Standardized Working Toward Zero Infections and Getting There


First off, there's nothing about “Lean” per se in this linked article from Quality Digest: “New York Pediatric ICU Ward Off Central-Line Infections for Entire Year“. That said, there are elements that are very similar to both Lean and the checklists methodology.

Standardized work has led to so many documented improvements in healthcare. There are still some (who might be lurking and reading this) who scream loudly about Lean turning people into unthinking robots, leading to poor quality. Lean standardized work and checklists aren't about shutting off your brain – it's about shifting from a current state where it can be true that “everybody does it different” to a middle ground where there's a standard method BUT people have the professional judgment to deviate from that when necessary.

The Steven and Alexandra Cohen Children's Medical Center of New York has reached a real milestone due to these sorts of methods…

From the article:

The Steven and Alexandra Cohen Children's Medical Center of New York announces it has gone an entire year without a central-line infection in its Pediatric Intensive Care Unit (PICU) – the only children's hospital in New York to achieve this milestone and one of only several in the nation.

This is truly a life-saving measure, as these infections can quite often be deadly. Before their improvements, there was an infection every 28 days. Their goal was to reduce the rate by 50% — but they reached ZERO (the goal any organization should have). How did they reach this mark?

They were smart to not just blindly copy the success of checklists from adult hospitals (as documented in the books The Checklist Manifesto: How to Get Things Right and Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out). They clearly learned from the approach, but realized how they were different (and not letting “we're different” be an excuse):

Efforts to reduce the incidence of CA-BSI in adult patients have been successful mostly by improving insertion techniques. “Pediatric CA-BSI is completely different,” Silver explains. “In children, insertion of the central line is the cause of only 10 percent of infections. The remaining 90 percent is attributable to maintenance procedures.”

So they had to focus more on line maintenance, not insertion.

They worked to improve and standardize methods — what's the best method for protecting the child? If something is an important step or should be done a certain way, how do you make sure it happens EVERY time?

These improvements included a lengthy scrub of the catheter port (“scrub the hub”) with a special cleansing solution for each entry into the catheter (to either administer a medication or to sample blood), very frequent changes of the catheter tubing, and a new protocol for changing the catheter dressing. Additionally, the necessity of the catheter itself became a topic for discussion on daily rounds; and an open conversation between the team of nurses and physicians caring for the patient became a must at the first warning sign of a brewing infection. To implement these last two aspects, however, a culture shift away from the more traditional hierarchical medical model was necessary.

As always, it's not about just writing a checklist document or having standardized work — you have to focus on the culture. How do you break down hierarchies and foster teamwork, where the team is focused on the customer (the patient and the family)?

“The shift can best be summarized with the catchphrase, ‘if you see something, say something,'” says Silver. “Our success is directly linked to the creation of a culture of safety and mutual responsibility where the opinion of all is actively sought and welcomed. Nurses are able to tell physicians that they contaminated their glove during a line insertion or that the line site looks red and needs to be removed. That ability to freely communicate has spread and improved the functioning of our PICU team throughout all aspects of patient care and has become a standard of quality and safety reengineering at Cohen Children's Medical Center.”

Again, none of this work was labeled as “Lean” but it would all be familiar to a lean thinker – reducing waste and having respect for people, that's the key to quality and safety. Not a bunch of warning signs!

Congratulations to the team for the improvements:

The hospital's infection control efforts have already saved the lives of children and have avoided significant costs to the health care system.

Silver said an added benefit of the collaborative was an improvement in employees' job satisfaction and a concerted effort to function as a team that takes great pride in its performance.

Another case where it all goes hand in hand:

  • Better quality
  • Lower cost
  • Happier employees

If it can be done at this hospital, why not every hospital? Why not this year??? I don't care if you call it Lean, checklists, what have you — we just need to get this done. We know how…

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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.



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