Thanks to my friends in the Michigan Quality System group, the internal Lean group at the University of Michigan Health System.
My contact in the MQS team says the video “is also an excellent example of standard work, PDCA, visual management, and a blame free culture.”
In the video, Jack talks about his own efforts to achieve 100% hand hygiene compliance when entering and leaving patient exam rooms.
He tried a method that worked… except when it didn't. That's because the method relied on a reminder that was easy to miss. It wasn't perfectly effective mistake proofing.
So, in the spirit of PDSA, he tried something else, but solving one problem created a different problem.
How did he eventually tweak his approach?
See here in the video:
Jack says he has been 100% compliant since 2008. It took him four weeks to experiment and develop a system that works for him.
“Vigilance is not a system,” he says. I agree.
My question would be about how to spread that method to other physicians in his group. Do they do the same thing? Or, do they get the same results through a different method?
How can we move beyond an approach that relies on posters, reminders, “be carefuls,” and such? Doctors and nurses know they are supposed to clean their hands, so it's not an awareness or education issue (but hospitals seem to treat it like an education issue, but more posters don't solve this problem).Vigilance is not a system, says Dr. Jack Billi, about hand hygiene Click To Tweet
How can we fix the system so we make it easier for people to the right things the right way?
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