Table Of ContentBusiness Management / Healthcare Process Improvement R
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Mistake Proofing for Lean Healthcare o
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Rona Consulting Group & Productivity Press G
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Samuel Carlson, MD, FACP and Maura May, Editors p
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The principles of mistake proofing, long used to eliminate errors and defects across a range of ity
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industries, are now being applied in healthcare organizations around the world to help ensure re Lean Healthcare
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patient safety, improve services, and eliminate waste. •
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Mistake Proofing for Lean Healthcare is based on the definitive mistake-proofing philosophy o
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and system developed by Shigeo Shingo. This reader-friendly book introduces the main concepts M Rona Consulting Group & Productivity Press
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and benefits of mistake proofing in healthcare and highlights common reasons that errors and y
defects occur. It also explains how to catch errors before they become defects, using the concept of
Samuel Carlson, MD, FACP and Maura May, Editors
“source inspection,” so you can ensure quality before a process is performed instead of afterward.
When systematically used, the mistake-proofing approach explained in this book will help you:
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• Create safer, more reliable, and more effective healthcare services for both patients i
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• Establish a culture in which mistakes and the conditions that cause them are readily e
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surfaced so they can be corrected
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• Lay the foundation for processes that flow smoothly, without disruption o
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• Eliminate rework, waste, and the need for extra resources and supplies
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Presenting real-world healthcare examples, the book shows different types of mistake-proofing r
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devices and methods (poka-yoke) that provide feedback quickly and automatically to prevent e
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errors and defects.
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The book is part of the Lean Healthcare Series and is designed for individual or group learning.
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Each chapter includes reflection questions to facilitate understanding and stimulate discussion t
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K11698
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K11698 cvr mech.indd 1 7/15/15 10:20 AM
Mistake
Proofing for
Lean Healthcare
Lean Tools for Healthcare Series
Series Editor: Thomas L. Jackson
PUBLISHED
5S for Healthcare
Standard Work for Lean Healthcare
Kaizen Workshops for Lean Healthcare
Mapping Clinical Value Streams
Mistake Proofing for Lean Healthcare
FORTHCOMING
Just-in-Time for Healthcare
Continuous Flow for Healthcare
Quick Setup for Healthcare
Kanban for Healthcare
Mistake
Proofing for
Lean Healthcare
Rona Consulting Group & Productivity Press
Samuel Carlson, MD, FACP and Maura May, Editors
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2016 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20150716
International Standard Book Number-13: 978-1-4822-8213-9 (eBook - PDF)
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Contents
Preface .........................................................................................................ix
Acknowledgments .......................................................................................xi
1 Getting Started ......................................................................................1
1.1 Purpose of This Book ........................................................................1
1.2 What This Book Is Based On ............................................................1
1.3 Two Ways to Use This Book .............................................................2
1.4 How to Get the Most Out of Your Reading ......................................2
1.4.1 Become Familiar with This Book as a Whole ......................2
1.4.2 Become Familiar with Each Chapter .....................................3
1.4.3 Using a Reading Strategy .......................................................3
1.4.4 Using the Margin Assists .......................................................4
1.5 Overview of the Contents ..................................................................5
1.5.1 Chapter 1: Getting Started .....................................................5
1.5.2 Chapter 2: The Production Processes
and Operations of Healthcare ...............................................5
1.5.3 Chapter 3: Introduction to Mistake Proofing ........................5
1.5.4 Chapter 4: Basic Elements of the Mistake-Proofing System....5
1.5.5 Chapter 5: Using Poka-Yoke Systems ....................................6
1.5.6 Chapter 6: Examples of Poka-Yoke Applications ..................6
1.5.7 Chapter 7: Reflections and Conclusions ................................6
2 The Production Processes and Operations of Healthcare ...................7
2.1 The Industrial Origins of Lean Healthcare ........................................7
2.2 Production, Process, and Operation ..................................................9
2.3 Principles of Lean Healthcare Management ....................................11
2.3.1 Standard Work .....................................................................12
2.3.2 Autonomation .......................................................................13
2.3.3 Flow Production ...................................................................13
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Contents
2.3.4 Plan–Do–Check–Act ............................................................14
2.3.5 Socratic Method ...................................................................14
2.4 Summary ...........................................................................................15
2.5 Reflections ........................................................................................15
3 Introduction to Mistake Proofing .......................................................17
3.1 What Is Mistake Proofing? ................................................................17
3.2 Why Focus on Zero Defects? ...........................................................18
3.3 How Mistake Proofing Makes Work Easier .....................................19
3.4 What Causes Defects? .......................................................................20
3.4.1 Communication Errors .........................................................20
