By Anne Foley, MBB, CSSBB, PMP, Director of Lean Six Sigma, IIL
Let me begin by saying that if you have started a diet in 2016, this story might help you stick to it.
I had just filled my plate with goodies at a holiday party when my friend Kim decided to tell me what happened to her eighty-two-year-old mother while recovering from abdominal surgery. (Hospital stories are not known to make us hungry and I ended up dumping my plate of cheese and crackers, but this is a story worth sharing because there are valuable lessons for us all.)
After a successful surgery, Kim’s mother was moved into a semi-private room. When she arrived, the second bed was empty but a few hours later another woman was moved into the bed closest to the window. It took about 24 hours for Kim and her mother to realize that the new roommate was admitted to the hospital for a serious stomach flu that was very contagious.
“Do you really think it’s a good idea for someone with a stomach flu to share a room with anyone, let alone someone who has a large and painful incision across her stomach?” Kim asked the head nurse. The color drained out of the nurse’s face as she knew that a mistake had been made, and she immediately called for someone to find another room for Kim’s mother. Unfortunately, it was too late and Kim’s mother ended up catching that stomach flu. It almost killed her. I won’t share all the details but suffice it to say it was very painful for all involved.
Hospitals are no different than any other business. They are staffed with human beings and none of us are perfect. We all make mistakes. That being said, the potential consequences of mistakes in hospitals are far greater than most businesses.
That’s why Lean Six Sigma in healthcare is so critical. The processes that healthcare professionals work within should be error proofed. Another word for error proofing that Lean practitioners use is Poka-Yoke. In Japan, that means to avoid inadvertent errors.
There are three techniques to error proofing a process:
- The first and most desired technique is to put a control into the process that will completely close the margin for error. In other words, prevent the mistake from ever occurring. What might that look like in a hospital admission process? The admission system recognizes the word “contagious” in the admission code and automatically assigns that person to their own room. Simple, right? But maybe their system doesn’t allow for this type of control.
- The second technique is to have some sort of an alarm or signal if a mistake has occurred, allowing the mistake to be self-corrected. If the hospital system did not allow for automated assignment, maybe it has the intelligence to sound an alarm if a human assigns someone with a contagious disease to a shared room. This relies on the admissions personnel to self-correct, so it’s not as effective as the first technique but sometimes there isn’t a choice.
- The third technique is to have the flow of the process stop before the undesired consequence. In this example, maybe the contagious patient is assigned to a shared room but the barcode on their patient bracelet sets off an alarm if they are wheeled into a room that has another patient.
The bottom line mindset of Poka-Yoke is that while it is fine to tell your workers not to make mistakes, it is smarter to put a process in place that makes it impossible to make them. Then let hospital personnel focus on helping the patients heal versus reacting to mistakes.
Is it expensive to put controls in place and prevent mistakes? Sometimes. But not nearly as expensive as a loss of life and/or potential lawsuit!
Learn more about IIL’s Lean Six Sigma training at www.iil.com/leansixsigma.
Anne F. Foley, PMP, MBB, CSSBB has been teaching Lean Six Sigma (DMAIC) and Project Management for eighteen years. Anne has served as the Director of Lean Six Sigma at IIL for the past thirteen years. She is also the author of The Passages to Peace (a novel) and a frequent contributor to Project Management, Lean Six Sigma and other various publications. Anne has a Bachelors of Science degree in Journalism and Mass Communications from Kansas State University.