Many healthcare organizations hit a patient safety roadblock on their Lean transformation journey. Leaders and staff who are learning to see waste discover the connection between good process design and patient safety. Suddenly, every problem seems to cry out for a full-blown root cause analysis (RCA) because it could have caused serious harm! It is easy to make the mistake of thinking you need to double down on patient safety rounds and start doing RCAs on every defect discovered on gemba visits. But you don’t need a new patient safety initiative. Your daily management system is your patient safety program. Done well, a daily management system improves reliability, decreases the number of RCAs you do, and increases the quality of your RCAs.
Weave Your Safety Data Into Your Daily Management System
It’s important to leverage your patient safety event reporting system as a problem-finding tool. Encourage your frontline staff to report any issue, no matter how small it seems. Ensure that your staff report defects, waiting, and other wastes in addition to the obvious safety problems. Then sort the data not just by event type and location, but also by how close the issue got to a patient. After you sort, then you should analyze the incoming data for process problems that need attention, as well as for safety events. Pull the data from your reporting system to use with your Lean daily management tools like scorecards, status sheets, visual management boards, performance huddles, and monthly performance reviews. All of these processes should all begin with safety data. By weaving daily safety data into your management operating system, you are hardwiring patient safety into the way your organization works.
Triage Your Safety Events To Avoid RCA Overload
Triage your incoming safety data, reserving full-blown investigations for big events. Let your daily management system and continuous improvement take care of the rest and divide your incoming reports into three categories:
1. Just Do Its
These are the kinds of problems a good frontline manager solves every day, like replacing expired medications in a code cart or correcting an error on a patient’s allergy list. The difference between plain old good management and a lean management system is visibility. You can use your event reporting system to record and track the small corrections that good managers take for granted. These small issues become visible, allowing you to see patterns.
2. Apparent Cause Analysis (ACA):
Assign incidents that are unnerving but do not result in serious harm to the ACA category. These require nothing more than a quick A3 problem-solving cycle to correct the apparent risk. In a Lean management system, frontline staff and managers handle these as part of their day job.
Near-miss serious events caught by a planned safety check, failures to follow standard work or protocols caught before harm was done, and small events that caused easily treated temporary harm are handled here. For example, an incident where a patient’s oxygen supply ran out but the pulse oximeter alarm caught it before harm was done would merit a quick, localized A3 (ACA) to understand why the oxygen ran out. Just Do Its that have become a recurring theme should be bumped up into the ACA category as well.
Save RCAs for the big events. Resist the urge to RCA everything - they should be your last resort. Otherwise you will waste time and talent on investigations done hastily because your Risk Management staff has too many to do.
A good RCA requires a trained investigative team and a significant commitment of resources. Train your RCA team not just in safety science, but also in A3 thinking and Lean process design. Conversely, you could provide safety and reliability training to your lean coaches. Use the A3 to document your RCAs. RCAs that leverage rapid PDCA cycles, scientific method, and strong work design principles produce lasting improvements.
Do high-quality RCAs when sentinel and near-miss events reach your patients. Near-miss sentinel events caught by random chance or plain dumb luck merit a real RCA too. Likewise, lower level events that are showing up organizationally as patterns, despite attempts to correct with ACAs, should be given the attention of an RCA.
Leverage Your Frontline Lean Practitioners to Improve Safety
Remember the holes in James Reason’s Swiss cheese model for system failures? Those holes are your Just Do Its and ACAs. When all the holes line up and a patient falls through, you get an event that requires an RCA. Lean management systems teach frontline staff and managers to improve their own work - to fix the holes in the Swiss cheese. Refocus your patient safety work on your Lean management system and let it take care of the holes. When improving work is part of everyone’s day job, your organization’s Lean journey merges with the road to High Reliability.
Creating a Lean Management System virtual workshop
Beyond Heroes by Kim Barnas