3.4.2 Cognitive Errors ...................................................................21
3.4.3 Red-Flag Conditions .............................................................21
3.5 Controlling Conditions So Defects Do Not Happen .......................23
3.5.1 The Traditional Quality Improvement Cycle ......................23
3.5.2 Integrating PDCA in the Mistake-Proofing Approach ........24
3.6 Summary ...........................................................................................25
3.7 Reflections ........................................................................................26
4 Basic Elements of the Mistake-Proofing System ................................29
4.1 Quality at the Source .......................................................................29
4.2 The Four Elements of Mistake Proofing ..........................................30
4.3 Three Approaches to Inspection .....................................................31
4.4 Judgment Inspections Reveal Defects..............................................32
4.5 Informative Inspections Reduce Defects .........................................33
4.5.1 Statistical Quality Control ....................................................33
4.5.2 Successive Checks ................................................................34
4.5.3 Self-Checks ...........................................................................35
4.6 Source Inspection Keeps Errors from Becoming Defects ...............37
4.7 100 Percent Inspection Catches All Errors ......................................38
4.8 A Short Feedback Loop Means Quicker Action on Problems ........38
4.9 Poka-Yoke Systems Catch Errors We Might Have Missed ...............39
4.10 Summary ...........................................................................................40
4.11 Reflections ........................................................................................41
5 Using Poka-Yoke Systems ...................................................................43
5.1 About Poka-Yoke Systems ................................................................43
5.2 Poka-Yoke Systems in Source Inspection and Informative
Inspection (Self-Checks and Successive Checks) ............................43
5.3 How Poka-Yoke Systems Regulate the Process ...............................44
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Contents
5.4 Types of Poka-Yoke Systems ............................................................45
5.5 Method Poka-Yoke............................................................................46
5.5.1 Checklists in Healthcare ......................................................46
5.5.2 Using Checklists Effectively .................................................48
5.5.3 Stop the Line—Stop the Process .........................................50
5.6 Physical Poka-Yoke ...........................................................................50
5.6.1 Contact or Identification Techniques ..................................51
5.6.2 Fixed-Value or Number Techniques ....................................51
5.6.3 Motion-Step or Sequence Techniques .................................53
5.7 Poka-Yoke Sensors ............................................................................54
5.8 Devices that Link to Poka-Yoke Sensors .........................................55
5.9 Summary ...........................................................................................56
5.10 Reflections ........................................................................................58
6 Examples of Poka-Yoke Applications .................................................59
6.1 Learning from Examples of Poka-Yoke Applications ......................59
6.2 Method Poka-Yoke Examples ...........................................................60
6.2.1 Thoracic Surgery Checklist ..................................................60
6.2.2 Red Event Safety Alert, Incident Command Checklist .......62
6.2.3 Chart Preparation Checklist .................................................63
6.2.4 Rounding Checklist ..............................................................64
6.2.5 Clinician Previsit Checklist ..................................................66
6.2.6 Electronic Health Systems ...................................................67
6.3 Contact or Identification Poka-Yoke Examples ...............................68
6.3.1 Integrated Color-Coding Systems ........................................68
6.3.2 Other Color-Coding Poka-Yoke Examples ..........................70
6.3.3 Wristbands with Bar Codes or Radio-Frequency
Identification Tags ................................................................71
6.3.4 Tactile Signals on Wrong Buttons .......................................72
6.3.5 Throat Pack Identification ...................................................73
6.3.7 Shrink-Wrapping on Dangerous Medications .....................74
6.4 Fixed-Value or Number Poka-Yoke Examples .................................75
6.4.1 Surgical Sponge-Counting Systems .....................................75
6.4.2 Automatically Timed Processes ...........................................76
6.4.3 Automated External Defibrillator ........................................77
6.4.4 Bed Angle Visual Aid ..........................................................78
6.4.5 Pulse Oximeter ....................................................................79
6.5 Motion-Step or Sequence Poka-Yoke Examples ..............................80
6.5.1 Oral Care Pegboard .............................................................80
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Contents
6.5.2 Glucose Test Reminder ........................................................81
6.5.3 Hand Hygiene Monitoring Systems .....................................82
6.5.4 Sheathed Needles .................................................................83
6.6 Summary ...........................................................................................84
6.7 Reflections ........................................................................................84
7 Reflections and Conclusions ...............................................................85
7.1 Reflecting on What You Have Learned ...........................................85
7.2 Applying What You Have Learned ..................................................86
7.2.1 Possibilities for Applying What You Have Learned ............86
7.2.2 Your Personal Action Plan ...................................................86
7.2.3 Opportunities for Further Learning ....................................87
7.3 Conclusion ........................................................................................88
Appendix ....................................................................................................89
Further Reading About Mistake Proofing and Related Topics.................89
Further Reading About Lean Healthcare ..................................................89
Useful Websites .........................................................................................90
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