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Patient Voices Prevent Tragedy

4/14/2017

 
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Last time on the blog, I talked about culture change. Culture change takes bold leadership—leaders who solve problems by putting quality first. Easy to say and not always easy to do.
 
Sometimes those leaders are patients and patients’ family members. When patients are bold enough to speak out, hospital caregivers better listen. Why? Because including patient voices can prevent future tragedy. I like this definition for tragedy from Merriam-Webster: “a very bad event that causes great sadness and often results in someone’s death.”

Watch this video of a young mother's experience of tragedy:

​Here’s how this mother’s story ended: An air ambulance was finally arranged for the baby. The mother had been trying to get her baby help for more than a week. She was frantic – her new baby died seven minutes after the helicopter landed.
 
The reason this mother could be as positive as she seemed in the video was that time had passed. When I spoke with her she wanted to tell her story, she asked that she be videotaped. She’d been invited to participate in a Lean 3P Clinic design event JBA conducted in Saskatchewan. Even though her concerns were discounted in more than two dozen interactions with the healthcare system, she was enthusiastic about trying to make sure such tragedies don’t happen again. She showed tremendous courage, and decided to become part of the solution for others.
 
Don’t misunderstand me, I’m not calling out Saskatchewan, there are many wonderful positive stories in that great Province. What about Seattle you might ask? Here in Seattle we saw another tragic example of a patient’s voice being silenced. Talia Goldenberg went in for elective surgery to fuse her neck, due to a rare joint-tissue disorder. After the surgery, her father, an MD, could tell something was seriously wrong with his daughter’s airway. Nurses moved her to the ICU. But then, in a critical mistake, the surgeon who performed the surgery ignored the father’s pleas and removed Talia from the ICU. Later, Talia suffocated to death in front of her father. If the surgeon had listened to Talia’s father instead of his ego, Talia would have survived. Tragedy.
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Left to right: Me, patient advocate Heather Thiessen, and JBA consultant Tina Hallberg.
​At JBA, we make patients part of the transformation process. Here’s Heather Thiessen’s experience collaborating with hospital staff:
“I was part of a design group for the adult ED. It was my second Lean event and so exciting. In my many years as a patient, I had never been asked what I think. But who better to help when making changes? We see waste and safety issues daily, but who do you tell? More often than not, our voices in the past would be hushed or we’d be told we don’t know what we are talking about.
 
Studies have shown that families are often the first to see when a patient is failing health-wise. When that’s not heard, that patient is in danger. My husband is a prime example. When I was hospitalized for my myasthenia, he could recognize when I was not doing well, especially when he had been away at work. He had that fresh perspective and knew if something was not right. He would ask the nurses, “What is wrong with Heather?” He knew right away if something was out of my normal. Often, if his observations were dismissed, I would have a trip to the ICU that evening.
 
This is why the patient and family voice is so critical. We were able to bring our perspective to the table, and what was so amazing in the ED design event is that everyone’s “professional hat” was not brought to the table. Instead it was, “How can we all come together to make sure we build a patient- and family-centered, safe hospital?” I am still part of the group that meets regularly on updates and decisions, with the patient and family voice first and center.
 
As a patient and family advisor I was so respected, and my thoughts and ideas were acted upon —  and that was a distinct change from the past.  Patients, for the first time in my 20 years of being a patient in the region, were seen as a valuable part of the team.”
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​Patient voices help hospital staff see problems before they become tragedies. Patient voices come up with solutions that hospital staff can’t.

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.

Deploying Quality Patient Care

12/23/2016

 
Last post, I talked about how world-class healthcare organizations focus on process. Before that, I talked about the importance of placing the patient at the center of that process. Today, I’m going to put that all together and talk about the end goal of any world-class healthcare facility: quality care.
 
In healthcare, your reason for being is quality care. To be a world-class healthcare organization, you must excel at deploying rapid, effective patient care.
 
Rapid quality care deployment begins with a sense of urgency.
 
World-class healthcare facilities feel a "survival sense of urgency" throughout the organization, always aware that patients may move on to other care providers offering better care.
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​This sense of urgency can be directly generated by outside forces. It is a defensive posture. Or, this sense of urgency can also be generated as an attack on a "crisis" whose impact has not yet been felt. 
 
