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I Believe in Zero Preventable Deaths

1/20/2017

 
Today I want to talk about why I’m passionate about this work. I want to talk about preventable deaths due to hospital errors. I want to talk about transforming healthcare so we can get to a mindset where, instead of feeling as though mistakes are “only human” and perfection is out of reach, ZERO preventable deaths are acceptable. We have a roadmap for this goal: Shingo’s Zero Quality Control.
Why is it when deaths happen one at time, there is less attention than when deaths happen in groups of 5 or 10, even if they add up the same? Fact: hospital mistakes kill enough people every day to fill two 747 planes. That’s as if we allowed two full 747s to crash, EVERY DAY, and did nothing! Every two months, it’s like 9/11 is occurring again. In anything else, we would not tolerate that degree of preventable harm. But in healthcare, we do!
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Unfortunately, statistics only say so much. Here are the real faces of a few medical errors in Canada, where JBA worked on the Saskatchewan Province hospital system.
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A 45 year-old Manitoba man died of a bladder infection in 2008 while in his wheelchair in a waiting room for 34 hours. No one even offered to help him when he asked or started vomiting. In 2013, a woman in Nova Scotia had a breast removed after a lab error mixed up her biopsy results with another patient’s. And this woman in Saskatchewan – after almost four years of agony and complications – insisted on diagnostic tests that revealed a piece of surgical mesh puncturing her bladder.
 
Examples are everywhere in the world. People being hurt or killed because of preventable mistakes. In one case a monitor was left on a boy’s finger during an MRI. Burned his finger to the bone. Another example: During routine surgery the doctor didn’t follow standard protocols. The patient bled to death – bled to death— during a routine procedure.
 
The World Health Organization shows that 1/3 to 1/2 of these medical defects can be prevented. Well, how? Through a systematic approach to patient safety that focuses not on people (who indeed may make misatkes), but on processes, which can be made mistake-free. Applying Shingo’s Zero Quality Control method of Poka-Yoke CAN deliver safer, higher-quality care. That’s how!
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​This is a famous Shingo quote. In particular the last sentence: “In contrast, a zero QC system pursues the active objective of eliminating defects.” Not just “reducing mistakes,” which implies that some (lower) level of mistakes would be acceptable. No, you MUST believe in and pursue the objective of zero defects.
 
When JBA got to Saskatchewan, we applied Shingo’s method to one of the most broken systems: surgery wait times. Waiting for necessary surgeries hurts patients’ health outcomes. At the time, the average wait for non-emergency inpatient surgery was 294 days, and 291 days for outpatient surgery. That’s almost 10 months. 4,000 people waited more than a year! This was not acceptable.
 
We achieved results by changing a culture that believed that waiting and mistakes were unavoidable. Our mistake-proofing training began by forming teams and selecting projects where direct harm had been caused to patients. Teams selected defects ranging from timely triaging of hospital emergency department patients to incorrect or insufficient cleaning of hemodialysis machines. Standard requirements included value stream maps and thorough patient/procedure quantity analysis. Each team then went on our week-long North American Tour. They studied and learned concepts at manufacturing and healthcare companies, all reiterating that zero defects WAS POSSIBLE. When they got home, the teams implemented corrective action plans. They collected defect data in 30-, 60-, and 90-day follow-ups, and utilized PDCAs and A3 thinking. Projects were not considered complete until they could report out a defect rate of less than a 1%, with 76% of projects reaching completion.
 
Achieving zero preventable deaths and preventable harm is possible. It is the moral obligation of all healthcare leaders from the top down in all of our major healthcare organizations and systems in America to lead this effort.  I believe that our frontline caregivers are doing what they can within the system they have to protect patients but the current system isn’t working.
 
There are two leaders that have said it best, Atul Gawande and Donald Berwick, both MDs. In a quote from Gawande’s book “Checklist Manifesto” page 184:
"One essential characteristic of modern life is that we all depend on systems--on assemblages of people or technologies or both—and among them our most profound difficulties is making them work. In medicine, for instance, if I want my patients to receive the best care possible, not only must I do a good job but a whole collection of diverse components have to somehow mesh together effectively. Healthcare is like a car that way. In both cases having great components is not enough.
 
"Were obsessed in medicine with having great components—our best drugs, the best devices, the best specialists—but pay little attention to how to make them fit together well. This approach is wrong-headed. Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence. We give the example of a famous thought experiment of trying to build the world's greatest car by assembling the world's greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo. What we get of course is nothing close to a great car; we get a pile of expensive junk.
 
