David A. Novis , MD David A. Novis , MD www.davidnovis.comwww.davidnovis.com
Reducing Error and Reducing Error and Patient Risk in the Patient Risk in the
Practices of Practices of Pathology Pathology
and and Laboratory MedicineLaboratory Medicine
© 2007 David Novis, MD All rights reserved. Ÿ
David Novis, MDDavid Novis, MD
Novis Consulting, LLCNovis Consulting, LLC www.davidnovis.comwww.davidnovis.com
[email protected]@comcast.net
603 659 6931603 659 6931
Chi Chi SOLUTIONS INCSOLUTIONS INC.
Brian Dapp Brian Dapp Chief Operating OfficerChief Operating Officer
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316-304-6498
AgendaAgendaTransfusion Audit Results (2nd study)
N = 233 Participants
0
20
40
60
80
100
10th 25th 50th 75th 90th
Percentile Ranking
% C
om
plia
nc
e
Patient ID
Vital Signs
Traditional Traditional Approach to Approach to
Reducing Reducing ErrorsErrors
Alternative Alternative Approach to Approach to
Reducing Reducing ErrorsErrors
Good Housekeeping July 2007Good Housekeeping July 2007
State orders Md. General to fix its labState orders Md. General to fix its labBy Walter F. Roche Jr. SUN STAFF By Walter F. Roche Jr. SUN STAFF Originally published April 3, 2004Originally published April 3, 2004
19991999 20012001 20062006
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
It’s not about working longer, harder ,faster It’s not about working longer, harder ,faster
It’s not about the PEOPLEIt’s not about the PEOPLE…………..It’s about the SYSTEM ..It’s about the SYSTEM
Traditional Approach to Reducing ErrorsTraditional Approach to Reducing ErrorsBenchmarking Benchmarking
Define a measurable quality indicatorDefine a measurable quality indicator
Determine performance benchmarkDetermine performance benchmark
Determine best clinical practicesDetermine best clinical practices
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
EXAMPLE: CAP Q-PROBES STUDIES1994 and 1995: Transfusion Errors
Complete all 4 Complete all 4
Identification Identification ProceduresProcedures
Complete all Complete all required vital sign required vital sign
measurementsmeasurements
Select a MEASURABLE Quality IndicatorSelect a MEASURABLE Quality Indicator
Audit of Transfusion Procedures in Audit of Transfusion Procedures in 660660 HospitalsHospitals
A College of American Pathologists A College of American Pathologists Q-ProbesQ-Probes™™ Study of Patient Identification and Vital Sign Study of Patient Identification and Vital Sign
Monitoring Frequencies in Monitoring Frequencies in 16,494 16,494 TransfusionsTransfusions
Novis DA, Miller KA, Howanitz PJ, Renner SW, Walsh, MK. Novis DA, Miller KA, Howanitz PJ, Renner SW, Walsh, MK. Arch Pathol Lab Med Arch Pathol Lab Med 2003;127:541–548.2003;127:541–548.
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Audit Audit transfusionstransfusions
Determine practicesDetermine practices
Benchmarking: Does It work?Benchmarking: Does It work?
Howanitz, PJ, Renner, SW, Walsh, MK. Arch Pathol Lab Med 2002;126:809-815.
Continuous Wristband Monitoring Over Two Years Continuous Wristband Monitoring Over Two Years Decreases Identification Errors: A College of American Decreases Identification Errors: A College of American
Pathologists Q-Tracks™ StudyPathologists Q-Tracks™ Study
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Benchmarking: Is It Helpful?Benchmarking: Is It Helpful?
Benchmarking: Is It Perfect?Benchmarking: Is It Perfect?
OUTCOMES ARE RARE EVENTS OUTCOMES ARE RARE EVENTS • FORCED TO EVALUATE PROCESSESFORCED TO EVALUATE PROCESSES• DIFFICULT TO ANALYZE SUCCESS OF DIFFICULT TO ANALYZE SUCCESS OF
INTERVENTIONSINTERVENTIONS
MEDIOCRITY ENCOURAGEDMEDIOCRITY ENCOURAGED RETROACTIVERETROACTIVE SLUGGISH RESPONSE SLUGGISH RESPONSE
• LONG INTERVALS TO REPAIR DAMAGELONG INTERVALS TO REPAIR DAMAGE• ROTTEN ENVIRONMENTS PERSISTROTTEN ENVIRONMENTS PERSIST
IDIOSYNCHRATIC PRACTICESIDIOSYNCHRATIC PRACTICES
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
* 2006 Personal Communication, R. Zarbo, MD
QUALITY INDICATORS QUALITY INDICATORS CLINICAL OUTCOMES OR CLINICAL OUTCOMES OR
PROCESSES?PROCESSES?
