ABSTRACT
BACKGROUND: A new cardiac surgery program was developed in a community hospital setting using the operational excellence (OE) method, which is based on the principles of the Toyota production system. The initial results of the first 409 heart operations, performed over the 28 months between March 1, 2008, and June 30, 2010, are presented. METHODS: Operational excellence methodology was taught to the cardiac surgery team. Coaching started 2 months before the opening of the program and continued for 24 months. RESULTS: Of the 409 cases presented, 253 were isolated coronary artery bypass graft operations. One operative death occurred. According to the database maintained by The Society of Thoracic Surgeons, the risk-adjusted operative mortality rate was 61% lower than the regional rate. Likewise, the risk-adjusted rate of major complications was 57% lower than The Society of Thoracic Surgeons regional rate. Daily solution to determine cause was attempted on 923 distinct perioperative problems by all team members. Using the cost of complications as described by Speir and coworkers, avoiding predicted complications resulted in a savings of at least $884,900 as compared with the regional average. CONCLUSIONS: By the systematic use of a real time, highly formatted problem-solving methodology, processes of care improved daily. Using carefully disciplined teamwork, reliable implementation of evidence-based protocols was realized by empowering the front line to make improvements. Low rates of complications were observed, and a cost savings of $3,497 per each case of isolated coronary artery bypass graft was realized.
Subject(s)
Cardiac Surgical Procedures/methods , Diffusion of Innovation , Efficiency, Organizational , Evidence-Based Practice/methods , Evidence-Based Practice/organization & administration , Thoracic Surgery/methods , Thoracic Surgery/organization & administration , Aged , Cardiac Surgical Procedures/economics , Cardiac Surgical Procedures/standards , Coronary Artery Bypass/economics , Coronary Artery Bypass/methods , Cost Control , Female , Humans , Institutional Management Teams/organization & administration , Male , Middle Aged , Patient Care Team/organization & administration , Pennsylvania , Problem Solving , Program Development , Quality Assurance, Health CareABSTRACT
BACKGROUND: An estimated 200,000 Americans suffer central line-associated bloodstream infections (CLABs) each year, with 15%-20% mortality. Two intensive care units (ICUs) redefined the processes of care through system redesign to deliver reliable outcomes free of the variations that created the breeding ground for infection. METHODS: The ICUs, comprising 28 beds at Allegheny General Hospital, employed the principles of the Toyota Production System adapted to health care--Perfecting Patient Care--and applied them to central line placement and maintenance. Intensive observations, which revealed multiple variances from established practices, and root cause analyses of all CLABs empowered the workers to implement countermeasures designed to eliminate the defects in the processes of central line placement and maintenance. RESULTS: New processes were implemented within 90 days. Within a year CLABs decreased from 49 to 6 (10.5 to 1.2 infections/1,000 line-days), and mortalities from 19 to 1 (51% to 16%), despite an increase in the use of central lines and number of line-days. These results were sustained during a 34-month period. DISCUSSION: CLABs are not an inevitable product of complex ICU care but the result of highly variable and therefore unreliable care delivery that predisposes to infection.
Subject(s)
Bacteremia/prevention & control , Catheters, Indwelling/microbiology , Cross Infection/prevention & control , Problem Solving , Total Quality Management/methods , Academic Medical Centers , Bacteremia/etiology , Catheterization, Central Venous/adverse effects , Catheters, Indwelling/adverse effects , Drug Resistance, Multiple, Bacterial , Hospital Bed Capacity, 500 and over , Humans , Inservice Training , Intensive Care Units , Pennsylvania , Sentinel SurveillanceSubject(s)
Cross Infection/prevention & control , Disease Notification/methods , Industry/methods , Mandatory Reporting , Quality Assurance, Health Care/organization & administration , Risk Management/organization & administration , Safety Management/organization & administration , Hygiene , Pennsylvania , Quality Assurance, Health Care/methods , Safety Management/methodsABSTRACT
The Pittsburgh Regional Healthcare Initiative (PRHI) is a coalition of 35 hospitals, 4 major insurers, more than 30 major and small-business health care purchasers, dozens of corporate and civic leaders, organized labor, and partnerships with state and federal government all working together to deliver perfect patient care throughout Southwestern Pennsylvania. PRHI believes that in pursuing perfection, many of the challenges facing today's health care delivery system (eg, waste and error in the delivery of care, rising costs, frustration and shortage among clinicians and workers, financial distress, overcapacity, and lack of access to care) will be addressed. PRHI has identified patient safety (nosocomial infections and medication errors) and 5 clinical areas (obstetrics, orthopedic surgery, cardiac surgery, depression, and diabetes) as ideal starting points. In each of these areas of work, PRHI partners have assembled multifacility/multidisciplinary groups charged with defining perfection, establishing region-wide reporting systems, and devising and implementing recommended improvement strategies and interventions. Many design and conceptual elements of the PRHI strategy are adapted from the Toyota Production System and its Pittsburgh derivative, the Alcoa Business System. PRHI is in the proof-of-concept phase of development.