"We have a thirty-billion-dollar-a-year National Institutes of Health, which has been a remarkable powerhouse of medical discoveries. But we have no National Institute of Health Systems Innovation alongside it studying how best to incorporate these discoveries into daily practice--no NTSB equivalent swooping in to study failures the way crash investigators do, no Boeing mapping out the checklists, no agency tracking the month-to-month results."
I am passionate about this work because I know we can do better. I know we use the Toyota Production System to save lives.

For more on how to achieve zero defects, check out my webinar here.

A look back at a talented team

1/9/2017

 
​On the blog today, I want to mention the recent announcement of Susie Creger’s retirement from Rona Consulting. I echo all the complimentary words written by Rona about Susie. Susie’s outstanding service to healthcare improvement will not be forgotten.
 
I’d like to give you the background story to the series of remarkable events that led to Creger’s role in Lean transformation. 
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Creger and King with me in Japan 2002 attending the first of many Virginia Mason 14 day Japan Gemba Kaizen Study Missions. Kaplan continues to lead these important missions to Japan, maintaining the rigor needed to craft meaningful study missions.


​1: A chance meeting

Let’s go back 15 years. When I met with Mike Rona, president of Virginia Mason Medical Center and his boss Dr. Gary Kaplan in early January 2001, I realized the depth of their interest and their willingness to take a tough approach to changing the way VMMC did business. 
 
The date was October 17, 2000. I was on my way from Seattle, Washington, to Madrid, Spain, to meet with the minister of health to discuss how Spain could improve its healthcare system through the application of Lean. My presentation to him was on my laptop computer.
 
As I settled into my seat, the businessman beside me introduced himself as Mike Rona, president of Virginia Mason Medical Center.
 
What an opportunity! Someone intimate with the healthcare field was right next to me—someone on whom I could try out my presentation. As we leveled out at 37,000 feet, I pulled out my laptop and said, “You really need to see this.”
 
When we headed for different connecting flights in Atlanta, I gave Rona a copy of my first Lean book A World Class Production System which the Boeing Company had sponsored. I figured I’d probably never hear from him again.
 
To my surprise, while still in Spain, I received an e-mail from Rona with more questions about Lean. Then I received a phone call asking me to meet with Rona and his boss, Dr. Gary Kaplan, Virginia Mason’s CEO. 

2: A culture open to change

​Lean leaders must be open to change to achieve success. My chance meeting only set transformation in motion because of Rona and Kaplan’s willingness to change. When I met with Rona and Kaplan in early January 2001, Rona and Kaplan were all ears, enthusiastic about Lean and obviously committed to changing how Virginia Mason operated. At that time, they were under pressure from the surgeons to build eight more operating rooms (ORs) at a cost of millions. One of their challenges was to increase OR capacity, but they didn’t have the money to fund what was thought to be needed.
 
They kept asking me, “How can we do it?” I told them capacity could be increased without a big expenditure, but only if they agreed to my plan.
 
The plan I had in mind for Virginia Mason was similar to the one we’d applied at Boeing. First, start by focusing at the point most vital to serving the patient. In the case of VMMC, that meant the OR. Second, define the value stream, and designate a portion of that value stream as a model line—that is, an area of surgery where you could drill down a mile deep and an inch wide. Third, create a Kaizen Promotion Office (KPO) and establish the infrastructure to support kaizen.
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Creger and King (Nurse Kaizen Leaders whose OR expertise and nursing skills helped shape the first KPO), receiving their certification with Smith and Miller.


3: A fight for great talent

​In order to execute the plan, we needed to build a solid team. That’s when I told both Rona and Kaplan and Ruth Anderson, Administrative VP that we needed to populate the Kaizen Promotion Office (KPO) with two nurses from OR operations. I asked who their best and brightest nurses were and was told about Susie Creger and Rosemary King who worked in the OR as special OR supply leads. Then I was told they were too valuable to take out of those positons I scheduled a time to meet with them, but let the issue rest for the moment.
​The first thing I did was to walk the route patients took from where they parked their car to where they entered the flow of perioperative services, gastroenterology and the ED and then were discharged. I walked with Dr. Steve Rupp, the Chief of Perioperative Services at my side as we created the first value stream map at Virginia Mason. Obviously we ended up value streaming the OR and the turf of Creger and King. I interviewed them on the spot. I then told Anderson and Rona they had to be reassigned immediately as we needed them in the first group to start certification. A good consultant identifies the expertise needed to achieve success, and then fights to bring that talent together.
Identifying talent: what made Creger and King so special?