Hemolytic Transfusion Reactions and Error*Hemolytic Transfusion Reactions and Error* 1 in 13,000 RBC units administered erroneously1 in 13,000 RBC units administered erroneously1 in 2 million result in fatality.1 in 2 million result in fatality.
We measure the frequency with which people do the jobs that they’re paid to do in the first place
* http://www.hhs.gov/ophs/bloodsafety/summaries/sumjan00.html* http://www.hhs.gov/ophs/bloodsafety/summaries/sumjan00.html
Establishing benchmarksEstablishing benchmarks: the 90: the 90thth percentile percentileSetting sights on Setting sights on MEDIOCRITYMEDIOCRITY
Transfusion Audit Results (2nd study) N = 233 Participants
0
20
40
60
80
100
10th 25th 50th 75th 90th
Percentile Ranking%
Co
mp
lian
ce
Patient ID
Vital Signs
Transfusion Audit Results (1st study) N = 519 Participants
0
20
40
60
80
100
10th 25th 50th 75th 90th
Percentile Ranking
% C
om
plia
nc
e
Patient ID
Vital Signs
RETROACTIVERETROACTIVE
Interventions Interventions triggered by poor triggered by poor performance and performance and errorserrors
IMPROVEMENT SLOW IMPROVEMENT SLOW LONG INTERVALSLONG INTERVALS ROTTEN ENVIRONMENTSROTTEN ENVIRONMENTS
IDIOSYNCHRATIC PRACTICESIDIOSYNCHRATIC PRACTICES
Completing all four patient ID proceduresCompleting all four patient ID proceduresPerforming required three VS proceduresPerforming required three VS procedures
Routine monitoring of transfusions Routine monitoring of transfusions Nursing/couriers receive transfusion/ID trainingNursing/couriers receive transfusion/ID training Transfusionists use checklists Transfusionists use checklists Two transfusionists read ID aloudTwo transfusionists read ID aloud Transporting blood directly to patient bedsidesTransporting blood directly to patient bedsides Having only one person handle blood units in routeHaving only one person handle blood units in route
Determining Best Determining Best PracticesPractices
Novis et al. Arch Pathol Lab Med 2003;127:541-548© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Other Models Other Models of Service Deliveryof Service Delivery
PerspectivePerspective
Does not imply that doctors are robots or patients are Does not imply that doctors are robots or patients are engine blocks….the difference between doctoring and engine blocks….the difference between doctoring and service deliveryservice delivery
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Business SystemsBusiness Systems Universal Ideals Universal Ideals
Low CostLow Cost
On On DemandDemand
SafeSafe
High High QualityQuality
Who Makes the Best Cars?Who Makes the Best Cars?
Consumer Reports, April 2008Consumer Reports, April 2008 Vehicle ProblemsVehicle Problems
Vehicle QualityVehicle Quality
A Business System to Achieve an A Business System to Achieve an Ideal: Ideal: SAFETYSAFETY
SPORTY CARS SPORTY CARS Audi A3Audi A3
LARGE SEDANSLARGE SEDANS TOYOTA AVALONTOYOTA AVALON
FAMILY SEDANS FAMILY SEDANS Honda AccordHonda Accord
SMALL CARS SMALL CARS TOYOTA TOYOTA COROLLACOROLLA
UPSCALE SEDANS UPSCALE SEDANS Acura TLAcura TL
LUXURY SEDANSLUXURY SEDANS Infiniti M35Infiniti M35
SMALL SUVs SMALL SUVs Subaru ForesterSubaru Forester
http://www.consumerreports.org/cro/cars/consumer-reports-cars-best-in-class-safety/index.htm. Accessed 12/2006.
Products on DemandProducts on DemandEFFICIENCYEFFICIENCY
How many hours does it take to How many hours does it take to assemble a vehicleassemble a vehicle? ?
ChryslerChrysler 3737
FordFord 35.935.9
ToyotaToyota 27.927.9
Industry Week, December 2006
ProfitabilityProfitability
www.zmetro.com/archives/cat_cars.php accessed January 29, 2005
Culture of continuousCulture of continuous improvementimprovement
PeoplePeople
Toyota Toyota ProductionProduction
SystemSystem
BusinessBusinessPhilosophyPhilosophy
Adapted from: Liker, JK. The Toyota Way. New York: McGraw Hill, 2004. Page 13.
