David A. Novis, MD David A. Novis, MD Reducing Error and Patient Risk in the Practices of Pathologyand Laboratory

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

GuestGuest

800 East 21st Street

PO Box 5045

Sioux Falls, SD 57117-5045

605-322-OPEX or 888-239-7110

www.AveraOpEx.org

[email protected]

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


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.


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


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


* 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


Percentile Ranking%

Co

mp

lian

ce

Patient ID

Vital Signs

Transfusion Audit Results (1st study) N = 519 Participants

0

20

40

60

80

100


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


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


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


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


Over ProcessingOver Processing

Admitting History and Admitting History and Physical NotePhysical Note

Surgical ReportsSurgical Reports


Unnecessary MovementUnnecessary Movement

Unnecessary TransportUnnecessary Transport


Point of CarePoint of Care

LaboratoryLaboratory

WaitingWaiting


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….”


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


Common Reactions to Waste Common Reactions to Waste

Building and CapacityBuilding and Capacity

OvertimeOvertime


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.


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


Build Quality Into ProductBuild Quality Into ProductMake Errors VisibleMake Errors Visible

Sakichi Sakichi ToyodaToyoda


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


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


JUDGEMENT INSPECTIONSJUDGEMENT INSPECTIONS

*Shingo, Zero Quality Control: Source Inspection and the Poka-yoke System, Productivity Press, 1985


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.]


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.


SOURCE INSPECTIONSSOURCE INSPECTIONS ULTIMATE FORM OF STANDARDIZATIONULTIMATE FORM OF STANDARDIZATION

Error corrected—defect preventedError corrected—defect prevented


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


WHAT DOES ALL THIS WHAT DOES ALL THIS LOOK LIKE IN THE LOOK LIKE IN THE

FACTORYFACTORY?


Traditional ProcessTraditional Process

PUSHPUSH

Finished Finished Products Products OutOut

PI

DEFECT BINDEFECT BIN

Batch and Batch and QueueQueue

C

SiloSiloSiloSilo


SuppliersSuppliers

WarehouseWarehouse

Quality?Quality?Low Cost ?Low Cost ?

Safety ?Safety ?On Demand?On Demand?

Lean Production SystemLean Production System

PROTOCOLSSTANDARDIZATIONREDUNDANCY


SuppliersSuppliers

PULLPULL


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)



HELP!

Suppliers

PULLPULL


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


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


*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


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:


C/O: 3-4 min

Communication Rm.

T

Batch Size: 1

U/ T: 100%

10-15 minC/ T:

Rate:

Rework:


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:


C/O: 3-4 min

MD Assessment

Batch Size: 1

U/T: 100%

380 (6 min)C/ T:

Rate:

Rework:


C/O: 0T

RNAssessment

Batch Size: 1

U/ T: 100%

100 (1.5 min)C/ T:

Rate:

Rework:


C/O: 0

T

Transcribe Orders

Batch Size: 1

U/T: 100%

240 (4 min)C/ T:

Rate:

Rework:


C/O: 3-4 min

Lab

T

Batch Size: 1

U/ T: 100%

Range?C/ T:

Rate:

Rework:


C/O: 0

0

120 sec.

Disposition Plan

T

Batch Size: 1

U/T: 100%

120 (2min.)C/T:

Rate:

Rework:


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:


C/O: 0

Report to Primary Physician

T

Batch Size: 1

U/ T: 100%

120 (2min.)C/ T:

Rate:

Rework:


C/O: 0

D/ C I nstructions

T

Batch Size: 1

U/T: 100%

120 (2min.)C/T:

Rate:

Rework:


C/O: 0

I V Start

T

Batch Size: 1

U/ T: 100%

300 (5 min)C/ T:

Rate:

Rework:


C/O: 3-4 min

MedAdministration

T

Batch Size: 1

U/ T: 100%

Range?C/ T:

Rate:

Rework:


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


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


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.


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.


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


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

Documents

David A. Novis, MD David A. Novis, MD Reducing Error and Patient Risk in the Practices of Pathologyand Laboratory