The pair:
1. Were highly competent in their field
2. Were respected by surgeons and their peers
3. Had a strong work ethic
4. Always put the patient first
5. Never said "I can't," "We don't have time," or "That won't work." They were willing to innovate.
​
Only later did I find out that Creger and King were pulling double duty, going through certification and still working in the OR, a testament to their commitment to improvement. I got them changed to full time KPO leaders, a team which then included Virginia Mason’s Diane Miller and Danielle Smith. Miller is now the VP of the Virginia Mason Institute.  ​

4: Results

The first year is always difficult, and the experience at VMMC would be no exception. The first Rapid Process Improvement Workshop, held the week of April 23 to 27, 2001, involved four teams with aggressive targets, all achieved. The results were excellent for the kickoff effort, but the real learning of the week, as reported by VMMC, was “that teams of process-knowledgeable people could make a major change in a one-week period.”
 
Creger and King were absolutely integral to the improvement effort. Their willingness to work double-time, their agility in switching on to the KPO team, and their invaluable years of experience as OR nurses helped catapult VMMC to successful implementation. I wish Creger the best in her retirement, and will always remember the combination of circumstance and determined commitment to change that brought together such a dynamic team at Virginia Mason.
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On the far left are Rona, Creger and King posing with first group of VM Kaizen Fellows attending 14 day Japan Kaizen Fellows Training in 2005. Rona and Kaplan and VM’s leadership immediately embraced the Kaizen Fellows program and Rona led many of the Kaizen Fellows trips. I required this first group of Kaizen Fellows to prior to the trip to review each value stream map for every sentinel event over the last 5 years, noting changes that had been made, possible changes they would pursue upon their return, and areas for which they were seeking insight as they went though our 12 days together. Others presented major inpatient and outpatient value streams as well as plant layout opportunities. Each Kaizen Fellows trip included not only rigor but rigorous documentation with a continuous feedback loop during the trip back to VM leaders and then a final report presentation when the team returned home. Those initial Kaizen Fellows trips produced significant turns of the PDCA wheel.

World Class Team Structures

1/6/2017

 
​World-class healthcare organizations are structured differently from the rest.  They have a "high performance organizational design." 
 
Traditional organizational designs don't allow employees to make nimble changes to the process of care delivery.  Traditional designs don't allow staff to be as patient-focused as they need to be. And traditional designs don't permit the kind of rapid, successful deployment of excellent patient care that typifies world-class organizations.
         
A "high performance organizational design" is different from traditional hierarchical structures.
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This chart illustrates how traditional organizational designs change to become high performance.  The traditional structure in Stage 1 is a hierarchy.  Obviously, top executives are at the top, workers at the bottom. A pyramid structure.  Not much direct communication.  Not much teamwork. Not much responsiveness to problems. Not much flexibility. Lots of rigid, formal structure. Plenty of work for producers of organization charts.
 
Stage 2 on the chart shows how the pyramid begins to flatten out on the top.  Less distance between top management and the workers, fewer layers of management, more teamwork.  Companies that aspire to become World-class are often in this phase. 
 
Stage 3 illustrates a World-class structure. A team structure. There is no long chain of command.  There are minimal layers of management. There are fewer structural barriers to communication. 
 
The advantages of team-centered organizational designs are many.  Communication is incredibly direct.  All functions needed for a project are present on the team.  New knowledge is created and integrated at a level far beyond what a traditional structure can achieve.
 
People and processes can be shifted to meet new innovations in patient care, and new requests from patients.  There is much more flexibility and responsiveness.  Responses are more focused and efficient.
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​Perhaps the most dramatic advantage is that frontline staff are empowered and rewarded.  They are no longer at the bottom of the pyramid following instructions. Processes established by managers are no longer far removed from the hospital floor and the patient.  Processes get improved by the ones who know best how to make them better—the doctors, the front desk, the nurses, everyone who makes the hospital hum.
 
World-class Lean leaders know how to step back and restructure to capitalize on their human potential. Most importantly, world-class organizations aren’t afraid to re-organize until they get it right.
 
Be sure to check out my other posts on world-class organizations. And as always, feel free to reach out to me for more ideas about how to make the transformations in quality patient care that will set your organization apart.
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    About the author
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    John Black, President and CEO of JBA, has implemented Lean improvements for four decades, first with the Boeing Company and later as a leading consultant in the healthcare industry.


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