Business Philosophy Business Philosophy
Sacrifice short-term profitability Sacrifice short-term profitability in order to achieve long-term goalsin order to achieve long-term goals
Hospital-Owned Hospital-Owned Medical PracticesMedical Practices
VS
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
What is Lean What is Lean Production?Production?
ELIMINATE WASTEELIMINATE WASTE BUILD QUALITY INTO THE PRODUCTBUILD QUALITY INTO THE PRODUCT
Taiichi OhnoTaiichi Ohno — — Father of the Father of the
Toyota Toyota Production Production
System LeanSystem Lean
Henry FordW. Edwards DemingW. Edwards Deming
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Lean ProductionLean ProductionWaste in the FactoryWaste in the Factory
1.1. OverproductionOverproduction
2.2. Excess inventoryExcess inventory
3.3. Unnecessary transportUnnecessary transport
4.4. Unnecessary movement Unnecessary movement
5.5. Waiting Waiting
6.6. Over processing and incorrect processingOver processing and incorrect processing
7.7. DefectsDefects
8.8. Unused employee creativityUnused employee creativity
Adapted from Liker, JK. The Toyota Way. New York: McGraw Hill, 2004. Pages 28-29.
OverproductionOverproduction
Slide DeliverySlide Delivery
Morning WorkloadMorning Workload
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Over ProcessingOver Processing
Admitting History and Admitting History and Physical NotePhysical Note
Surgical ReportsSurgical Reports
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Unnecessary MovementUnnecessary Movement
Unnecessary TransportUnnecessary Transport
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Point of CarePoint of Care
LaboratoryLaboratory
WaitingWaiting
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Excess InventoryExcess Inventory
DefectsDefectsOutpatient Order Accuracy: A CAP Q-Probes StudyOutpatient Order Accuracy: A CAP Q-Probes Study©© of of Requisition Order Entry Accuracy in 660 Institutions.Requisition Order Entry Accuracy in 660 Institutions.
Valenstein P, Meier F. Outpatient Order Accuracy. Arch Pathol Lab Med 1999;123:1145-1150.© 2007 David Novis, MD All rihts reserved. www.davidnovis.com
Unused Employee CreativityUnused Employee Creativity
““I don’t know I don’t know why we do it why we do it this way. It this way. It would be so would be so much simpler much simpler if….”if….”
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Common Reactions to WasteCommon Reactions to Waste
Workarounds and Workarounds and CamouflageCamouflage
Increase overheadIncrease overheadrather than concentrating on rather than concentrating on
eliminating wasteeliminating waste
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Common Reactions to Waste Common Reactions to Waste
Building and CapacityBuilding and Capacity
OvertimeOvertime
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
A Lean ApproachA Lean ApproachStep 1:Step 1: Remove the SilosRemove the Silos
PhlebotomyPhlebotomy
TransportTransport
ReceivingReceiving
AccessioningAccessioning
TransportTransport
WaitingWaitingProcessingProcessing
TranscribingTranscribing ReportingReporting
The Process: what provides The Process: what provides valuevalue to the patient to the patient??
SPECIMEN INSPECIMEN IN
REPORT OUTREPORT OUT
PhlebotomyPhlebotomy AccessioningAccessioning
ProcessingProcessing
ReportingReporting
The Process: what provides The Process: what provides valuevalue to the patient to the patient??
SPECIMEN INSPECIMEN IN
REPORT OUTREPORT OUT
Removing Steps Removes Removing Steps Removes Opportunity for ErrorOpportunity for Error
CAP QCAP Q-Probes-Probes™™ Transfusion Audit* Transfusion Audit*
Routine monitoring of transfusions Routine monitoring of transfusions
Nursing/couriers receive transfusion/ID training Nursing/couriers receive transfusion/ID training
Transfusionists use checklists Transfusionists use checklists
Two transfusionists read ID aloudTwo transfusionists read ID aloud
Transporting blood directly to patient bedsidesTransporting blood directly to patient bedsides
Having only one person handle blood units in routeHaving only one person handle blood units in route
*Novis et al. Arch Pathol Lab Med 2003;127:541-548.
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
PICC Line Project PICC Line Project Kim et al. (U Michigan). Kim et al. (U Michigan). Journal Hosp MedJournal Hosp Med 2006;1:191-199 2006;1:191-199
.
