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Reliable DesignFrank Federico

May 2014

Why Are Processes Not Reliable?

Individual Autonomy

Focus on benchmark performance

Over-reliance on training, vigilance and hard work

Expecting that having a policy will result in improved

reliability

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3Example of a Run Chart Showing Implementing

the VAP Bundle

Integrate daily

goals with MDR

to identify

defects as a

Step 1 change

concept

Education

Baseline

Feedback on

compliance

Redundancy in the

form of a check by

RT built into 1 hour

scheduled vent

checks as a Step 2

change concept

(Baptist Memorial, Memphis)

What Makes Processes Reliable?

Deliberate design

All employees focus on reliability

Ideas are tested-tested-tested

Measure-measure-measure

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The Reliability Design Strategy

Prevent initial failure using intent, simplification and standardization

Identify defects (using redundancy/backup plans) and mitigate

Measure and then communicate learning from defects back into the design process

IHI Reliable Design MethodologyStart small- subset/segment of the population

Visualize the steps in the process using a high-level flow

diagram

Identify the defects in each step

Lead with the change concepts of simplification and

standardization

Develop a ‘back-up plan’ or redundancy

Test-test-test

Measure-measure-measure

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Start Small

Experience tells us that not all situations are the same

One standardized process will not work for all

Design a process to deliver reliable care for a group that

is easiest to work with

Learn from that group and spread to others

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Selecting a Subset/Segment

Characteristics:

Easy to identify

Willing participants

Can learn how to design for other subsets

High enough volume to be able to test daily or every other day

“If we cannot make our process reliable for this group, what

are our chances with other groups?”

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Subset for the Ventilator Care Bundle

One ward

One doctor’s patients

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Population

Segment

Small Test

of Change

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Visualize the Steps

High level flow diagram

3 to 5 Steps-keep it simple

Identify defects

– Is there a cascade?

– Where is the biggest defect?

– Identify what you will fix

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Example of High Level Diagram

Patient

Admitted

Assessment

Completed

Prophylaxis

OrderedProphylaxis

Administered

Patient

Discharged to

Home

Fail to complete assessment

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At least 95% of the patients will be assessed

VTE Prophylaxis

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13Example: Ventilator Care Bundle “Set Up”

Patient placed

on ventilator

Elements of

the bundle

ordered

Elements of

the bundle

accomplished

Patient

removed from

ventilator

Segment: Medical ICU With 2 Willing Doctors

Of the elements of the bundle, the

head of the bed elevation is most

commonly not accomplished

Our aim is to achieve 95% or better reliability at

keeping the head of the bed elevated

What is your goal?

At least 95% reliability for the process

Why not 100%?

Process must be capable and reliable

Process must be linked to outcome

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Will Patients Be Harmed?

Focus on non–catastrophic processes

If process fails, patient will not be harmed within next few

hours

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Problem Solving

First order Problem Solving

– Fix the problem you see

Second order Problem Solving

– Solve the root of the problem

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Step 1

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Getting Started- Let’s Work on Your

Identified Problem

Select subset or segment of population

Select process you want to make more reliable

Develop a high level flow diagram

Identify defects in each step

Select which defect you will fix first

State your reliability goal

– At least 95% reliable

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Step 2

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Change Concepts

Simplification

– Are there steps in your processes that can be eliminated?

Standardization

– Best known process to achieve desired results

– But known today-may change with new knowledge or new

context

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Definition of standard work

“…current best practice, standardized work forms the

baseline for kaizen or continuous improvement. As the

standard is improved, the new standard becomes the

baseline for further improvements, and so on. Improving

standardized work is a never-ending process.”

http://www.lean.org/workshops/WorkshopDescription.cfm?WorkshopId=20

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How to Standardize

Determine what you want to standardize and why

Ask people who do the work to contribute ideas

Ideas from others

Test-test-test

Measure-measure measure

Do not be afraid of giving up an idea if it does not work

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Standardize the Process

Who

What

When

Where

How

With what

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Step 3

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Why Develop a Back Up Plan?

Very difficult to reach 100% every time with only one

step

Allowing for 80% reliability in first step gives opportunity

to design more freely

You may achieve 95% or better with only the first step-

but is it sustainable?

You should have a safeguard/backup plan in place

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Examples of Backup Plan

Checkout after primary care visit

Visual marker for head of bed elevation

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Standardize the Backup Plan

Who

What

When

Where

How

With what

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When to move to this step?

Standardization step must be at least 80%

reliable over time

Do not introduce backup plan if the first step is

not reliable

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When will the backup plan fail?

When it becomes the primary process

When it never finds a defect in the primary

process

When it becomes another function in our busy

days

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Measurement

Needed to determine reliability of processes

Sampling is useful

Measurement alone does not result in

improvement

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Measurement

Select 5 to 10 events daily

Plot over time

Display charts

Easy to do

Collected by people who do the work

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5 Charts/Day Run Chart 32

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5 Charts/Day Run Chart 33

How to Help Your Teams

Start with segmentation, flow diagram and

standardization

Standardization must achieve at least 80% before

moving on

If reliability not improving consider testing some other

steps

Use the following grids to coach teams

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Key Questions To Analyze Testing and

Implementation

Key Question Your Evaluation

Is the connection between goals and process clear?

Is the design strategy primarily vigilance and hard

work?

Has some degree of segmentation been used to test

the design?

Has standard work with testing been part of the

design?

Is a design methodology being used?

Are small tests of change being used in a rapid cycle?

Is data collection rapid enough?

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Key Questions To Analyze Spread

Key Question Your Evaluation

Have you repeated the small test cycles as you

spread from the initial site?

Is the process of spread dependent on one person?

Has some degree of segmentation been used to

spread?

Has customization been allowed or encouraged?

Is the same team who developed the pilot now

responsible for spread?

Have you shifted your focus from process reliability

to outcomes too early?

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Take a moment to reflect on the work you

will be doing

What will you incorporate from

this session?

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