Seeking Zero Defects: Applying the Toyota Production System to Health Care

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Seeking Zero Defects Applying the Toyota
Production System to Health Care

• Implementation of a Patient Safety Alert System
• Cathie Furman RN MHA
• Vice President, Quality and Compliance
• Virginia Mason Medical Center - Seattle, WA

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A Lecture Itinerary

• Toyota Production System
• Why Zero Defects?
• The Patient Safety Alert System
• Results
• Reflections

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First, Some BackgroundVirginia Mason Medical
Center

• An integrated healthcare system
• 501(c)3 Not for Profit
• 336 bed hospital
• 9 locations (main campus and regional centers)
• 400 physicians
• 5000 employees
• Graduate Medical Education Program
• Research center
• Foundation

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Virginia Mason Medical Center Strategic Plan
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A Defective ProductHospital Complications Exceed
9 Billion(Study based on data from 994
hospitals in 2000.)
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An Unaffordable Product
Source Mercer National Survey of
Employer-Sponsored Health Plans 2004
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A Lecture Itinerary

• Toyota Production System
• Why Zero Defects?
• The Patient Safety Alert System
• Results
• Reflections

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When We Looked at the Auto Industry
Total labor cost per vehicle
(In the U.S.)
6,052
Japanese transplants
8,655
Big three
Source USA Today, 8/6/2003
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We Saw Higher Quality Safety
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Seeing with our EyesJapan 2002
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What We Learned

• Air conditioners, cars, looms, airplanes and
  forklifts...
• What do any of these products have to do with
  health care? 
• Health care, too, is full of production processes
• Japanese products, like our services, involve the
  concepts of quality, safety, customer
  satisfaction, staff satisfaction and cost
  effectiveness
• The completion of a product involves thousands of
  processesmany of them very complex
• Many products, if they fail, can cause fatality
• They are in many ways, just like us

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VMPS Tools in Action

• Value Stream Development
• RPIW (Rapid Process Improvement Workshop)
• 5-S (Sort, simplify, standardize, sweep,
  self-discipline)
• 3-P (Production Preparation Process)
• Everyday Lean Idea System
• Patient Safety Alert System

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Taiichi Ohnos Seven Wastes
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A Lecture Itinerary

• Toyota Production System
• Why Zero Defects?
• The Patient Safety Alert System
• Results
• Reflections

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So What is Zero Defects ?

• Pursuing what the customer really wants
• Distinguishing mistakes from defects
• Eliminating defects with source inspection
  Check each product (one-by-one) Check at the
  source Stop and fix at the source

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Why Zero Defects is the Only Acceptable Standard

• At 99.9 quality levels, here is what happens
• 22,000 checks are deducted from the wrong bank
  accounts every day
• 2,000 unsafe airplane landings are made every day
• 2 major airplane accidents per week
• 500 incorrect surgeries are completed every week
• 2,000,000 loss IRS documents per year
• 10,000 medication errors per year at VMH

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A Lecture Itinerary

• Toyota Production System
• Why Zero Defects?
• The Patient Safety Alert System
• Results
• Reflections

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Stopping the Line
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• Virginia Masons Patient
• Safety Alert System?

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The Basic Strategy forStopping the Line

• Inspect, stop, and fix at the source
• Every employee is an inspector
• Every employee can stop the line
• When you cant fix on-the-spot STOP

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Patient Safety AlertProcess Overview

• Report if likely to cause harm
• 24/7 hotline, procedure, and staffing
• Drop and run commitment (code)
• Evaluate and fix immediately
• Or stop the process find root causerestart when
  fixed (lt29 days)

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Accountability is on the Shop Floor
Department Chief and the Vice President are

• First to know
• Make primary decision on go or no go
• Provide primary direction for remedy
• Make decision to restart a process

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Promoting a Culture of Safety

• Promote reporting of mistakes
• Increase interactions with staff about safety
• Enhance skill sets in communication of
  unanticipated outcomes
• Train and support workforce in their role
• Closed loop communication

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A Lecture Itinerary

• Toyota Production System
• Why Zero Defects?
• The Patient Safety Alert System
• Results
• Reflections

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Cumulative Declared PSAs
Number
Cumulative Orange and Red PSAs as of 2005
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Distribution of Declared PSAs
Professional Conduct
Facilities Equipment
Diagnosis Treatment
Systems
Medication Errors
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Who Reports PSAs?

• Managers 20
• Physicians 8
• Nurses 44
• Pharmacists 5
• Support personnel 23
• Patients/families (yr) 0.003

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Days to Completion of PSA
Number
2002
2003
2004
2005
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AHRQ Patient Safety Culture Survey Virginia
Mason Medical Center - 2006 Results
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A Lecture Itinerary

• Toyota Production System
• Why Zero Defects?
• The Patient Safety Alert System
• Results
• Reflections

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Virginia Mason Medical Center November 23,
2004 Investigators Medical mistake kills
Everett woman
Hospital error caused death
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Ensure the Safety of our Patients Eliminate
Avoidable Death and Injury

• 1. Zero avoidable Deaths (Broadened in
  2006)
• Zero failures to follow specified critical safety
  policies
• Patient ID Procedural Pause Solutions/Medication
  Identification
• MD Response to Calls Patient Summary List
• Critical Results Reporting (added in 2006)
• Clinical Hand-Off Communications (added in 2006)
• 3. 100 performance with Clinical Care
  bundles
• Acute Myocardial Infarction (heart attack) AMI
  Congestive Heart Failure CHF Stroke (added in
  2006) Central Line Placement CL Ventilator
  Associated Pneumonia VAP Surgical Site
  Infection Prevention SSI
• 4. Zero Adverse Drug Events
• Medication Reconciliation

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Case Study Unlabeled Medication Cups
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Case Unlabeled Medication

• 69 y.o. female
• R aneurysm coiling in Radiology
• Vascular access through femoral arteries
• Procedure seemed uneventful
• Transferred to Recovery Room
• R leg weakness and sensory loss in 1 hour

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Case Unlabeled Medication

• Evaluation by Radiologist
• No stroke
• No hematoma
• Diffuse evolving compartment syndrome why?
• Technician contacted and queried 3 unlabeled
  solutions on procedure table saline, contrast
  dye, chlorhexidine
• Radiologist called PSA

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Case Unlabeled Medication

• Day 1
• Error no labels, chlorhexidine injection
• Family and primary physician notified
• VP of Radiology directs investigation
• Staff and process taken off-line
• Aggressive patient care

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Case Unlabeled MedicationEvent timeline

• Day 2 No liquid prep on procedure tables
• Day 5 Standard process for med labeling
• Day 6 E-mail message to all employees
• Day 12 New kits labels distinct cups
• Day 15 Mandatory in-service for all managers
• Day 18 Death of patient
• Day 19 Public announcements begin

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Case Unlabeled Medication

• Key findings
• Unlabeled medication cups
• Change in procedure sequence
• Change to a colorless prep
• Prep-stick available but not chosen
• Other staff had noted and wondered
• Same event 2 years earlier innearby hospital
  not reported