Reinforcing Continuous Reinforcing Continuous Improvement Improvement
PICC Line ProjectPICC Line Project
Kim et al. (U Michigan). Journal Hosp Med 2006;1:191-199.
MetricsMetrics Pre-LeanPre-Lean Post-LeanPost-Lean
Waiting TimeWaiting Time 1 ½ to 4 Days1 ½ to 4 Days 7-10 Hours7-10 Hours
Process TimeProcess Time(Value time)(Value time)
78 Minutes78 Minutes 81-86 Minutes81-86 Minutes
Errors and Errors and DefectsDefects
(First Time Quality)(First Time Quality)
34%34% 88%88%
Remove Opportunities for Error Remove Opportunities for Error ELIMINATE WASTE ELIMINATE WASTE
Remove SilosRemove Silos Examine the Process Examine the Process Remove Non-Value ComponentsRemove Non-Value Components Augment Value ComponentsAugment Value Components
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Build Quality Into ProductBuild Quality Into ProductMake Errors VisibleMake Errors Visible
Sakichi Sakichi ToyodaToyoda
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
STANDARDIZATIONSTANDARDIZATION
REDUNDANCYREDUNDANCY
Standardize Work in the FactoryStandardize Work in the Factory
Fit one way onlyFit one way only Color-codedColor-coded
Standard protocols
Monotonous configurationMonotonous configuration
PREVENT ERRORS FROM OCCURRING
Standardize Work in the LaboratoryStandardize Work in the Laboratory
PREVENT IDIOSYNCRACY AND IMPROVISATIONPREVENT IDIOSYNCRACY AND IMPROVISATION
REDUNDANCYREDUNDANCYREDUCE INTERVAL BETWEEN ERROR AND REDUCE INTERVAL BETWEEN ERROR AND
REPAIRREPAIR
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Where in the process do you discover Where in the process do you discover errors?errors?
Final inspectionFinal inspectionPatient
Department Department inspectioninspection
Next person Next person
in processin processOperator: during workOperator: during work
Source of processSource of process
REDUNDANCYREDUNDANCY Making Errors Visible Making Errors Visible
Judgment inspectionsJudgment inspections
Informative inspectionsInformative inspections
Source inspectionsSource inspections
[Shingo, Zero Quality Control: Source Inspection and the Poka-yoke System, Productivity Press, 1985.] © 2007 David Novis, MD All rights reserved. www.davidnovis.com
Judgment InspectionsJudgment InspectionsDISCOVER DEFECTS DISCOVER DEFECTS AFTERAFTER THEY OCCUR THEY OCCUR
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
JUDGEMENT INSPECTIONSJUDGEMENT INSPECTIONS
*Shingo, Zero Quality Control: Source Inspection and the Poka-yoke System, Productivity Press, 1985
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Too LateToo Late
——damage has occurreddamage has occurred
Long intervalsLong intervals
——rotten environments persistrotten environments persist
Protocol too focusedProtocol too focused
Least effective in Least effective in
reducing errorsreducing errors
Informative InspectionsInformative InspectionsCORRECT ERRORS BEFORE THEY BECOME DEFECTSCORRECT ERRORS BEFORE THEY BECOME DEFECTS
Statistical quality Statistical quality controlcontrol
Self checks
Successive checksSuccessive checks© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Successive ChecksSuccessive Checks
Reduce defects by (80-90%)*Reduce defects by (80-90%)*
Used infrequently in health careUsed infrequently in health care
*Shingo. Zero Quality Control: source Inspection and the Poka-yoke System. Productivity Press. New York 1985.
*Shingo, A Study of the Toyota Production System from an Industrial Engineering Viewpoint, Productivity Press, 1989.]
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Standardization and RedundancyStandardization and Redundancy(Successive Checks)(Successive Checks)
Transfusion Audit QTransfusion Audit Q-Probes-Probes™™ Study Study**
ASSOCIATED WITH FEWER ERRORS: ASSOCIATED WITH FEWER ERRORS: Routine monitoring of transfusions Routine monitoring of transfusions Nursing/couriers receive transfusion/ID trainingNursing/couriers receive transfusion/ID training
Transfusionists use checklists Transfusionists use checklists Two transfusionists read ID aloudTwo transfusionists read ID aloud Transporting blood directly to patient bedsidesTransporting blood directly to patient bedsides Having only one person handle blood units in routeHaving only one person handle blood units in route
*Novis, Miller, Howanitz, Renner, Walsh, Arch Pathol Lab Med 2003;127:541-548.© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Successive Checks Successive Checks Studies in Anatomic PathologyStudies in Anatomic Pathology
REDUCED ERRORS IN SURGICAL PATHOLOGYREDUCED ERRORS IN SURGICAL PATHOLOGY
ERROR RATESERROR RATES Safrin: (N=5,397) Safrin: (N=5,397) Am J Surg Pathol Am J Surg Pathol 1993;17:1190-1192.1993;17:1190-1192. Lind: (N=2,6945) Lind: (N=2,6945) Am J Clin Pathol Am J Clin Pathol 1995;104:560-566. 1995;104:560-566. Whitehead: (N=3000) Whitehead: (N=3000) Am J Clin Pathol Am J Clin Pathol 1984;81:487-491. 1984;81:487-491.
