Commentary: "Who was caring for Mary?" revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement.

Over 15 years have passed since Mary's near death (Annals of Internal Medicine. 1993;118:146-148). Disappointment in the care by fellow academic physicians persists; however, a reanalysis of her case through the lens of complex systems design and performance yields a more accurate and actionable perspective. Mary's suffering was not due to human failure alone. Human failure was provoked and exacerbated by broken processes including ambiguous assignments of responsibility; inadequate transfers of information and authority; unreliable or unavailable protocols for providing safe, effective treatment; and a failure to integrate the deep but narrow perspectives of individual specialists into a complete picture of Mary's condition. Her case exemplifies, in personal terms, many of the system challenges academic medical centers face: Faculty have other missions that can conflict with patient care; disease complexity is high, requiring input from multiple subspecialists; clinical departments serve as roadblocks to communication; and novice physicians, requiring close supervision, have primary responsibility for the day-to-day care of acutely ill patients. The academic physicians who first cared for Mary unwittingly accepted flawed systems, and they failed to work around them. At great monetary and emotional expense, last-minute heroics saved Mary. In a dysfunctional system, even the most conscientious physician may be viewed as uncaring. As Mary's case so clearly illustrates, patients and their families see the system and the physician as one. Only by working to improve the systems of delivery will academic physicians again be consistently viewed as caring.

Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients.

There is a marked gap between the potential of medical science to treat illness and injury and the performance of the health care system in which hard-working, intelligent, well-trained people put that science to work. Care is available to too few, and costs and risks of injury are too high. This is avoidable. Experience in Boston, Pittsburgh, Salt Lake City, Seattle, and elsewhere indicates that quality can be raised-while risks and costs are dramatically reduced-by applying lessons from the highest-performing industrial organizations to designing, operating, and improving health care processes. What are these lessons? Improve sick processes with the same approaches used to treat patients. Specify "normal." When problems in quality, safety, efficiency, responsiveness, and the like occur, quickly determine exactly what is abnormal and determine what might be causing them. Develop a "treatment plan"-process changes that will eliminate or counteract the causal factors. Run the process (or a facsimile) with a modified, watching for gaps between actual and expected outcomes. When gaps occur, do a new work-up, diagnosis, treatment plan, and test. Lessons in designing, operating, and improving processes can be taught just as medical expertise is developed. Teach basic frameworks didactically; then, provide hands-on experience in applying those principles to real problems. Start with simple well-bounded situations that can be practiced frequently, with rapid feedback and close mentoring before advancing to more complex, less well bounded situations that occur less frequently and provide less immediate feedback between action and outcome. Incorporate development of process improvement skills into residency training so that deepening expertise within specialties is complemented by greater skill at integrating functional knowledge into well-integrated care processes.

Operational failures and interruptions in hospital nursing.

OBJECTIVE: To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care. DATA SOURCES: Primary observation, semistructured interviews, and surveys of hospital nurses. STUDY DESIGN: We sampled a cross-sectional group of six U.S. hospitals to examine the frequency of work system failures and their impact on nurse productivity. DATA COLLECTION: We collected minute-by-minute data on the activities of 11 nurses. In addition, we conducted interviews with six of these nurses using questions related to obstacles to care. Finally, we created and administered two surveys in 48 nursing units, one for nurses and one for managers, asking about the frequency of specific work system failures. PRINCIPAL FINDINGS: Nurses we observed experienced an average of 8.4 work system failures per 8-hour shift. The five most frequent types of failures, accounting for 6.4 of these obstacles, involved medications, orders, supplies, staffing, and equipment. Survey questions asking nurses how frequently they experienced these five categories of obstacles yielded similar frequencies. For an average 8-hour shift, the average task time was only 3.1 minutes, and in spite of this, nurses were interrupted mid-task an average of eight times per shift. CONCLUSIONS: Our findings suggest that nurse effectiveness can be increased by creating improvement processes triggered by the occurrence of work system failures, with the goal of reducing future occurrences. Second, given that nursing work is fragmented and unpredictable, designing processes that are robust to interruption can help prevent errors.

Using real-time problem solving to eliminate central line infections.

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.

Fixing health care from the inside, today.

Today, you are about as safe in a U.S. hospital as you would be parachuting off a bridge or a building. But it doesn't have to be that way. Right now, some hospitals are making enormous short-term improvements, with no legislation or market reconfiguration and little or no capital investment. Instead of waiting for sweeping changes in market mechanisms, these institutions are taking an operations approach to patient care. In case after detailed case, the article describes how doctors, nurses, technicians, and managers are radically increasing the effectiveness of patient care and dramatically lowering its cost by applying the same capabilities in operations design and improvement that drive the famous Toyota Production System. They are removing ambiguity in the output, responsibilities, connections, and methods of their work processes. These changes-which can be done in the course of an ordinary workday, sometimes in a matter of hours-are designed to make the following crystal clear: Which patient gets which procedure (output); Who does which aspect of the job (responsibility); Exactly which signals are used to indicate that the work should begin (connection); and Precisely how each step is carried out (method). Equally important, managers are being transformed from rescuers who arrive with ready-made solutions into problem solvers who help colleagues learn the experimental method. Thus, these hospitals are breaking free of the work-around culture that routinely obscures the root causes of so many problems, creates so much waste, and leads to so many unnecessary deaths.

