Better Healthcare Quality Won’t Cost Less This Way


    Device Alerts Doctors To Items Left Behind After Surgery – Indiana News Story – WRTV Indianapolis

    Healthcare is often stuck in the mindset that's considered outdated in lean manufacturing settings — the old idea that better quality must inherently cost more.

    In the automotive industry (and the rest of manufacturing), companies assumed there were tradeoffs. When Toyota started importing high-quality low-cost cars, many automakers thought this was impossible. Conspiracy theorists thought that Toyota was “dumping” products at a price lower than their cost, which is illegal. It took time for companies to realize that Toyota was getting better quality through better processes — not by having more quality inspectors. Through error proofing (“poka yoke”) and other methods, Toyota could “build it right the first time.”

    In healthcare, hospitals often rely in inspections to “catch” errors rather than working to prevent them. This can be seen in laboratories, blood banks, and pharmacies — it's considered better to have more inspection steps. If a double check is good, a triple check is even better, or so the thinking goes.

    One error that can occur in a surgical setting is leaving objects inside a patient that remain after the patient is sewn up. In the linked article, a technology solution is being implemented:

    It's a medical mistake that strikes nearly 1,500 people every year — they wake up from surgery only to find out later that something's been left behind.But Clarian Health is now using a new, high-tech approach to try and prevent that from happening, 6News' Stacia Matthews reported.

    Does this really require a technology solution? What about better processes? Many hospitals go through a process of counting items after surgery, using a checklist of items that were brought into the operating theatre.

    This article talks about the counting in hospitals:

    Hospitals typically count everything three times — once during set up, again before surgery and immediately after. Regan reported that sometimes that count is wrong. He found something that can stop that from happening.

    Do these checklists always get used? Maybe not… so we have to use technology? This adds cost — it's an inspection. This type of method for quality improvement will lead to higher costs than a process-driven solution.

    Doctors and nurses at Clarian North use a special wand that, when waved over a patient while they're still on the operating table, can pinpoint any sponges or gauze left behind using micro-biocompatible tags.

    So now we have to buy more expensive sponges with tags in them and the wand. This is probably cheaper than the cost of re-opening a patient to retrieve lost items (and it's better for the patient), but it's too bad we can't find a way that ensures perfect quality without this extra investment.

    “I like it because I can feel confident that I haven't done any harm to my patient,” said Clarian North Dr. Amy Moon. “I know that when I leave the case, 100 percent, for sure, that there is no doubt in my mind.”

    So is this “inspection” or “prevention”?? It feels like inspection to me… and a costly one, at that.

    Clarian Health is one of the first in the nation to use the technology.

    Will we be seeing more of this? Are we prepared to pay for this? Or can we find a less expensive way that's just as effective? Does anyone have experience working in this area, preventing items being left inside patients?

    Maybe there is no better way… this article talks about a hospital being fined for this surgical error and describes of the process:

    According to the incident report, the nurse and scrub technician – who were required to count the sponges before the surgery and after it was completed, before the incision was closed – both said they followed the required procedure. However, the technician “stated that this particular case was very bloody and the lap pads (sponges) could have stuck together.”

    The doctors also stated that counts are not always sufficient for preventing sponges from being left behind. Of the cases that the Boston doctors looked at in which counts were performed, 88 percent involved a final count that was erroneously thought to be correct.

    The chips in the sponges are said to be the size of a penny. They undoubtedly cost more than that! I just wouldn't be ready to give up yet on a low-tech process-driven solution that would actually cost less.

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    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


    1. Mark,

      This issue has me conflicted. I agree with prevention as the ultimate goal, but on the other hand, if this technology, if not TOO spendy (don’t ask me to define that), can eliminate anything being left in a patient, then I, as a patient/customer, would certainly want it. If it’s the best method we have to date – no other idea/technology is superior -then it could be the way to go until we truly can get a very effective preventive method.

      This one makes a person think… hard.

      Interesting post, Mark.

      Mark W.

    2. Mark – I’m conflicted too as you put it. I wouldn’t discount a technology just because it costs more (like you said, it might be the best way today). But have we really challenged ourselves to truly errorproof?

      If the general statement, “better quality costs less” is true, it might also be true that adding a little cost (the RFID system) might prevent a lot of cost (an extra surgery and the risk to the patient), then maybe that’s OK.

      I’ve been thinking about it too even since when I wrote the post. Maybe I need a question mark in the post title?

    3. What about using a string on the sponges? this string could be tied to a large plastic object or something, so you can easily see that there is a string hanging outside of the surgery area.It seems like something like this would be simple and effective.

    4. Strings! Great idea – why not?

      Or embed a non-toxic compound that gives the used swabs a noticeably different colour from blood?

      I’m not in healthcare (if it weren’t obvious already), but I bet the surgical team could come up with a dozen or more ideas like this.

      Then, let them experiment with the effectiveness of each – retaining the count as a ‘safety net’ in the meantime if need be.

      That way, the medical team can learn what works best and refine it over time.

    5. Well, that’s a common problem happening in many industries, not only Healthcare: technology companies try to bring a bunch of services, which could be as effective as lean, but much more expensive indeed.

      The problem is, many consultancy companies are strictly technological. To be honest, I used to work for one of them delivering RFID solutions as well: consultants along with bringing nice and useful solutions try to catch and grab literally any possibility to sell the technology. I’ve seen companies building really complex RFID systems where simple paper cards or items physical queue would be sufficient…

      But sometimes it is so difficult to say No to a smart young consultant who brings such an attractive business case calculation to the management meeting.



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