This is urgency generated by internal forces, ordinarily by the organization’s leadership.  It is an offensive posture. Internal urgency is what I see from leaders who are ready for change. Leaders who are ready to overhaul their systems and commit to delivering the best care to every patient, every time.
 
News services must be quality assured, they must meet customer expectations, they must be state of the art, and they must be available immediately. This sense of urgency intensifies improvement and quality assurance efforts. It intensifies focus upon customer expectations. It intensifies efforts to incorporate new technology. And it pulls together all organization’s human capital to get new services and standards of care ready for the very next patient who walks in the door. 
 
The result is that world-class organizations accomplish amazing development speeds for new care technologies and new methods of care delivery. Patients are satisfied—and impressed. Quality care deployment is rapid and effective.
 
Longer-term benefits are realized. Patient satisfaction increases. Quality improves dramatically. Patient care achieves total quality goals. Patients return again and again because they trust that they are going to get a safe, quality product, fast.
 
Up next on the blog: building a world-class leadership structure.

Process Makes Perfect at World-Class Organizations

12/9/2016

 
​In many ways, the healthcare and manufactuing industries seem at odds. Healthcare is about healing people. Manufacturing is about processing materials. But my mission has been to bridge the gap, to prove that delivering the best healthcare relies on the processes you have in place—the processes that create the flow of patients, family, providers, medicines, supplies, equipment, and information.
 
Bottom line: Cut down your time getting everything in place, and you increase face time with patients.
 
World-class healthcare organizations understand this principle. They think of their processes as a strategic weapon—The Big Gun.
 
What does that mean?  The best healthcare. The least waste. The lowest price. The shortest time.  Right the first time. Processes are valued as core competencies.
 
Kanban, a way of automatically signaling when new parts, supplies, or services are needed, is essential to transforming hospital operations. If supplies aren’t in their correct place when they’re needed, you jeopardize patient safety. At the same time, oversupply leads to wasted space and inventory. When I was in the Saskatchewan province in Canada, I watched the Five Hills Health region design their kanban process the right way, working and re-working the system:
​World-class organizations search relentlessly for ways to reduce waste, reduce cycle time, and reduce inventory. They look constantly at their processes. They search ceaselessly for improvements. They work patiently for small refinements. 
 
During the Japan Study Missions, we noticed that there were more "process engineers" in the world-class factories we visited then we'd seen at other companies. These process engineers work on production processes and methods every single day. They know their processes. They take pride in that knowledge. They understand better than anyone else how the production system fits together, how the factory machinery operates in the process, what they want the process to do, and how important it is to find better ways.  Processes are not just studied—they are aggressively scrutinized and regularly improved. 
 
Do you know what one process engineer told us during our visit to his factory in Japan?  He told us that the manufacturing equipment is in the worst shape it will ever be in on the day it is delivered new from the supplier!
 
Healthcare organizations need people with the same kind of process focus, people whose primary responsibility is to improve the processes that can improve the care. Leaders are also essential to continuously improving process. Lean leaders need to be on the front lines, seeking improvements at every level of operation.
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​Here’s Maura Davies, former CEO of the Saskatoon region in Saskatchewan, Canada, implementing kanban at Home Health under the expertise of Sensei Narita. She’s a great example of what it takes to achieve the promises of the Toyota Production System. She’s not in her office. She’s on the front line, getting involved in improving the process, piece by piece.

Patient Focus Enhances Quality of Care

12/2/2016

 
​World-class healthcare organizations have an intense patient focus.
 
Talk is not enough.  "Patient focus" is more than just a pleasant slogan.
 
World-class healthcare organizations are redefining the idea of patient focus.  They know that true patient focus is not passive—it is active, aggressive, passionate, fervent, energetic, and tireless. You must have an unconditional commitment to your patients.
 
The patient is not just involved in the process—the patient is an indispensable part of the process, and it doesn’t work without the patient's involvement. Care cannot be delivered or innovated in a vacuum.
 
This means inviting patients into their care.  This means pursuing what the patient wants—chasing down what they need both in terms of medical care and in terms of the atmosphere, logistical processes, and family support that may be involved—until you get it right. It also means leaving behind attitudes such as, “That’s the way we have to do it,” and “Look, this is how we do it around here,” or worse yet, “Patients may not like it, but it works better for the doctors or staff this way.”
​World-class organizations have realized that success happens when they center operations on patient needs. What do I mean? I mean you no longer have to make educated guesses about patient expectations. You just ask the patient. Then you shut up and listen.
 
