|Starting your Journey to be a High Reliability Organization by Stopping|
|Contributed by Kelly Wheeler, MBA, MHA, LSSMBBI|
Healthcare administration is a dynamic discipline and healthcare leaders continue to pursue excellence in the areas of quality, safety and efficiency. The healthcare industry has advanced and benefited by borrowing from and utilizing lessons learned from other industries
Chassin and Loeb, characterized health care quality and safety as showing pockets of excellence on specific measures or in particular services at individual health care facilities in their article, The Ongoing Quality Improvement Journey: Next Stop, High Reliability (1.). In 2014, former Secretary of Defense Chuck Hagel directed a 90-day review of the Military Health System which focused on access to care, safety, and the quality of care. The final report found that the Military Health System (MHS), provides quality care that is safe, timely, and comparable to civilian sector performance. However, there were areas in which the MHS excelled and there was considerable variation across the system, for specific clinical measures and for individual medical treatment facilities (2.).
Based on studies of high reliability organizations, Chassin and Loeb (1.) outlined three key requirements for healthcare organizations to achieve high reliability: leadership commitment to high reliability, a safety culture, and robust process improvement. Six sigma, lean management, and change management when used together provide a systematic problem solving approach that is considered to be more robust.
In post-World War II Japan, resources were scarce and the need to rebuild was great. Leaders at Toyota revisited Henry Ford’s thinking of assembly line production and flow in production while providing variety and invented the Toyota Production System, or TPS (3.). The core of the TPS is to maximize customer value while minimizing waste. Waste can be categorized in eight broad categories including transportation, inventory, motion, underutilized (over-utilized) talent, waiting, over-processing, over-producing, and finally, defects. Lean organizations seek to reduce and eliminate waste, enabling the organization to be poised to provide customers with better quality at a reduced cost.
Process Improvement Techniques for High Reliability
The TPS is characterized as a house with two pillars: Just in Time and Jidoka. Loosely translated, Jidoka, is “automation with a human touch.” It is a system’s or processes’ ability to “stop and respond to every abnormality”, regardless of if the process is involving a machine or human (3.). Toyota has accomplished this both by machinery that will shut down and by empowering employees to slow or stop the process to address the defect by the pull of an andon cord. Andons* come in the form of visual, auditory, or process. Many healthcare organizations have andons, such as auditory beeps when a patient’s infusion pumps or when there are errors in tubing. Seattle’s, Virginia Mason Health System, through its Virginia Mason Production System, has a process andon for its’ Patient Safety Alert System, which enables any employee to alert managers or colleagues of quality or process defects (4.).
Poka-Yoke is Japanese for “mistake-proofing.” Shigeo Shingo, considered the father of poka-yoke, is quoted as saying, "The idea behind poka-yoke is to respect the intelligence of workers by taking over repetitive tasks or actions that depend on the vigilance of memory” (5.). This may include designing features within a process that assist an employee in the completion of a task that either prevents a defect or error or allows a defect or error to be easily detected in order to achieve zero-defects. The automotive industry has applied poka-yoke to auto design features including child-proof locks, back-up cameras, to newer features of audible beeps when the car is drifting towards another lane or nearing another vehicle. Healthcare has numerous examples of mistake proofing from color coded medical gas lines, barcoding for patients ensuring correct patient with supplies and prescriptions, mechanisms to avoid mistaking look-alike, sound-alike medications; among numerous others (6.).
Military Enterprise Opportunity and Performance Outcomes
The Army Medical Command and Army Regional Health Command-Pacific seek zero-harm and to reduce the variation in performance for critical quality and safety measures. In 2016, the Army Medical Command Quality and Safety Division hosted its first quality summit focused on compliance with the National Committee of Quality Assurance (NCQA) Healthcare Effectiveness Data & Information Set (HEDIS) quality indicator for appropriate imaging of acute low-back pain. Utilizing lean thinking, root causes for performance of the enterprise to be below the NCQA 75th percentile benchmark were identified and countermeasures developed. Common root causes included knowledge by clinical staff of clinical practice guidelines and incorrect coding. Enterprise solutions included standardized clinical staff training and coding cheat sheets.
In late 2017, an improvement team at Brian Allgood Army Community Hospital, with clinics across the South Korean peninsula, identified that despite provider training and coding cheat sheets, inappropriate orders for x-rays occurred regularly. The multi-disciplinary team assessed errors were unable to be detected, so they sought to mistake proof. The detection poka-yoke the team implemented requires the ordering provider to add specific comments in the x-ray order that the x-ray technician screens prior to imaging. If the comments are missing, the x-ray tech is empowered to not image with a series of mitigating actions, i.e. contact the clinic officer in charge. This mistake proofing catapulted performance from 77% to 85% at project close out and as of November 2017, 91.94% appropriate imaging compliance (90th percentile is 83.2%). Regional Health Command-Pacific replicated this leading practice where possible and data from October 2017-December 2017 shows the command 5 percentage points higher than the enterprise’s scores and exceeding the 90th percentile.
Healthcare organizations must re-think how care is delivered and the value-streams that support how care is delivered to remain not only financially viable, but to provide the value and the quality of care expected by healthcare consumers and payers. There are a variety of ways that processes can be slowed or stopped and mistakes prevented or detected, thereby reducing waste and reducing cost. Evidence from major health systems adopting lean principles suggests that lean principles of Jidoka and Poka-yoke make it possible to increase quality while decreasing cost and achieve zero-harm. To err is human, but to mistake proof may get us a little closer to divine.
*Note: Andon refers to a signaling system used to call for help when an abnormal condition is recognized, or that some sort of action is required.
1. Chassin, M. R., & Loeb, J. M. (2011, April). The Ongoing Quality Improvement Journey: Next Stop, High Reliability. Health Affairs, 30(4), 559-568. doi:10.1377/hlthaff.2011.0076
2. “Final Report to the Secretary of Defense Military Health System Review.” Health.mil, 29 Aug. 2014, health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/MHS-Review.
3. “The Origin of the Toyota Production System.” Toyota Global, www.toyota-global.com/company/vision_philosophy/toyota_production_system/origin_of_the_toyota_production_system.html.
4. “Patient Safety Alert System Prevents Patient Harm.” Virginia Mason Institute, Sept. 2015, www.virginiamasoninstitute.org/2015/09/patient-safety-alert-system/.
5. Stamatis, Dean H. Six Sigma Fundamentals: A Complete Introduction to the System, Methods, and Tools. Productivity Press, 2003.
6. Grout, John R, and John S Toussaint. “Mistake Proofing: Why Stopping May Be a Good Place to Start.” Business Horizons, 2010, pp. 149–156.