Chapter 131

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2148 PART 6 ■ Specific Considerations Figure 131-5. Lean philosophy—5 Ss. beginning of a project and opportunities for improvement are highlighted. A future state VSM is also created to depict an idealized (future) process. Thereafter, front-line staff members generate ideas for improvement. The improvement team is expected to test their ideas using highly structured, rapid-change events called rapid process improvement workshops in which improvement ideas are expeditiously tested and implemented. Children’s Hospital and Regional Medical Center in Seattle, Washington, has been using lean methods for quality improvement in the operative setting since 2002. Adapting these methods to fit the health care (service) setting, these methods are called continuous performance improvement (CPI). The CPI philosophy is to focus on patients and families using quality, cost, delivery, safety, and engagement as metrics (Figure 131–7). This philosophy highlights differences between traditional and lean quality improvement. First, it eliminates waste, complexity and variation to enhance quality and reduce cost rather than eliminate labor. Second, quality, cost, and cycle are addressed concurrently as related rather than as competing priorities. Finally, focus is on whole system rather than subsystem improvements. The initial 2 years were focused on point improvements within the operating rooms. However, during the last 3 years, attention has been focused on improvements in the operative services value stream using the full array of lean tools, e.g., Just in Time service and Built in Quality (Figure 131–8). Just in Time is one pillar of the CPI management system. Simply put, Just in Time delivers the right items at the right time in the right amount. The power of Just in Time is that is allows staff to be responsive to the day-to-day shifts in customer demand. Products that move continuously through the processing steps with minimal waiting time in between and the shortest distance traveled will be produced with the highest efficiency. Sustaining continuous flow also serves to surface any problem that would inhibit that flow. In essence, the creation of flow forces the correction of problems, resulting in reduced waste. The other pillar is Built in Quality. This pillar requires making problems visible, never letting a defect pass along to the next step in the process, and stopping when there is a quality Figure 131-6. Lean philosophy—5s levels of achievement.
CHAPTER 131 ■ Quality Improvement 2149 Figure 131-7. Continuous performance improvement (CPI) philosophy. problem. The key to developing effective mistake proofing lies in understanding how or why the mistake occurred. The quality of a system can be defined by five separate levels, as shown in Table 131–3. The distinction between error and defect is important in this system. An error is, as the name implies, an error in the process at the point of creation. A defect is defined as an error that is passed on down to the next step in the process or ultimately to the customer. The highest level of quality is to prevent the occurrence of the error completely. If it is not possible to completely prevent the error, then try to detect the error as it occurs. In any case, it is important to prevent any defective items (or mistakes) from affecting the customer. “Continuous flow” and “pull” are fundamental elements that help us achieve Just in Time and Built in Quality. Continuous flow is producing and moving one item at a time through a series of steps, with each step making just what is requested by the next step; pull dictates when material is moved. Nothing is produced by the upstream supplier process until the downstream customer process signals a need, often via a Kanban card (used as a signaling system to trigger action), about what, when, and where it is needed. Toyota describes standardized work as a “foundation for kaizen (impro vement).” If the work is not standardized and it is different each time, there is “no basis for evaluation,” meaning no reference point from which to compare or improve. A degree of stability is needed in three areas before moving to standardized work: (1) The work task must be repeatable. If the work is described in “If, then” terms, it will not be possible to standardize unless these are just a few very simple rules. (2) The Figure 131-8. Value stream improvement through waste reduction. line and equipment must be reliable and downtime should be minimal. It is not possible to standardize if the work is constantly interrupted and the person doing the work is sidetracked. (3) Quality issues must be minimal so that the person is not constantly correcting or struggling with poor quality. Over the last 5 years using CPI as the primary methodology for quality improvement, our institution has been able to achieve and sustain several important improvements in our operating rooms. A good example is the enhancement in admission process that has improved the quality (compliance) of the required preoperative documentation and reduced the admission work time such that we have decreased our scheduled arrival time before surgery to 75 minutes, greatly improving patient and parental satisfaction. Failure Modes Effects Analysis Failure Modes and Effects Analysis (FMEA) was developed in the industrial setting and is now being used in health care to assess TABLE 131-3. Toyota (“Lean”) Levels of Quality Quality Level Site of Action Classification 1 Customer inspection Check for defects 2 Company inspection 3 Unit inspection 4 Self-inspection Detect errors 5 Mistake proof Prevent errors
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Chapter 131

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