Notes from My First IHI National Quality Forum (#ihi09)


Today was an exciting day at the Institute for Healthcare Improvement‘s 21st annual National Forum on Healthcare Quality Improvement. It's my first time here, to learn and network. They have over 5,000 attendees who are committed to quality and patient safety improvement. The energy and enthusiasm is contagious (in a good way!).

To read Twitter updates from attendees, search the hashtag #ihi09 during the day on Wednesday, if you like.

Donald Berwick

I had a chance to briefly meet Dr. Donald Berwick before his keynote address, which Paul Levy summarized here.

Don mentioned Lean and Toyota methods four or five times during his talk and, early on, showed a number of slides with results from organizations like Denver Health and ThedaCare. One major theme of Don's was that the quality movement can't ignore the need for cost reduction, given financial realities. This is a message that ties in well with Lean, that quality improvement leads to cost reductions, in addition to all of the benefits for patients in avoiding harm and providing the best care possible.

He made a provocative statement on “value”:

“Health CARE has no intrinsic value, health DOES.”

He is suggesting that value to the customer (the patients) has more to do with outcomes than it does to activity and effort.

Don also talked about the need for change and how:

“Command and control solutions seem weaker every day.”

Supporting Nurses

One of the breakout sessions that had an impact one me was from Kaiser Permanente and Ascension Health about freeing up time for nurses to spend with patients.

They cited a 2006 study that showed nurses spent only about 30% of their time in patient rooms due to waste of all varieties.

In looking at the factors that impacted nurse productivity, the studies showed that architecture and physical layout was NOT a statistically significant factor. They found high variability across shifts in the same hospital and across different nurses on the same shift.

The productivity was all a matter of personal work style and support process that often don't provide support so nurses can provide the right patient care.

The lack of standardized work is described by the presenter who said:

“Everyone develops their own style.”


“They don't teach you in nursing school how to organize your time.”

That seems like a recipe for inconsistent care and inconsistent quality.

The recommendations for improving productivity and patient care included having supplies and equipment available ON DEMAND at the point of use and the time of need.

That sounds so basic and fundamental, doesn't it? Shocking to those of you from outside of healthcare?

One health system did a study of their “smart pumps” and discovered that, due to a lack of organization and 5S and lack of standard process, that they had overpurchased this one item to the tune of $20 million since the pumps they had often couldn't be found, so additional ones got purchased. What an easily preventable form of waste and overspending.

Nurses often hoard and hide equipment as a workaround to make sure THEY can provide care to THEIR patients. It might seem selfish, but it's well-intended in the short-term, but does nothing to fix the real system. One presenter said the “strangest” place they found a piece of hoarded/hidden equipment was a pulse oximeter found in the CEILING above the tile in a patient room. Nurses and hospital staff shouldn't have to go to such lengths to ensure they have the tools to do their jobs.

One quote given about the lack of support to nurses was:

“It's like they sent me a door but no door frame? What am I supposed to get done with that?”

Whose job is it to make sure people have the right tools, equipment, supplies, and systems? Quoting Dr. Deming, it's top management's job.

The final principle they encouraged was “patient-centered design” of processes and spaces. Again, seems pretty basic to focus on the customer, eh?

One final thought: a presenter opined that for all of the talk about the “hospital of future” (which every hospital thinks they are building, they said), that it doesn't really exist yet. If it did, such a hospital would have 25% to 30% better labor productivity and the presenters said that's not here. My suggestion was that they look at what ThedaCare has delivered through their Collaborative Care model – they have delivered such productivity improvements while also providing better quality. It is possible, now.

Sorrel King

Another highlight was being able to meet patient safety advocate Sorrel King in person finally (check out my podcast with her and her recent book, Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe. I'm about 80% of the way through her book and I highly recommend it.

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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. Just a little story that relates to "everyone develops their own style."While at a training session last summer a trainer was presenting the principles of standardized work. A nurse sitting toward the front of the room proclaimed to him with a delightful yet indignant smile, "You can't tell us what to do!" (She hadn't given the trainer time to explain that standardized work is developed by the people who work in the system.) So an ER doctor at the back of the room responded with this…"A few months ago a patient was transported to our ER bleeding to death. We sterilized and gowned up, and once we were all in the room we realized we were missing a piece of equipment that was critical to the procedure we were about to perform. We had no one designated to gather instruments prior to procedures and we were losing precious time. So one of us left the ER, found the instrument, washed up again, and re-entered the room. All this while the patient's life was hanging in the balance."This statement by the doc wiped the smug smile off that nurse's face in a hurry.

  2. I would like to relate to the following statement from your post about lack of support to nurses:"It's like they sent me a door but no door frame? What am I supposed to get done with that?"Whose job is it to make sure people have the right tools, equipment, supplies, and systems? Quoting Dr. Deming, it's top management's job.My comment:I am having the same problem in Japan. we recently got a new order for making electrical wires for a particular product. Its a very small order and does not add a lot to the bottom line and hence was ignored in the following manner :- In order to be able to do the job well, the shop floor workers were given the electrical circuit designs, the material and a place to work and that was it!!!they were not given any information on the time frame within which they were suppose to complete the order. No information about how to do the work. No explanations. no training. no one to contact in case they had questions or problems. The person who was suppose to give them initial training was send to the customers plant due to shortage of staff.As a result of the lack of support from the production manager and the top management leaving all the decisions regarding production in the production managers hands. The shop floor workers in charge had to figure everything out by themselves and had to work based on process schedules that was set up by production manager , who did not consult with person in charge for material supply from the customer(all the material is supplied by the customer). The person in charge for material supplies from the customer could not pressurize the customer for the required material, when ever there was a delay. In spite of the delay, the delivery time was not changed so, when the delayed material finally arrived, the shop floor workers had to work under intense pressure, with all the help they could get to finish the product and pass it on to the next process on time else the line would stop. The process was not stable , the electric circuit diagram which was used as the standard operating procedure, was difficult to read and to see and hence was easy to make mistakes leading to defects. Although all these problems could have been fixed before the occurrences of defects. No actions was taken till there were defects.why, because as long as things are working fine, no one says anything.BUT, when defects went undetected and were passed on to the end customer, the production manager and the top management were upset with the shop floor members and asked for the problem solving analysis. it was at this point only, when I was called for problem solving and I found out the lack of support given to the shop and I in turn asked the Top management including the president the following question- I agree that it is the shop floor members job to make the product defect free, in the time frame requested by the management. BUT- ( here I am using your post verbatim) Whose job is it to make sure people have the right tools, equipment, supplies, and systems (Quoting Dr. Deming,) to do their Job???it is the top management. As a countermeasure. the management has agreed to make sure that the production manager will hence forth work closely with the shop floor members in setting up the production schedule and ensure that the material required for production is delivered on time. He will also make sure that the electrical circuit designs be changed into easy to read designs with mistake proofing. finally, for the next 3 months till the process is stabilized, the production manager will participate in all the problem solving exercises to better understand, where he needs to provide improvement and support in terms of the process and the system.

  3. Quote:"The recommendations for improving productivity and patient care included having supplies and equipment available ON DEMAND at the point of use and the time of need."My comment:At Toyota and at my current employer we call the above statement as HITUYOU NA MONO (the required material, supplies, information)HITUYOU NA TOKI (at the required time)HITUYOU NA DAKE (in the required quantity)Although the above statement sounds basic and fundamental,it requires a lot of work especially in the case of companies which do no have a standard operating procedure and have a dominant island system.


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