AMENDED REPORT RATESAMENDED REPORT RATES Nakleh: (N=1.6 million) Nakleh: (N=1.6 million) Arch Pathol Lab Med Arch Pathol Lab Med 1998;122:303-9. 1998;122:303-9. Novis DA: (N =16 378) Novis DA: (N =16 378) Pathol Case Rev. Pathol Case Rev. 2005; 10: 63-67. 2005; 10: 63-67.
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
SOURCE INSPECTIONSSOURCE INSPECTIONS ULTIMATE FORM OF STANDARDIZATIONULTIMATE FORM OF STANDARDIZATION
Error corrected—defect preventedError corrected—defect prevented
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Radiofrequency Device (RFD)Radiofrequency Device (RFD)
POC glucose analyzersPOC glucose analyzers
RFD’s in medical wrist bandsRFD’s in medical wrist bands
BUILDING IN QUALITYBUILDING IN QUALITYMake Errors VisibleMake Errors Visible
STANDARDIZATIONSTANDARDIZATION UNIFORMITY, CONSISTENCYUNIFORMITY, CONSISTENCY PREVENT ERRORS FROM OCCURRINGPREVENT ERRORS FROM OCCURRING
REDUNDANCYREDUNDANCY INSPECTION SAFETY NETINSPECTION SAFETY NET PREVENT ERRORS FROM BECOMING PREVENT ERRORS FROM BECOMING
DISASTERSDISASTERS
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
WHAT DOES ALL THIS WHAT DOES ALL THIS LOOK LIKE IN THE LOOK LIKE IN THE
FACTORYFACTORY?
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Traditional ProcessTraditional Process
PUSHPUSH
Finished Finished Products Products OutOut
PI
DEFECT BINDEFECT BIN
Batch and Batch and QueueQueue
C
SiloSiloSiloSilo
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
SuppliersSuppliers
WarehouseWarehouse
Quality?Quality?Low Cost ?Low Cost ?
Safety ?Safety ?On Demand?On Demand?
Lean Production SystemLean Production System
PROTOCOLSSTANDARDIZATIONREDUNDANCY
PROTOCOLSSTANDARDIZATIONREDUNDANCY
SuppliersSuppliers
PULLPULL
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Parkland Hospital Emergency RoomParkland Hospital Emergency Room
Dallas, TexasDallas, Texas Thursday Aug. 8, 2007Thursday Aug. 8, 2007
Lean Production SystemLean Production System
Level the loadLevel the load 11 Piece Flow Piece Flow
Continuous flowContinuous flow (No Silos)(No Silos)
PROTOCOLSSTANDARDIZATIONREDUNDANCY
PROTOCOLSSTANDARDIZATIONREDUNDANCY
HELP!
Suppliers
PULLPULL
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Andon BoardAndon Board
Maximizing Effort of the Your Maximizing Effort of the Your Most Important ResourceMost Important Resource
Get the right people on boardGet the right people on board Grow leaders from within Grow leaders from within Job securityJob security Technology to support not replace peopleTechnology to support not replace people
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Culture of Continuous ImprovementCulture of Continuous Improvement Developing Trust* Developing Trust*
General General Enlisted MenEnlisted MenBefore Before the battlethe battle
After the After the shooting shooting startsstarts
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
*2006 G. Konstantakos, personal communication
General General Enlisted MenEnlisted Men
Continuous ImprovementContinuous ImprovementExample: Hypertherm, Inc., Example: Hypertherm, Inc.,
Hanover, NHHanover, NH
700 employees 700 employees Paid to brainstormPaid to brainstorm Conduct scientific experimentsConduct scientific experiments Proactive, blameless, perpetualProactive, blameless, perpetual 2,500 suggestions/1,800 incorporated2,500 suggestions/1,800 incorporated
““the only people team members need to convince are fellow team the only people team members need to convince are fellow team members.”members.” Hypertherm manufacturing engineer George Konstantakos Hypertherm manufacturing engineer George Konstantakos
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
How to Do It*How to Do It*1. Secure commitment from the top 1. Secure commitment from the top
2. Educate and communicate 2. Educate and communicate
3. Select a target area in the laboratory 3. Select a target area in the laboratory
4. Select and train team (“change agents”)4. Select and train team (“change agents”)
5. Team selects “1st areas” for improvement5. Team selects “1st areas” for improvement• Diagram Value Flow: Current StateDiagram Value Flow: Current State• Calculate Outcome MetricsCalculate Outcome Metrics• Identify WasteIdentify Waste• Set Goals: Future State Set Goals: Future State • Develop Plans Develop Plans
6. Implement and measure6. Implement and measure
*2006 Adapted from G. Konstantakos Consultant (personal communication).© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Why Are We Doing This?Why Are We Doing This?