The best intentions in the world mean nothing if your patient isn't satisfied with and impressed with his care.  Patient satisfaction is the key measure of performance.
This focus on patient satisfaction does not compromise medical care or organizational efficiency. It enhances both.
 
Patients are at your doorstep because they need your help. They are hurting. They are going through medical crises they can’t solve on their own. But at the end of the day, you have to believe that the patient ultimately knows what is best for them. The patient — and sometimes, their loved ones — can and should collaborate with you on their care.
 
How are the best organizations focusing on their patients? First, they include the patient in the process of collecting information about his needs and expectations. Next, healthcare professionals analyze what that information means and learn to understand it in the context of the medical situation and care environment. Then, they implement the results by creating the care plan that best meets patient expectations, needs, and preferences. Finally, they measure patient satisfaction, including the medical, emotional, and logistical aspects of their care. From start to finish, the approach is true patient focus.
 
When world-class Lean leaders focus on their patients, they achieve real results. They put patient input into action. Take a look at the experience of Ted Gachowski, a patient at Virginia Mason when JBA was consulting there.
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​I highlighted Ted’s case and the leadership of his doctor in the second edition of my book:
Every week, a patient suffering from lymphoma had to make a three-hour drive from his home to receive a six-hour chemotherapy treatment. The travel and treatment was worse than the disease, at least initially. Because of the travel and treatment time, he stayed overnight in Seattle
​Ted’s physician, Dr. Henry Otero, saw the needless difficulties created by the treatments that were supposed to be helping Ted feel better. Otero galvanized the hospital staff to find solutions, and greatly improved the quality of Ted’s care.
The staff listened to the patient’s needs and went to work to cut his treatment time at the hospital. They cut his time at the hospital by 2 hours and 40 minutes (25 percent), his lead time by 2 hours and 30 minutes (63 percent), his in-hospital travel distance by 567 feet (76 percent), and his non-value-added time in the hospital by 142 minutes (73 percent). Bottom line, instead of checking in at 8 a.m. and completing his treatment at 6:25 p.m., he checked in at 8 a.m. and left the hospital at 3:45 p.m

​Patient focus, front and center, put into action by Dr. Henry Otero, a world class leader who gets it.


If you missed it, be sure to check out my first post on world-class healthcare organizations here.

"We care for patients, not cars"

11/4/2016

 
​Change can be difficult for some, not for others. It can be a mixed bag of attitudes, opinions, resistance, support when you start talking about the Toyota Production System (TPS) among healthcare leaders at all levels. I’ve gotten comments like, “What do you mean TPS, we care for patients, not cars – or at Boeing when we first started, “What do you mean TPS, we build airplanes.”
 
I’ve been told, “If we bring you in don't use Japanese words or terms, don’t bring in Japanese consultants, don’t start telling us about Toyota, we serve patients, not cars – don't talk about the Toyota Production System.” My comment usually is, “what do you want me to talk about, what do you want?”
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Mike Rona, Dr. Gary Kaplan, and me on the factory floor in Japan at Hitachi.
I didn’t hear those words from Dr. Gary Kaplan and Mike Rona, when they brought me in for a one-on-one meeting fifteen years ago in Seattle. What I remember was, “Black, we’ve got a problem around quality and safety issues at Virginia Mason – we care deeply about our patients and it is obvious we can do much better.” They were very open to blowing up their mission statement and vision. Also, they weren’t a least bit arrogant. They said, “John Black, we don’t have a method, a management system, to make happen what your talking about.”
 
So, what about results? Rona and Kaplan, with coaching from John Black and Associates, led the adaptation of the Toyota Production System into the Virginia Mason Production System (VMPS). With VMPS methods, the team has achieved increases in patient and staff satisfaction, huge reductions in patient wait time and medical errors, stable economic performance.
 
Rona, now CEO of Rona Consulting, explains the promise of the Toyota Production System best: “What was such an eye opener for us was that this was exactly what we were seeking in healthcare: A zero defect product that exceeded the expectations of its customers, the highest quality, the highest staff satisfaction, the lowest possible cost and reasonable economic performance.”
 
Lean leadership is an immersive experience, a total transformation. The Toyota Production System is a universal process that translates to all industries and will revolutionize your organization’s ability to harness its human capital.
 
Ready to start your Lean transformation? Check out my book here, or contact me with questions.
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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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