Ambiguity and workarounds as contributors to medical error.

Why are some organizations error-prone-regularly subject to interruptions and inconveniences, some of which periodically coalesce catastrophically-whereas other organizations, although similar in the products and services they generate and the process technologies they use, are reliable, adaptable, and continuously self-improving, relentlessly learning from experience to get ever better? Analyzing medical error reports and studies of high-performing, non-health care organizations reveals 2 differences. High performers know how to prevent problems from producing further consequences once they occur and how to prevent their recurrence. They do this by specifying how work is expected to proceed-who will do what for whom, with what purpose, when, where, and how-before work is actually done. Then, when anything contrary to expectations occurs, it is immediately identified as a problem. Through this approach, the effects of problems are contained, the causes are quickly investigated, process knowledge is deepened, and recurrence is prevented. In contrast, error-prone organizations tolerate ambiguity, a prevailing lack of clarity over what is supposed to happen at any given time. Problems are thus hard to identify, and, even when recognized, they are worked around. People "get the job done," but don't initiate efforts to learn from the problem or improve the process. We believe that coupling high degrees of specification with rapid responses to individual problems can improve health care. Superlative manufacturing, service, and military organizations apply this approach to myriad processes and situations, and initial health care trials of this approach have been promising. We discuss how such an approach could be initiated in health care more broadly.

Medical education as a process management problem.

With complaints that new doctors are less prepared for residency and practice than expected, are burdened with debt, and then take even longer to complete their specialty training, the authors ask whether medical education can be designed more effectively. Curriculum redesign and pedagogical reform efforts to date address fragments of medical education-the content of particular courses or clerkships or the way in which the courses or clerkships are conducted. However, these reforms do not typically address the relationships among the various elements, that is, in what order skill sets should be sequenced, how communication should occur between disciplines, and by what mechanisms skills or knowledge should be mastered and assessed by the end of one phase so students are prepared adequately for the next. In failing to address these systems issues, current reform efforts may forgo some opportunities to convey and properly insure greater mastery of knowledge and skills in less time, at less cost. A case study of a typical student's third- and fourth-year clerkships illustrates how focusing only on educational elements leads to the exclusion of opportunities to systemically facilitate the relationships among them. This situation is contrasted with how other demanding, high-tech, knowledge-intensive industries with outstanding operations have learned to achieve superlative performance by managing and designing both the elements and the interactions among them within complex work and learning systems. The authors' exploratory research offers suggestions for medical education reform and frames additional opportunities for further discussion.

Learning to lead at Toyota.

Many companies have tried to copy Toyota's famous production system--but without success. Why? Part of the reason, says the author, is that imitators fail to recognize the underlying principles of the Toyota Production System (TPS), focusing instead on specific tools and practices. This article tells the other part of the story. Building on a previous HBR article, "Decoding the DNA of the Toyota Production System," Spear explains how Toyota inculcates managers with TPS principles. He describes the training of a star recruit--a talented young American destined for a high-level position at one of Toyota's U.S. plants. Rich in detail, the story offers four basic lessons for any company wishing to train its managers to apply Toyota's system: There's no substitute for direct observation. Toyota employees are encouraged to observe failures as they occur--for example, by sitting next to a machine on the assembly line and waiting and watching for any problems. Proposed changes should always be structured as experiments. Employees embed explicit and testable assumptions in the analysis of their work. That allows them to examine the gaps between predicted and actual results. Workers and managers should experiment as frequently as possible. The company teaches employees at all levels to achieve continuous improvement through quick, simple experiments rather than through lengthy, complex ones. Managers should coach, not fix. Toyota managers act as enablers, directing employees but not telling them where to find opportunities for improvements. Rather than undergo a brief period of cursory walk-throughs, orientations, and introductions as incoming fast-track executives at most companies might, the executive in this story learned TPS the long, hard way--by practicing it, which is how Toyota trains any new employee, regardless of rank or function.

Driving improvement in patient care: lessons from Toyota.

Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)--a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance. The authors discuss the rationale for applying TPS to healthcare and implementation of the system through the development of "learning unit" model lines and initial outcomes, such as dramatic reductions in the number of missing medications and thousands of hours and dollars saved as a result of TPS-driven changes. Tracking data further suggest that TPS, with sufficient staff preparation and involvement, has the potential for continuous, lasting, and accelerated improvement in patient care.