LEAN SIGMAReducing Medical Errors in the Healthcare Environment

Pamela Parham HSMG 301 Spring 2015

Lean Sigma DefinedAccording to the Center for Innovation in Quality and Patient Care at Johns Hopkins Medicine, Lean Sigma combines two quality improvement approaches: Lean and Six Sigma.

Lean methodologies focus on eliminating waste and streamlining processes. Six Sigma projects involve increasing quality and yield while reducing defects and variation.

8 Types of WasteType of Waste Description Healthcare Example

1. Defects Time wasted doing something wrong, looking for errors, and correcting errors.

Medical Errors: Errors in Medication Administration, missing item from surgical case cart.

2. Overproduction Doing more than what is needed. Ordering too many, or uneccessary diagnostic tests.

3. Transportation Unnecessary movement in a system. Poor layout: Nurses walking long distances from supply rooms to patient rooms.

4. Waiting Waiting for the next activity or event to occur.

Nurses waiting for room to be cleaned for new patient admission.

5. Inventory Excess inventory costs: financial, storage, movement, spoilage, and waste.

Expired medications that must be disposed of.

6. Motion Unnecessary movement of employees in the system.

Lab workers walking miles per day due to poor hospital layout.

7. Overprocessing Doing work that does not contribute to quality patient care.

Time stamps that are required, but never used to collect data.

8. Human Potential Waste and loss due to not engaging employees.

Nurse and Physician burnout

Defects: Medical Errors

Nearly 187,000 people in the US die from medical errors making it the 3rd leading killer in the United States behind heart disease and cancer. (cdc.gov)Types of medical errors:

Medication errors Hospital Associated InfectionsOther errors in HospitalsUnnecessary surgery

Reducing Medical Errors (DMAIC)

Definition: A medical error is defined as: an act of omission or commission in planning or execution that contributes or could contribute to an unintended result. (www.ncbi.nlm.nih.gov/) Medical errors could also be defined as failed processes that are apparently linked to adverse outcomes. Attempts to reduce errors should be in relation to their impact on outcomes (preventable morbidity, mortality, and patient satisfaction) and the cost of preventing them in the first place. (http://ecp.acponline.org/novdec00/hofer.htm)

Measuring Medical Errors

Analyzing Medical Errors Medical Errors are caused by:1. Communication problems/Inadequate information flow: The most common cause of medical

errors. Often, necessary information does not follow the patient when he or she is transferred to another service or is discharged from one treatment area or organization to another.

2. Human problems Problems that may occur include failures in following policies, guidelines, protocols, and processes; even lack of adequate clinical policies and procedures.

3. Patient-related issues can include improper patient identification, incomplete patient assessment, failure to obtain consent, and inadequate patient education.

4. Staffing patterns/work flow This causes errors when physicians, nurses, and other health care workers are too busy due to inadequate staffing or lack of supervision.

5. Technical failures include device failure and complications or failures of implants or grafts. In many instances equipment and devices such as infusion pumps or monitors can fail and lead to harming the patient.

Improve and ControlPreventing Medical Errors:According to the Agency for Healthcare Research and Quality, changes in organizational culture,

the involvement of key leaders, educating providers, establishing Patient Safety Committees, developing and adopting safe protocols/procedures, and incorporating technology are all essential elements in hospital and healthcare facilities' efforts to reduce medical errors and improve patient safety.

Tracking:Almost every hospital in the US has some form of medical error reporting system because the

current JCAHO standards require that some form of patient safety reporting system must be in place to track adverse events, such as falls in the healthcare setting. Depending on the state, many hospitals may be tracking other required information, such as surgical errors, infections, and other information as required by professional organizations and various agencies in the Federal government. Unfortunately, many of these reporting systems are operated independently of one another and data may be infrequently shared.

ReferencesGraban, Mark. Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Second Edition. CRC Press. 2012.

http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/lean_sigma/about/

Defining Medical Error. National Center for Biotechnology Information. Retrieved on March 26, 2015, from www.ncbi.nlm.nih.gov/

What is an Error? Effective Clinical Practice. Retrieved on March 26, 2015, from http://ecp.acponline.org/novdec00/hofer.htm

AHRQ's Patient Safety Initiative: Building Foundations, Reducing Risk. Agency for Healthcare Research and Quality. Retrieved on March 27, 2015; fromhttp://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini2.html

www.cmwf.org/snapshots

www.cdc.gov