Welcome to our third part, Inspection and Poka-Yoke. First I want to ask the question, what is the difference between a mistake and a defect? As we previously discussed, mistakes are inadvertent errors, as we emphasize, humans make mistakes all the time. Defects are mistakes that are passed along to the next step in the process or passed along to the patient. We need to design systems to prevent errors from reaching patients. Ideally, as practiced on the Toyota production line, when a defect is recognized, the operation must stop, by pulling an Andon and supervisors respond immediately to correct the defect. We want to be defect free! Inspection as an important tactic for preventing errors from reaching patients. And there are six levels of inspection and the higher the level the less likely a mistake will ever become a defect and reach the patient. Level 1 red is bad there is no inspection and a customer finds out the problem themselves. When this happens, the patient has usually been impacted by the defect. The air has reached the patient. Level 2, end of the line inspection, is fair, and, in our color code, is between red and orange. Level 3 is fair to good, and is the coded orange, and consists of checking yourself with judgment. This requires your full attention at all times, and we know that humans are incapable for attention for prolonged periods. Level 4 is yellow and is somewhat better and consists of successive checks. You inspect the worker before you. Level 5 is better, also yellow, and is self-checked with a smart machine, Poke-Yoke, inspection. Finally, level 6 is best, color coded green, error proofing that prevents the error from ever happening. Using the tools described in the previous video, we hope you can help your health systems to reach this ultimate goal. Now, let's look at each level of inspection in more detail. Here is a schematic diagram of level 1, no inspection. Operator 1 performs a proper action, operator 2 makes a mistake, and operator 3 builds on the mistake. Converting a mistake into a defect, and the defect reaches the patient. Patients, too often, fail to complain about, or fail to recognize the defect, and therefore, there is no feedback, and the system cannot improve. Level 2, end of the line inspection. Operator 1 performs the proper action, operator 2 makes a mistake, and operator 3 does not correct it. The defect is detected by an inspector at the end of the line. As you see it does not result in feedback to the operator 2 because the inspector does not have the time and may not be able to determine who is primary responsible for the defect? Again, the system cannot improve. Level 3, self-inspection with judgment. Operator 1 performs the proper action, operator 2 makes the mistake, recognizes, and self corrects the mistake and usually learns from the mistake. This requires continuous vigilance and judgment on the part of operator 2 and is an unrealistic expectation for the human brain. We all have temporary periods of inattention and mental fatigue. Make me miss an unreliable approach. Warning signs has been used to encourage individuals self inspection and self correction. However, despite such signs, the usual adherence rate for hand hygiene is 40% to 60%. Therefore, self inspection with judgment even with the assistance of warning signs does not achieve high enough reliability. Could level 4 inspection significantly hand hygiene compliance? Level is 4 downstream inspection by operator 3. Operator 3 can provide feedback to operator 2 who made the error. However, operator 3 may not always be able to fully reverse operator 2's mistake. With regards to hand washing, this would require that a second person follow the nurse or physician around and repeatedly remind them to wash their hands. This would be an extremely labor intensive and costly method. And could lead to discord between operator 2 and 3. To determine the root causes of poor hand hygiene, I have constructed a driver diagram based on prior studies of hand hygiene conversations with nurses, physicians, sanitation workers, and food delivery personnel. There are generally four primary drivers resulting in poor hand hygiene compliance. One, I don't have time. Two, I forgot. Three, I don't think it is important. And four, I'm worried about the alcohol based solutions drying out my hands. If you ask why, for each of these drivers secondary drivers can be identified. Nurses often claim they don't have time to wash their hands, because they have too many other tasks to perform. They have too many patients, or because they need to prioritize their activities after an emergency. Nurses may forget to wash their hands because they are distracted by an emergency. Or because they have not developed a habit of washing their hands every time they walk in and out of a patient room. They must specifically think about washing their hands, this is called slow thinking. Rather than having conditioned themselves to automatically wash their hands as they go in and out of rooms. Fast thinking, some providers in my experience primarily doctors, do not think hand washing is important because administrators have not emphasized this activity, or not created a plan to hold physicians accountable. And because doctor's have not been properly educated in the importance of hand hygiene. Finally, some worry about the drying out of their hands. Often these individuals are using soap and water washes for every patient, rather than using an alcohol and hand cream based solution, that is less drying. As shown in the far right column, these secondary drivers provide a number of interventions that have the potential to improve compliance. Based on our understanding of inspection, level 5 inspection. Using a smart machine to remind individuals to wash their hands has in my view and many systems expert's view, the highest likelihood of cheating a high compliance rate and encouraging provider to habitually wash their hands. So is there a smart machine, smart machines are sometimes call Poka-Yoke, that can detect hand washing. The answer to this question is yes. There is an alcohol detector that is worn in the lapel, as shown here by my colleague and friend, Kelly Jacowitz, the nurse clinical leader for our floor. When she walks through the threshold of a door, a detector above the door identifies the badge. And if she does not rub her hands with the alcohol based solution and place her one hand near the detector to detect the alcohol fumes, the badge will beep and turn yellow, followed by red within 30 seconds. This badge counts each even as compliant or non-compliant when the detector is placed in the charger all these events are then downloaded to a central data repository. And every week, Kerry receives a report on her compliance by email. This approach represents level five inspection. Self inspection with smart machine warning. Of course, Kelly could ignore the warning and not wash her hands of because this adherence data is made available to all administrators they can closely monitor compliance. Within two to three weeks after initiating hand hygiene badges, adherence has increased to 96%. Illustrating the power of level 5 inspection. Poka-Yoke machines monitor processes in three ways. By the contact method, a machine senses conditions like temperature or weight, or will warn if too warm or too heavy. The machine being worn by Kelly detects alcohol. A second way the machines can monitor is by a fixed value method that detects an expected fixed number of objects or drops. The operator receives a warning or the device will not let the operator proceed. An example is patient controlled analgesic pump, PCA pump. After a certain number of requests or button pushes, the pump stops administrating the intravenous medication to prevent an overdose. And finally, there are machines that can detect motion or whether or not a motion or an action has been completed. Such machines can send a warning or prevent the operator from performing a second action. Level 6 is our final and ultimate goal. Operator 2 is not able to make a mistake, because using Poka-Yoke, self-inspection and by creating procedural controls, the potential air has been eliminated. High level inspection is important and a useful approach, and we should all aspire to 0 defects. The lives of our patients are depending on it. Thank you.
