Every hospital seems to have the same issues: preventable adverse events which will no longer be paid by Medicare and other insurers. This article will address the errors that occur, why they occur and proven methods of Lean Six Sigma to prevent them; all to create a faster, less expensive and better hospital in a matter of days.
Some of the more common preventable adverse events include:
- Catheter-associated urinary tract infections (UTI)
- Blood stream infections (BSI)
- Pressure ulcers
- Surgical errors: Objects left in, surgical infections, wrong site and wrong patient surgeries.
- Blood incompatibility
- Ventilator acquired pneumonia
- Patient falls
A recent RAND study found that only about one out of every two patients will receive care that meets generally accepted standards. The CDC estimates that hospital-acquired infections alone result in an additional $27.5 billion in unnecessary costs per year.
What one element is critical to both improved outcomes and patient satisfaction?
Reducing Defects (i.e., medical mistakes)
In October 2008, U.S. hospitals no longer receive Medicare reimbursement for healthcare-associated infections: Catheter-associated urinary tract Infections (UTI), Central venous catheter-related bloodstream infections (BSI), and ventilator-associated pneumonia (VAP).
Dr. Peter Pronovost at Johns Hopkins Hospital came up with a five-item checklist that reduced catheter infections to zero in 77 Michigan hospitals. The checklist included simple solutions like washing hands before touching patients, clean patient’s skin with antiseptic, wear masks, caps and gowns, etc.
A better operating room in five days
“We’ve celebrated cowboys, but what we need is more pit crews.”- Atul Gawande
Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston, authored The Checklist Manifesto, a book about using surgical checklists to reduce operation times, infections and deaths by more than a third. Gawande advocates simple things like having everyone on the surgical team introduce themselves by their first name.
Every 120 minutes a retained foreign body occurs in the U.S. Retained foreign objects (i.e., surgical left ins) occur in one out of a thousand abdominal operations resulting in significant adverse outcomes. In 2005, the Mayo Clinic Rochester averaged one RFO every 16 days. By changing the process for counting and tracking surgical supplies and instruments, they were able to extend time between RFOs to 69 days.
Wrong site or wrong patient surgery
In 2001, the Joint Commission analyzed 126 wrong site or wrong patient surgeries. Most involved orthopedic surgeons and wrong body part or site. This led to the creation of a universal protocol to prevent these kinds of mistakes: http://www.jointcommission.org/PatientSafety/UniversalProtocol/.
Another study in 2007 found that “The number of sentinel events reported to the Joint Commission has not changed significantly, despite the required use of the Universal Protocol. Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification.”
In one state over 30 months, there were 427 reported incidents and 83 patients had incorrect procedures done to completion. 31 formal time-out processes were unsuccessful in preventing wrong surgery. Most common type of incident? Wrong side surgery. Who is most likely to catch the error? Patients and nurses.
Most common root cause: the actions of the surgeon in the OR (92 reports). Second: Failure of the Time Out Process (59 reports). Either of these may be a function of confirmation bias (the psychological tendency to confirm an impression despite the facts). Another common thread in wrong site surgeries: symmetrical body parts like left/right arm, leg, knee, chest, etc. and, positioning of the patient.
In 2005 in Florida, there were 31 wrong-site operations, five wrong patient surgeries and 86 instances where the wrong procedure was done according to Dr. Allen Livingstone (Miami, Florida).
It seems that the longer the patient is awake before surgery and the greater the involvement of the surgeon and anesthesiologist in preop, the greater the chance of preventing wrong site or patient surgeries. Time outs don’t seem to work that well. What would work better?
Eliminating never events
- Track each Never Event with g chart
- Use Pareto Charts to analyze most common contributor to Never Event
- Analyze root causes of “big bar” of Never Event
- Implement countermeasures and verify results
- Monitor improvement forever
A better pharmacy in five days
At one hospital, medication orders were causing problems. The error rate was 3,300 per million orders. The most common type of error? Order not received.
Second runner up? Wrong frequency of dose. These two accounted for almost half of all order errors.
Most orders were faxed and fax line congestion prevented orders from being received. Nurses sometimes missed changes in frequency or dosage.
After implementing a computerized order entry system and other procedural changes, order errors fell from 3,300 to 1,400 per million, a 55 percent reduction with an estimated cost savings of $1.2 million per year.
A better lab in five days
As much as two-thirds of lab errors occur in the order and labeling process, before testing begins. In 2003, North Shore Long Island Jewish Health System set out to use Six Sigma to reduce these errors. They found that five out of 100 samples were inaccurate or incomplete. The team analyzed 5,667 laboratory requisitions and identified 285 errors. The most common? Social Security Number errors.
Root cause: Skilled nursing facilities used addressographs instead of available bar code labels for sample identification.
Countermeasure: Use bar code labels.
They also color coded samples and parts of the lab to ensure that samples were delivered to the correct location for processing, saving additional time and reducing errors.
Defects per million opportunities fell from 7,210 to 1,387.
Staff productivity rose from 20 to 23 requests per hour to handle additional volume:
Combined improvements resulted in $339,000 in increased revenue and cost reduction.
