Today, I'm linking to a fantastic interview and discussion between two luminaries in the patient safety world – Dr. Robert Wachter (read his blog) and Dr. Richard Shannon (who is featured, among other places, in the “Good News: How Hospitals Heal Themselves” video and the companion book “The Nun & the Bureaucrat.“
Dr. Shannon talks about the application and adaptation of Toyota methods at the Hospital of the University of Pennsylvania. Dr. Shannon is helping recreate earlier efforts that, under his leadership, dramatically reduced central-line infections at Allegheny General Hospital in Pittsburgh.
From the interview:
“… the 26-bed unit in Pittsburgh where we did this effort has now gone 35 months without a central line infection. Once you ingrain the process as a culture, I think it is sustainable. By the same token, engaging people in rapid process improvement and being able to share with them the daily resultsâ€”every member of this team gets a daily report on whether or not there's an infection on their unitâ€”begins to create a different type of process improvement science that I think people can at least begin to understand and appreciate”
Dr. Shannon understands that improvement work like this must involve the front-line staff (one of the inspirations from lean) and you must focus on sustaining improvement – this is done through the management system and culture. It's not a simple one-time exercise.
Their early results at UPenn are encouraging:
The early outcomes here are quite astonishing. In the 6 months prior to the effort with central lines, 86 patients had central line infections in those four units. In the 5 months since we started, there have been four infections. So the concept of actually putting these tools in the hands of people who do the work, much in the way that Toyota does on its assembly line, is very effective.
This is quite arguably saving lives – 20% of these infections lead to patient death.
Beyond the quality and patient safety impact, there's a direct connection to patient flow, hospital capacity, and cost. Payers are increasingly unwilling to pay for what are arguably preventable hospital-acquired infections.
Dr. Shannon talks about the impact of infections on flow:
- A patient who gets a central-line infection has a hospital stay that's 17 days longer than normal. Patients with urinary tract infections stay 6 days longer than if they didn't get an infection.
- Preventing infections creates bed capacity in the hospital.
- Freeing up this capacity might eliminate or minimize the need for hospital expansion
The final part I'll share is Dr. Shannon talking about the general notion of “defects” in healthcare. The definition of a “defect” goes beyond something that causes patient harm. Dr. Shannon says:
That's where the toolkit using lessons borrowed from Toyota is so widely applicable. The concept is to be able to identify defects in any domainâ€”to understand your capability to identify the defect and solve it.
In the course of these observations, we encounter not only defects in the processes around placing, maintaining, and manipulating catheters, but we find defects in medication delivery. We find defects in laboratory blood draws and labeling of tubes. We find all these defects that we can begin to codify and do the same type of real-time problem solving around them. The problem at the start is that the number of defects is overwhelming. When you begin to codify them, it's just staggering.
Our notion is to build upon some early successes by truly committing to an audacious goal of eliminating infections, and then build upon that success to begin to move into areas like medication errors, or timeliness of service delivery. I mean, how often when a patient is scheduled to be in a cath lab at 10:00 AM does it actually happen at 10:00 AM? That's arguably a defect. Industry wouldn't tolerate that imprecision. Looking at those systems across what we call the customer-supplier relationship between the cath lab and our inpatient medicine unit is the next opportunity that these skills can be applied to.
Great stuff. I hope many many hospitals, leaders, and clinicians are inspired by this work. If your lean efforts are focused on “how many pens are in the nurses' station desk drawer,” you're likely missing the full potential of lean healthcare.
I cant' mention Dr. Shannon without also giving another endorsement for Naida Grunden's outstanding book The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods that goes into more detail about their success in Pittsburgh.
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