FinancialFinancialErrorsErrorsCosts Costs CapacityCapacity
Secure Commitment from the TopSecure Commitment from the TopSacrifice short term profitability for long term Sacrifice short term profitability for long term
growthgrowth
How to Do ItHow to Do It
Educate and CommunicateEducate and Communicate
Select and Train Team Select and Train Team (“change agents”)(“change agents”)
Change Team Selects a Project Change Team Selects a Project by Criteriaby Criteria
Advance hospital mission Advance hospital mission and strategic planand strategic plan
Significant financial impact Significant financial impact
Doable in reasonable Doable in reasonable
time periodtime period
Governed by Outcome metricsGoverned by Outcome metricsLaboratory Testing Errors/Million Opportunities
0
20
40
60
80
100
120
140
160
180
200
Jul
y 20
05
Aug
ust 2
005
Sep
t. 20
05
Oct
. 200
5
Nov
. 200
5
Dec
. 200
5
Jan.
200
6
Feb
. 200
6
Mar
. 200
6
Apr
-200
6
May
-200
6
Jun-
2006
Jul.
2006
Aug
-200
6
Sep
-200
6
Oct
-200
6
Nov
. 200
6
Dec
. 200
6
Jan.
200
7
Feb
. 200
7
Mar
. 200
7
Apr
. 200
7
May
-200
7
Jun-
2007
testing errors/millionopportunitiesLinear (testing errors/millionopportunities)
Select a Target Area in the Select a Target Area in the LaboratoryLaboratory
OutcomesOutcomes• ErrorsErrors• EfficiencyEfficiency• FinancialsFinancials
Current State Value Stream Current State Value Stream MapMap
Triage
T
Batch Size: 1
U/T: 100%
240 (4 min)C/T:
Rate:
Rework:
Shif ts/Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
Total Lead Time
Process Time240 sec.
.15 min. 10 min. 4 min.
600 sec. 300 sec
ED Patient
Customer
Hospital Suburban home
Admissions ED Documentation
LAB
RAD
DEPT
Patient
Paper Record
Verbal Communication
Triage Nurse Registration Patient Nurse MD Unit SecretaryPatient Care
Tech
Face SheetPhysician Orders
Consent FormHIPPA
Patient Labels
“NURSE TO SEE” SLOT “MD TO SEE” SLOT PATIENT CHART IN “ROOM SLOT”
3:45 pm – 12:15 amDouble Shift
0
100 sec.
7 min.
380 sec. 240 sec.
20 min.
Physician Orders
Lab Labels Lab Results
Radiology Slot
CAT Slot
Patient Record PrintedDischarge
Instructions
Exit Writer
Copy to Patient
88 Patients / Day
85% discharged13% Admitted2% Transfered
84% walk in 16% arrive by ambulance
Medical Records
MEDITECH
Tuality HealthcareEmergency DepartmentCurrent State July 2006
Legend of INFORMATION FLOW Electronic Communication
Written/Paper Communication
Verbal Communication
Phone Call
Blood Specimen Storage
I I I I I I II I
I
I I I
Decrease Lead Time and
increase thru-put
Standardize Rooms /Supplies
Increase flexibility of rooms by creating
specialty carts
T
Batch Size: 1
U/ T: 100%
240 (4 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 2S / 7DAvailable: 16 hrs.
