The Tolerated Defects in
Healthcare
Introducing a new approach to safety in small rural hospitals
Aug 22, 2012
Roger Resar MD Senior IHI Fellow
1
The Small Hospital Challenge
• Large scale projects promoted for large hospitals frequently
do not apply (either by volume or nature)
• Staff time for team meetings is much less available
• Improvement skills are less available
• Resources are frequently very limited (travel, consultants,
etc)
2
A New Concept
1-Projects are small with the entire emphasis on frontline driven identification .(meaning not top down)
2-All work on the project is done by a dyad in a dyadic fashion (meaning no teams)
3-There are no team meetings (meaning work takes place on the project as work takes place on the unit)
4-Has no relationship to a large change package (meaning every unit will have unique projects with little chance
of sharing ideas unless the finished project is spread to other units in the organization)
5-The cost in resources to design the improvement is essentially nothing (meaning even small hospitals, clinics
etc can afford the methodology)
6-Measurement is local with pencil and paper and emphasis is based on bimodal simplicity (meaning data
collection is simple without need for IT)
7-Emphasis on JIT teaching rather than more formal quality improvement modules (meaning less cost, less time
lost and better application of what QI knowledge the organization currently has)
3
Frontline Defect Driven Project Model
x
Collect
Data
Suggest
Strategie
s
Small
Tests
Leading
To
Project
Success
Non-clinical
Clinical
Frontline
Defects
Frontline
Structured
Conversation
Frontline Engagement
Frontline Defect Driven Project Framework
Timeline
Design
Benefits
Actions
90 min
Frontline
Engagement
Surface
Defects
2 Days
Anchoring
Questions
Frontline
Feedback
x1
60 min
Leadership Frontline
Tester
Engagement Engagement Engagement
Scope
Defects
Conversation Align work
Specific
Design
Basics of Methodology Gauge
Capacity
the
Actions
1 day
Articulate
Implications
Study the next
defect
Validate
Y/N
Frontline
Data
Collection
Determine
frequency
60 min
30 days
Frontline
Engagement
Select
specific
work
Design
Strategy
Define
Boundaries
Frontline
Input
Determine
Simple
measures
Small
Tests
Finish
Project
R Resar
The Framework
• Multidisciplinary Team
• 90 Minute Visits
─Intro
─Identification of “defects”
Normalization of Deviation
• Non-threatening & blame free
environment
6
Check List for setting up the
Conversation
• Pre-arrange for a 90 minute conversation
(preferably the conversation occurs on the
unit)
• Pre-arrange a time for the conversation
(chose a time when a representative
group of frontline staff can participate)
• Invite a leadership representative
7
Technique to Start the Conversation
• Make introductions
• Have one lead person (others can
participate later) initiate the conversation
by asking individual frontline staff to
describe their daily routine (without
questions or interruption)
• Spend about 15-20 minutes in the start of
the conversation (to allay fears)
8
Technique to Surface Defects
• Use anchoring questions to start to surface defects
Examples:
1-We all have good and bad days at work, describe the last
difficult day you recall?
2-Things have to be adjusted in work flow to make the day
smooth, describe how you make adjustments to accomplish
getting the work done
3-What clinical diagnoses are most common on this unit,
describe the most difficult cases you work with?
4-The unexpected is bound to occur from time to time, describe
the last unexpected event that occurred in your work?
9
The Defects
• Each anchoring question usually surfaces at least one
defect
• Most 90 minute conversations surface from 12-20
defects
• Avoid spending time on possible solutions (that will
come later)
• Have a scribe write down each of the defects with as
much detail as possible
• Finish the conversation by listing the defects
surfaced, assure the frontline staff one or more of
these will be solved and then thank the team
10
Some Observations
• Daily interruptions are commonly viewed as normal,
so little or no attempt is currently made to change
processes
• The units function primarily at an artisan level of work.
Staff pride themselves in their unique ability to deal
with defects (scrambling).
• “Victimized” by external factors. Most areas described
problems with a system “out there”—units, physicians,
scheduling systems, a physician’s preference and
they are viewed as beyond their control
11
Cedars-Sinai Examples
• CVIC
─ Patients arrive for a procedure still on anticoagulation
─ Daily search for equipment
• OR/PACU
─ Cases delayed due to wrong equipment
• Radiation Oncology
─ Add-ons
─ Missing information
12
Cedars: Initial learnings
• It became clear that the seeds for the next event
have already been sown in the day-to-day missteps
described as “normal” by staff.
• Start small with the creation of small islands of
stability. An island of stability represents an area of
work that has been reviewed and changed to create
a new standardized way to organize workflow.
• Build unit-based learning, reflection on work,
measurement, and change leadership systems to
support work at the local level.
13
Frontline Defect Driven Project Framework
Timeline
Design
Benefits
Actions
90 min
Frontline
Engagement
Surface
Defects
2 Days
Anchoring
Questions
Frontline
Feedback
x2
60 min
Leadership Frontline
Tester
Engagement Engagement Engagement
Scope
Defects
Conversation Align work
Specific
Design
Basics of Methodology Gauge
Capacity
the
Actions
1 day
Articulate
Implications
Study the next
defect
Validate
Y/N
Frontline
Data
Collection
Determine
frequency
Select
specific
work
60 min
30 days
Frontline
Engagement
Design
Strategy
Define
Boundaries
Frontline
Input
Determine
Simple
measures
Small
Tests
Finish
Project