsafe practices that are predictive of Safety issues. The three factors FMEA looks at are:
- Chance of error occurring
- Chance of error not detected
- Harm error causes
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