Urgent ( Lean Management A3 project presentation)
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SystemsRedesignImprovement-AWARE.pptxSystems Redesign & Improvement
By: Andrea Ware
August 10, 2020
The Michael E. DeBakey VA Medical Center
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Overview
Wrong-patient errors in blood transfusion have an adverse impact on the quality of patient care.
Errors linked to blood transfusion in a health care setting should be prevented to minimize the risk for preventable deaths (Hensley et al., 2019).
Accurate patient identification and correct labeling of blood for transfusion in every healthcare setting is indispensable to efforts to address patient safety issues in healthcare.
Purpose: To identify an interdisciplinary team-based improvement project based on the Root Cause Analyses (RCA) of the safety events.
Aim: To decrease the wrong-patient errors in Blood Transfusion by the 25% at the end of the 1st Quarter/ FY 21. Eliminate barrier for the facility moving toward High-Reliability Organization (HRO) to deliver value to the veterans it serves.
The Michael E. DeBakey VA Medical Center
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Draft Problem Statement
The Problem is that there is poor communication between the Interdisciplinary Team, with a preoccupation failure and reluctance to simplify.
Preoccupation with failure is a principle that applies to the presented situation since the staff feel that nothing is ever done to correct the errors.
Reluctance to simplify the complexity in the organization has been attributed to poor communication between clinical staff.
The Michael E. DeBakey VA Medical Center
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Proposed Project
An interdisciplinary team-based improvement project proposed based on the RCA of the safety events at MEDVAMC involves the use of BARCODES and Offering Communication training.
Barcoding will help improved the accuracy of labels on blood and minimize the RISK of patient receiving blood of the wrong blood type.
Communication training will equip clinical staff with the knowledge, skills and abilities needed to reduce errors arising from inadequate communication between the staff.
The Michael E. DeBakey VA Medical Center
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Managing & Leading the Project
The main Objective is incorporating Barcoding System.
Improving the Communication, between the Nurses and Physicians
First Step: Weekly Team Meeting should be initiated
Develop communication FRAMEWORK from weekly meeting Structures, processes and outcomes
Use the FRAMEWORK to guide the team’s communication.
The Michael E. DeBakey VA Medical Center
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Improvement Methodology
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To address and track the safety failures, the failure mode and effect analysis (FMEA) will be used.
Failure – Potential – “Lack of Communication; labels in error
Mode – Types, Ways, & Possibilities -
Effect – Negative Effect on process under study
Analysis – Study RISK and Reduce it
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The Michael E. DeBakey VA Medical Center
Data
Patient Safety Report (Joint Patient Safety Reporting (JPSR) – Hospital Administration
Regardless, data on the effectiveness of barcoding when it comes to addressing blood labeling errors will be considered.
The data will be used to evaluate the effectiveness of the proposed solution.
Interviews that have been conducted by the organization will also be used to identify the specific issues that the project will address.
The Michael E. DeBakey VA Medical Center
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A3 Tool
| 1. Reason for Action | 4. Gap Analysis | 7. Completion Plans |
| Improve Communication & Add New Barcoding System | Communication Barriers Lack of Spirit | Making Sure Completion plan is on Track |
| 2. Initial State | 5. Solution Approach | 8. Confirmed State |
| Poor Communication. Led to medical errors. Three patients died | Increase Staff Interaction through meetings. Improve communication. Provide sustainable solution. | Confirmed State metrics should be in place. Like the Final Reports. |
| 3. Target State | 6. Rapid Experiments | 9. Insights |
| Proper Coordination & Communication Between the Teams | Checking whether the solution s are working Using the FMEA. | Key Lessons will be documented and Future Opportunities Identified. |
The Michael E. DeBakey VA Medical Center
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Required Resources & Tools
A3 is the suitable tool
It will document learning, decisions and planning
Automated error-proofing tools will also be indispensable to efforts to minimize laboratory errors that contribute to erroneous labeling.
E-learning platforms will be used to train the teams to carry out the improvements.
Training programs will be designed and implemented in collaboration with trainers and subject matter experts.
The Michael E. DeBakey VA Medical Center
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Ensuring Project Sustainability
Develop partnership.
Involve Key Stakeholders
Ongoing Training
Regularly evaluation of project
Avoiding Mission Drift
The Michael E. DeBakey VA Medical Center
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Using Change Management
Used to prepare the service line to accept, implement and sustain improved processes.
This will happen through the following five levers:
Communication Plan
Sponsor Roadmap (for the MCD)
Coaching & Training Plans
Change Management plan
The Michael E. DeBakey VA Medical Center
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Incorporating Dashboards and Graphical Reports
Data Dashboard will be instrumental
Visually tracks, analyzes and display Key Performance indicators to monitor the process.
Robust Barcoding System – for data support
These tools will be helpful in making the organization sensitive to operations and committed to resilience.
Dashboards and graphical reports are interactive data VISUALS, which will provide feedback toward sustainability
The Michael E. DeBakey VA Medical Center
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Project Closure
The project will be closed by
Gaining Stakeholder Acceptance (Medical Center Director)
Collect and present Outputs (Project Documents; Final Reports)
Final Report & Presentation to the Senior Management.
Tracking the Results will help confirm if the project goals are met.
The Michael E. DeBakey VA Medical Center
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Benefit of Project to MEDVAMC Veterans
Improve communication
ADD -Robust Barcoding System (Minimize Errors)
More Coordination of the TEAMS
Improve/rather revamp the reputation of Facility
Decrease barriers from becoming HRO
Overall restore confidence of the Veterans
The Michael E. DeBakey VA Medical Center
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References
Hensley, N. B., Koch, C. G., Pronovost, P. J., Mershon, B. H., Boyd, J., Franklin, S., ... & Stierer, T. L. (2019). Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration. The Joint Commission Journal on Quality and Patient Safety, 45(3), 190-198.
Kaufman, R. M., Dinh, A., Cohn, C. S., Fung, M. K., Gorlin, J., Melanson, S., ... & Degree, L. (2019). Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfusion, 59(3), 972-980.
Weick, K. E., & Sutcliffe, K. M. (2015). Managing the unexpected: Sustained performance in a complex world. Hoboken: Wiley.
The Michael E. DeBakey VA Medical Center
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The Michael E. DeBakey VA Medical Center
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