C/O: 0
Short Registration
Admit Physician
T
Batch Size:
U/T:
C/T:
Rate:
Rework:
Shif ts/Days: Available:
C/O:
Report to Admission Unit
T
Batch Size:
U/ T:
C/ T:
Rate:
Rework:
Shif ts/ Days: Available:
C/O:
I npatient Registration
T
Batch Size:
U/T:
C/T:
Rate:
Rework:
Shif ts/Days: Available:
C/O:
Transport to Unit
T
Batch Size:
U/ T:
C/ T:
Rate:
Rework:
Shif ts/ Days: Available:
C/O:
Registration /Assemble Chart
T
Batch Size: 1
U/ T: 100%
600 (10 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 3-4 min
Communication Rm.
T
Batch Size: 1
U/ T: 100%
10-15 minC/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
Establish Continuous Flow Patient
Care
Create Standard
Work / and Order
Protocols
Bedside Registration
Demand - > 31,989 / year88 / Day
Takt Time Based on X BedsPeak Demand Day TT =Peak Demand Hours 3p - 11p
Category Percent ADDDirect Admit = Admit = Procedures+Transfer to Alt= Transfer Outs =Nursing Home = True D/C Home =24 hr Returns =
Available: 24 hrs. Available: 24 hrs. Available: 24 hrs. Available: 24 hrs.
240 sec.
T
Blood Draw
T
Batch Size: 1
U/ T: 100%
300 (5 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 3-4 min
MD Assessment
Batch Size: 1
U/T: 100%
380 (6 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 0T
RNAssessment
Batch Size: 1
U/ T: 100%
100 (1.5 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
T
Transcribe Orders
Batch Size: 1
U/T: 100%
240 (4 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 3-4 min
Lab
T
Batch Size: 1
U/ T: 100%
Range?C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
0
120 sec.
Disposition Plan
T
Batch Size: 1
U/T: 100%
120 (2min.)C/T:
Rate:
Rework:
Shif ts/Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
Establish Nursing Floor Pull System /
Census Management
Plan
71 min.
1630 sec (27 min.)
Establish equipment home
address locations / check-out
system
Admission Bed
T
Batch Size: 1
U/T: 100%
120 (2min.)C/T:
Rate:
Rework:
Shif ts/Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
Report to Primary Physician
T
Batch Size: 1
U/ T: 100%
120 (2min.)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
D/ C I nstructions
T
Batch Size: 1
U/T: 100%
120 (2min.)C/T:
Rate:
Rework:
Shif ts/Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
I V Start
T
Batch Size: 1
U/ T: 100%
300 (5 min)C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 3-4 min
MedAdministration
T
Batch Size: 1
U/ T: 100%
Range?C/ T:
Rate:
Rework:
Shif ts/ Days: 3S / 7DAvailable: 24 hrs.
C/O: 0
98 min
27 min
Identify WasteIdentify WasteSet GoalsSet Goals
Develop a PlanDevelop a Plan
Implement: Staff Takes ChargeImplement: Staff Takes ChargeMaximize the effort of your greatest assetMaximize the effort of your greatest asset
Management provides support onlyManagement provides support only
Management provides supportManagement provides support
© 2007 David Novis, MD and Chi Solutions Inc, All rights reserved. www.davidnovis.com
Reinforcing Continuous ImprovementReinforcing Continuous ImprovementEvaluate Gains Evaluate Gains
476%476%
99%99%
78%78%
83%83%
93%93%
35%35%
50%50%
Reagent Reagent FormulationFormulation
220%220%
63%63%
77%77%
84%84%
75%75%
30%30%
45%45%
Surgical Surgical SupplySupply
170%170%
63%63%
73%73%
30%30%
73%73%
31%31%
10%10%
EDED
112%112%
92%92%
92%92%
73%73%
90%90%
35%35%
35%35%
Clinical Clinical LabLab
Labor Value AddedLabor Value Added
Labor TravelLabor Travel
Patient/Prod TravelPatient/Prod Travel
Lead Time Lead Time
WIPWIP
Floor SpaceFloor Space
ProductivityProductivity
MetricMetric
Improvement Improvement %%
How to Undermine Your SuccessHow to Undermine Your Success
Fail to gain support from top Fail to gain support from top managementmanagement
Fail to build an infrastructureFail to build an infrastructure Assume improvements are one time Assume improvements are one time
eventsevents Substitute technical silver bullets for Substitute technical silver bullets for
system improvementssystem improvements Be complacentBe complacent