A better nursing unit in five days
Blood stream infections (BSIs) from IVs are a serious problem. One hospital found that monitoring infections using fresh needle sticks vs. using blood from the IV provided a better detection method. They also used colored tape to mark IVs inserted under less than desirable conditions (ambulances, EDs, etc.) These were then changed as soon as the patient got settled in a nursing unit which reduced infection rates.
Hospital case study
The Institute for Healthcare Improvement (ihi.org) estimates that preventable physical harm to patients occurs 40,000 times a day in U.S. Hospitals. The Center for Disease Control and Prevention estimates that two million people are affected by surgical site infections, drug reactions and bedsores. 99,000 people die as a result of hospital-acquired infections.
While infections are a problem, misuse of antibiotics can lead to other problems.
Providence Saint Joseph Medical Center (PSJMC) found that nursing units often failed to discontinue antibiotics within 24 hours of surgery end time for up to 1,000 patients per year. Failure to stop antibiotics can lead to adverse reactions and increased medical costs.
PSJMC found that average stop time for antibiotics was 39 hours after surgery. Only 25 percent of cases were compliant with guidelines. And there was no standard process or protocol used in the nursing units. They also found that orthopedic and colon surgeons had the highest noncompliance rates.
- Revise order sets with support from surgeons.
- Identify applicable cases in the operating room.
- Automate discontinuation of antibiotics by the pharmacy at the 24th hour for applicable cases.
- Add orange stickers to patient chart to visually identify the patients.
- Monitor compliance daily.
In a few months, compliance rose to 90 percent vs. 36 percent which generated $35,000 in savings.
Bar codes bust medication errors
Good news: When the VA adopted bar codes for patients and medicines, medication errors plummeted. By bar coding medications and patients, and using hand held scanners, clinicians can ensure that the right patient gets the right dosage of the right medication at the right time.
Bad news: An estimated 7000 people die in hospitals of medication errors. One out of every 14,000 transfusions get the wrong blood resulting in at least 20 deaths each year. Only about 125 of the nation’s 5000 hospitals use bar codes now.
Good news: The FDA required bar codes on all medications starting in February, 2004.
Bad news: National average for wristband inaccuracies in hospitals is 3 percent. (If you get the band wrong, everything else can go wrong too.)
Sadly, safety technology isn’t a big diagnostic machine that generates revenue; it’s a protective device that reduces the cost of treatment and litigation. The good news is that the technology is out there to make our healthcare safer than ever before. All we have to do is embrace it.
How to get a better hospital in five days
The only realistic hope for substantially improving care delivery is for the old guard to launch a revolution from within. Existing players must redesign themselves. -Richard M. J. Bohmer
Although the case studies in this report offer some constructive ideas, most clinical staffs will not implement an improvement unless they have a hand in its design.
Improvements are possible if it helps the patient or the provider
Healthcare professionals want to help create improvements that:
- Increase patient safety and satisfaction
- Improve quality of care
- Reduce lead or turnaround times
- Improve productivity without compromising patient outcomes
- Reduce medical errors
- Appeal to their need to provide better care
- Show them the data
- Shift to a patient-centric model of healthcare
- Switch to using standardized protocols and routines to optimize care
How is it possible to get a better hospital in five days or less? It takes a team.
- Gather a team that believes it’s possible to improve patient flow (e.g., ED doctor, ED nurses, ED clerk, and ED admissions). Some people just don’t believe it’s possible; if so, they won’t be useful on the team. Don’t load the team with skeptics.
- Prework: Use pedometers to gather travel data about the clinicians. Identify and collect “wait times” for patients between steps in treatment.
- Have a trained facilitator assist the team in identifying the major delays and unnecessary movement of people or supplies using tools like value-stream mapping and spaghetti diagramming. Have the team identify possible countermeasures to these problems.
- Implement the countermeasures and measure results
- Implement process-oriented improvements immediately
- Move machines or supplies to more convenient locations immediately
- Project manage more complicated changes (e.g., IT systems changes, hardware changes, etc.)
- Verify that the countermeasures actually reduce turnaround times. (Some times they don’t.)
- Standardize the improved methods and procedures as a permanent way of doing things.
- Measure and monitor turnaround times to ensure peak performance.
About the Author
Jay Arthur, the KnowWare Man, works with hospitals that want to get faster, better and cheaper in a matter of days using the proven methods of Lean Six Sigma. Jay is the author of Lean Six Sigma Demystified and the QI Macros SPC Software for Excel. Jay has worked with healthcare companies to reduce denied claims by $3 million per year, appealed claim turnaround time and lab turnaround times by 30-70 percent. Readers can take Jay’s free Lean Six Sigma “Yellow Belt” training online at www.lssyb.com. He may be reached at firstname.lastname@example.org or 888-468-1537.
Nancy B Reibling, et. al., CT Scan Throughput, ISixSigma Magazine, Jan/Feb 2010, pgs. 49-54.
Gette Wennecke, Kaizen – Lean in a week, www.mlo-online.com, August 2008.