In this session, I want to introduce you to additional tools designed to eliminate errors. When an errors occurs as we discussed in Fixing Healthcare 1.0, it's important to ask why five times, and to perform a root cause analysis. I would now like to introduce you to two very helpful tools that we have not covered before. The Pareto chart and Failure Mode and Effects Analysis, FMEA. Next, I want to discuss a helpful modification of the standard PDSA cycles, Plan Do Study Act cycle, we introduced you to in Fixing Healthcare 1.0. A modified PDSA cycle provides additional steps to more effectively complete the planning stage. And finally, I want to describe the A3 Form. This is a very helpful document that assures a more consistent approach, do plan, do study, and I like to call adjust cycles. And succinctly documents the rationale behind and the solutions to be achieved during a set of improvement cycles. The Pareto chart is a simple method for assessing the frequency of a specific process or error. A Pareto chart allows you to prioritize your improvement projects. There is only so much time during a day. As you begin to identify errors in your health system, you will quickly realize there are far too many problems to correct all of them at one time. It is critical to establish priorities and to identify which improvement projects we'll have the biggest impact. In the graph in the lower part of this slide, I have plotted the sample of 135 Medicare patients who experienced medical errors, and this was reported by the Office of the Inspector General in 2010. The frequency of each type of error is represented by the left vertical axis and the bar graphs. The cumulative percentage of errors is represented by the red line plotted on the right vertical axis. You can quickly determine the error types that represent 80% of the problems, shown by the blue arrow. This plot should encourage those taken care of Medicare patients to focus on three major processes, improving medical judgment. And I covered this and our videos on waste reduction and iterative care, correcting for substandard treatment. This will be discussed in our section on standard work and improving the monitoring of patients. I discussed this in our section on digital controls, specifically discussing the Rothman index. Our Pareto chart should be constructed before planning your quality projects. An important tool for proactively reducing errors is called the Failure Mode and Effects Analysis, FMEA. This process focuses on potential problems. FMEA is particularly helpful when a new process is being designed. Frontline providers who perform the procedure or are involved in the process should be recruited to mentally run through each step in the process and anticipate all the potential problems. Pick a process that has the potential to cause harm. For example, the case of Mary McClinton. An FMEA could of quickly identified the danger of having two clear solutions with very different purposes placed together in unmarked bottles. An FMEA would of saved Mary McClinton's life. Another dangerous process that lends itself well to FMEA is cancer chemotherapy. Too often when an FMEA suggested, potential participants claim there is no problem with the procedure or the process. We all need to remember that no problem is a problem, we can always improve. I recommend using the IHI FMEA application. The web address is listed here and takes the participants through a systematic step by step approach for identifying all potential errors. When performing this exercise, it is important to first define the current process. And this will require to use a process or value stream map. Go through each step and brainstorm with regards to potential errors. Then score each potential error using a three component scoring system that assesses, one, severity likely death with equal 10 to likelihood of that occurring, very high likelihood will equal 10 and 3. The difficulty of detecting that error, high difficulty with equal 10. The 3 scores are then multiplied and the highest possible score will then be 1,000. The team that should then use PDSA cycles to correct the highest scoring potential errors. This brings us to PDSA cycles. And a modified more in depth planning approach shown here. Rather than planning, representing a single step, this approach developed at breaks planning into five separate steps. First, clarifying the problem by asking what, where, when, who, and how. Second, breakdown the problem and narrow the scope. A Pareto chart as well as value streams and process maps are very helpful for this step. Third, clearly define the problem using a problem statement. Fourth, use the five whys and root cause analysis to understand the true cause of the problem. Without this step, seemingly common sense. First glance improvement plans will be implemented, they fail to address the true underlying causes. After completing these four steps, design potential countermeasures that will prevent the error from ever occurring. Then do, implement the countermeasures. Study, there effects using a run chart or other objective measures. And if the countermeasure is effective, adopt the countermeasure. Rather than using the term act to represent the A in PDSA, I like the term adjust. Because what this team is doing is adjusting the current procedure or process to reduce the likelihood of an error. Also, the term adjust rather than act emphasizes the new process is not permanent, but requires further iterations and adjustments. In most cases, it will take four to five PDSA cycles to create the most effective improvement plan. Before initiating a PDSA cycle, go to the front line where the work is being done, creating a precise problem statement is also critical. Remember to keep the scope narrow and to set milestones and targets, then create and implement countermeasures. Measure determine that if the countermeasure has worked and then create a standard work protocol to formally adopt the new process. As we discussed in Fixing Healthcare1.0, using athletic analogies, this is equivalent of adding a new play to the playbook. How can we system and ties and document an improvement plan? Toyota and many improvement teams in health care have embraced the A3 form. It is similar to the abstract summary provided in a scientific research publication. The A3 form captures the rationale behind the improvement plan, the experimental design, the measure used to prove the efficacy of the plan, and the cost and benefits. There are nine components of an A3 form. One, what is the issue? This is the Title. Two, Background. Three, current condition. Drawings are often helpful in describing the current condition. Four, problem analysis. Five, what is the target condition? What do we want to aim for? It is important, again, to draw the ideal state whenever possible. Six, describe the countermeasures. Seven, describe the implementation plan, what, who, when, and the expected outcome. And include a cost/benefit analysis. And finally, describe the plan for follow up to assure the plan is being adopted and sustained. Here is a blank A3 form showing how the form is laid out. There are many different A3 forms available on the Internet. I've included my form on the website as a Word file that you can download. You need to learn by doing. Just being familiar with these tools is not enough. Remember the ship captain described by Kierkegaard, fresh out of training who encounters his first storm at sea. He has not known the sense of impotence that comes when the pilot sees the wheel in his hand become a play thing for the waves. The learner has no conception of the change that takes place in the knower when he has to apply his knowledge. You can only learn by applying these error reduction tools. You must act. Our patients are counting on you. Thank you.
