Utilizing Rapid Process Improvement To Help Prevent Medical Errors

1. Utilizing Rapid Process Improvement To Help Prevent Medical Errors A Six Sigma Methodology January 30, 2006

2. Rapid Process ImprovementCourse objectives • Understand the components of Rapid Process Improvement (RPI) • Become familiar with the tools and processes required for a successful RPI • Understand how to prevent medical errors by utilizing a structured methodology that helps identify where an error may occur

3. Rapid Process Improvement 7 Components Align with the Plan Do Study Act Cycle • Set Direction • Understand the process • Identify and analyze barriers • Identify, test and select solutions • Implement • Ensure results • Remaining issues and future plans

4. Plan, Do, Study and Act Cycle (PDSA) Adopt the change, abandon it, or run it through the cycle again Plan for a change aimed at improvement 1 Act Plan 5-7 Study Do Carry out the change with proper testing 2-4 Study the results. What did we learn?

5. Rapid Process Improvement Where it May be Appropriate • No one else is performing the process well enough to replicate • You know the process to be fixed and the solutions to improve likely lie within the process • Employees likely know the barriers and potential solutions

6. Rapid Process Improvement Where it May be Appropriate • Multiple work units or locations are involved in the process • You are willing to implement known improvements now and study unknowns over time

7. National Patient Safety Goal - 2005 Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

8. Rapid Process Improvement –1. Set Direction • PurposeTo identify the process to be reviewed, the measure of success and the team’s missionUnderstand how the customer is impacted by the processTo quantify the financial impact of the project

9. Rapid Process Improvement –1. Set Direction • Tasks for Set Direction Prepare a “View of the system” in order to understand how the system impacts the processClarify the target mission Complete a team charter for agreement on scope, direction, resources and timing Form the team

10. View of the System Process

11. Rapid Process ImprovementTeam Charter • Methodology • Interdependencies • Time Commitment • Team members • Project support • Management review plan • Problem • Background • Link to strategic goal • Scope • Objective/Goal Mission of team

12. Rapid Process ImprovementStep 2: Understand the Process • Baseline process map • Identify high level issues • Understand regulatory requirements of the process • Confirm that RPI is the right process and should be continued

13. Rapid Process ImprovementStep 2: Understand the Process Basic activity or task Decision point Delay Movement or hand off Connector coding

14. Rapid Process ImprovementStep 2: Understand the Process • Identify and name the process • Identify the process boundaries • Determine the process level • List players in process • Identify the steps for each player • Review and validate

15. Rapid Process Improvement • Step by step review of the process helps identify barriers that may cause medical errors • Example: Medication errors may occur during a patient transfer; such as omission of a medication, medications continued that are not appropriate or duplication of administration of medications.

17. Rapid Process ImprovementStep 2: Understand the Process • High level considerations:High-level issues relate to issues of business logic and decision making on a larger scale. They are issues that involve the large scale way in which work is performed as opposed to issues in certain process steps. • Duplication of work, complex process with many handoffs or many players involved.

18. Rapid Process ImprovementStep 2: Understand the Process Handling High Level Issues Make a decision before moving onor Make a decision for future actionor Document for consideration by a sub team

19. Rapid Process ImprovementStep 3: Identify and Analyze Barriers • Barrier documentation is brainstorming • Identify all barriers to achievement of the mission • Classify and prioritize the barriers • Identify additional staff needed to remove barrier • Identify causes and potential method of removal from the work process

20. Rapid Process ImprovementStep 3: Identify and Analyze Barriers • Anything that keeps staff from optimizing their efforts as they relate to the mission must be identified and removed. • All barriers must be identified no matter how small they appear to be. • Without meaningful and detailed barriers the team will be unable to fix the process and errors may still occur

21. Examples of Barriers Hand Off Communication RPI - (Actual # 114) • No report given from nursing unit to all procedural areas and error may occur • MAR is not routinely sent with patient to procedural areas and medication to be given is missed • Sending nurse put "on hold" waiting for receiving nurse to answer • Delay in transport could result in need for an updated report

22. Rapid Process ImprovementStep 3: Identify and Analyze Barriers • Barrier Types & Type Coding Type 1 – We can fix (80-85%) Type 2 - We can fix with help (bench-strength) Type 3 – Not likely to be fixed (<1%)

23. Rapid Process Improvement Solutions to Barriers • Barrier • Barrier impact ( High, Med, Low) • Probable causes • Most likely cause(s) • Possible solutions • Recommended actions

24. Rapid Process Improvement Solutions to Barriers A good solution finds the root cause

25. Rapid Process Improvement Solutions to Barriers Aspects of Good Solutions Cost effective • Minimum negative impact on any part of the system • “Upstream fix” • Employs “Poka-yoke” (cannot fail) no error will be made • Involves the customer • Allows you to meet your performance target (Mission)

26. Rapid Process Improvement Solutions to Barriers Designing a process so it cannot fail (3 types of Poka-yoke) • Not allow the system to work unless all required criteria are met • System shuts down • Alarm sounds

27. Rapid Process Improvement Solutions to Barriers • Lasting solutions usually come from changing the work process, not from awareness or training • If people have been trained once on a system or procedure, re-training is not the best solution

28. Sometimes solutions don’t resolve the problem

29. Rapid Process Improvement Why Test? Step 4 – Identify, test and select solutions • The purpose of this step is to evaluate recommended actions and agree on desired solutions • Test solutions before implementation Welcome aboard the initial SMH Flight 001. Just thought you might want to know, this plane has never been tested.

30. Rapid Process ImprovementStep 4 – Identify, test and select solutions • Action Plan ComponentsAction steps: What and how it will be doneWho is responsibleWhen it will be completedComments

31. Rapid Process ImprovementStep 5 – Implement • Purpose • To identify key actions that must be taken to be successful • To provide a plan that assigns accountability • To provide a plan to make changes during the implementation

32. Rapid Process ImprovementStep 6 – Ensure Results • Purposes • To evaluate the success of the implemented plan • Place corrective actions in place when performance is not as expected • To ensure that the desired performance is maintained • Identify candidates for replication

33. Rapid Process ImprovementStep 6 – Ensure Results • You must track the same indicator that you used to define your problem in the Set Direction step of this process • Display data graphically. Show data “before and after”

34. Before and After Graph Nursing Correct Responses to Handoff Communication Questions Gap Good

35. Patient scheduled for handoff M1 Communication given to receiving unit M2 Communication received from sending unit M3 Patient handoff to receiving dept. completed Q1 Q2

36. Rapid Process ImprovementStep 7 – Remaining Issues and Future Plans • Develop a standardization plan to ensure lasting results • Identify areas for replication • Determine next steps that will be taken by project team • Identify any remaining issues to be resolved by others

37. Rapid Process Improvement Methodology • Using the methodology, can you think of any processes in your own work area that you can analyze to prevent errors? • Some examples might be: specimen labeling; medication administration and patient identification

38. Any Questions?