Show Me The DataShow Me The DataNot So EasyNot So Easy
Double Blind Controlled vs Double Blind Controlled vs Before/After Before/After
Procedures customizedProcedures customizedNon standardizationNon standardizationProprietaryProprietary
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Henry Ford HospitalHenry Ford Hospital
Zarbo, D’Angelo The Henry Ford Production System Effective Reduction of Process Defects and Waste in Surgical PathologySystem Am J Clin Pathol 2007;128:1015-1022
Baseline in-process defect rate:Baseline in-process defect rate:
1 in 3 cases (27.9%)
Post improvement in-process defect rate: Post improvement in-process defect rate:
1 in 8 cases (12.5%)
LEAN IMPLEMENTATIONLEAN IMPLEMENTATION
Time: One YearTime: One Year
Workers: 77 workersWorkers: 77 workers
Process Improvements: 100Process Improvements: 100
University of PittsburghUniversity of PittsburghCytopatholgyCytopatholgy
Pap smearsPap smears11 ↓↓ Unsatisfactory* (Unsatisfactory* (Lacking transition zone)Lacking transition zone) ↓↓ ASCUS Rate ASCUS Rate ↓↓ Diagnostic ErrorsDiagnostic Errors ((↑Pap/Bx Concordance)↑Pap/Bx Concordance)
ThyroidThyroid22
↓↓ False-negative rateFalse-negative rate ↑ ↑ SensitivitySensitivity
1. Raab. 1. Raab. Arch Pathol Lab MedArch Pathol Lab Med 2006;130:633-7. 2006;130:633-7. 2. Raab et. al. Am J Clin Pathol. 2006 Oct;126(4):585-922. Raab et. al. Am J Clin Pathol. 2006 Oct;126(4):585-92
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Testing ErrorsTesting Errors
Laboratory Testing Errors/Million Opportunities
0
20
40
60
80
100
120
140
160
180
200
Jul
y 20
05
Aug
ust 2
005
Sep
t. 20
05
Oct
. 200
5
Nov
. 200
5
Dec
. 200
5
Jan.
200
6
Feb
. 200
6
Mar
. 200
6
Apr
-200
6
May
-200
6
Jun-
2006
Jul.
2006
Aug
-200
6
Sep
-200
6
Oct
-200
6
Nov
. 200
6
Dec
. 200
6
Jan.
200
7
Feb
. 200
7
Mar
. 200
7
Apr
. 200
7
May
-200
7
Jun-
2007
testing errors/millionopportunitiesLinear (testing errors/millionopportunities)
Definition: Verified result is edited/changed
117 DPMO
79 DMPO
Henry Ford HospitalHenry Ford Hospital
Zarbo, D’Angelo, Transforming to a Quality Culture The Henry Ford Production System Am J Clin Pathol 2006;126(Suppl 1):S21-S29
Pre Lean: Pre Lean: 81%81%
Post Lean: Post Lean: 93%93%
Biopsy Turnaround Time: Biopsy Turnaround Time: 9 hours9 hours
University of IowaUniversity of Iowa
↓↓Pre-analytic chemistry prep timePre-analytic chemistry prep time ↓↓Chemistry test turnaround time Chemistry test turnaround time
Persoon. Persoon. Am J Clin PatholAm J Clin Pathol 2006;125:16-25. 2006;125:16-25.
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
DSI Labs, FloridaDSI Labs, Florida
Streamlined phlebotomy serviceStreamlined phlebotomy service
Saved $400K in 1Saved $400K in 1stst year year
↓↓Overtime by 60%Overtime by 60%
Sunyog. Manag Rev 2004;18:255-8.
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Future DirectionFuture Direction
MedicareMedicare Says It Won’t Cover Hospital Says It Won’t Cover Hospital
ErrorsErrors ROBERT PEAR 08/19/07
Health Plans Say New RulesImprove Safety and Cut Costs;Hospitals Can’t Dun Patients
VANESSA FUHRMANS 1/18/08 http://online.wsj.com/
MedicareMedicare
Won't Pay Hospitals for Won't Pay Hospitals for Errors Errors
02/18/0802/18/08
VT hospitals will stop billing for "never
events”101/08/08
WA hospitals won't charge for
'never events‘01/31/08
SummarySummaryFixing Systems ProactivelyFixing Systems Proactively
© 2007 David Novis, MD All rights reserved. www.davidnovis.com
Reduce Opportunities for ErrorsReduce Opportunities for Errors
Commitment to Commitment to philosophy of businessphilosophy of business
Catch defects Catch defects before before releaserelease
Vest people closest to Vest people closest to productionproduction
Build safety culture into job Build safety culture into job descriptiondescription
Reduce WasteReduce Waste
StandardizationStandardization
Safety NetSafety Net
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