Today, I'm going to discuss an underappreciated, but very helpful strategy for improving health care delivery, visual controls. Many industries, particularly Toyota, have been utilizing this helpful approach for decades. because they have recognized the importance of using a key sense or sight to allow workers to monitor their progress and to relay important information. What are visual controls? Visual controls are images, lights, boards and other visible signals that can convey key information at a glance. A picture is worth a thousand words. They can remind and inform those on the front lines and they can provide immediate feedback or guidance. When properly used, they can stimulate conversations that encourage interdependence and problem solving. There are many types of visual controls. One of the best known and the most efficient is the Andon. The Andon provides an immediate visual alert to an abnormality, deficiency or a need. At Toyota, assembly workers are able to pull a cord or push a button that sends a signal to the supervisors, and other workers, that an abnormality has been detected. And activates the swarming problem solvers to the location to quickly correct the defect and to prevent further mistakes from occurring. In addition to Andons, other visual controls include defective item displays. They show the number of defects and displays of this data help prevent further problems. Error prevention displays identify error prone situations and can explain how to prevent them. Kanban is a tool that calls for a supply to be ordered. Line demarcations are taped lines that identify pathways, work locations and they expected placement of specific objects. Production management boards show current conditions, the frequency of defects, delays, unmet demands and encourage everyone to focus on improvement. Red tags distinguish needed from unneeded and we discussed them in our 5S video. Sign boards, signs indicating what belongs where and in what number, was also discussed in our 5S lesson. Standard operations tools are charts that identify the right people, equipment, and supplies. We have all seen Andons in our daily life. A railroad crossing light warns us of an approaching train. One helpful Andon on health care, is a call light at the entrance of a patient's room, requesting help from a nurse. There are many types of Andons. The first example I showed you was a paging Andon requesting the nurse. A second type, is an emergency Andon, designed to alert everyone to an abnormality. Some places have sepsis lights in their emergency room. There is the Rothman Index and MEWS, which I would describe in just a minute. A third type is an operations Andon that shows the equipment's operating status. We see this on intravenous pumps, cardiac monitoring and when someone needs a supply. And, finally, Andons can be used to monitor the progress of work with long cycle times. For example, OR, a light to show induction, surgery, closing, exit from the operating room. Failure to rescue patients who are deteriorating is a major problem in many healthcare systems, and Andons have been designed to alert nurses and physicians that patients are in danger. Two of these emergency Andons are the MEWS, a scoring system based on blood pressure, heart rate, respiratory rate, temperature and mental status. This warning system detects sudden changes but can generate a significant number of false alarms. The second emergency Andon is the Rothman Index that includes all the parameters of MEWS, plus laboratory data and nursing assessment. This system accumulates the data from the electronic records and graphs trends over time. This system is able to identify long term trends and provides an earlier warning system to encourage more timely interventions. This system has been shown in preliminary studies to reduce in patient mortality by nearly 30%. Here is a typical Rothman Index plot showing the score of a hospitalized patient over time. The higher the score, the better the health status of the patient. As you can see, this patient has deteriorated during his hospitalization, and his score has dropped to below 40, reaching 20. Robust in patient data has shown that a patient with a score of below 40 has a 20% risk of dying during the next year, and, therefore, the patient's condition should be regarded as critical, warning special attention by nurses and physicians, they need to swarm to the bedside. This red flag on the top of a hand hygiene dispenser provides a signal that the dispenser is out of liquid and needs to be resupplied. Here, is a defect display board, documenting the frequency of defects on our medical surgical floor. We have not had a mislabeled specimen, wrong specimen in tube, WSIT, in 844 days. As you can see, falls have proved to be a particularly tough problem among our frail and elderly patient population. To address this issue, a checklist has been created, and we are beginning to implement this approach. As the production display shows on the left, in the first month adherence to the checklist has been difficult, but new habits take time to become ingrained. Visual aids can prevent equipment from being placed in the wrong location. One of my favorite visual controls is the whiteboard, a production board at each patient's bedside that includes the date, list the physician and the nurses caring for the patient, and has a space where the patient treatment plan for the day can be summarized. This is left blank because of confidentiality concerns. How do we decide and design visual controls? I recommend using the Plan, Do, Study, Act cycles we described in Fixing Healthcare 1.0. To plan, you need to ask, what problem am I trying to solve? What is my goal? What process do I want to monitor? What visual control would be most effective for achieving my goal? What's standard response do I expect? Then, do. Implement the control and responses. Then, study. Evaluate the effectiveness and act upon your findings. Continue to present visual control if it proves to be effective. If it is ineffective, begin a second PDSA cycle. When designing your visual controls, make sure they are clear in their meaning, in other words, are unambiguous. That they are consistent across the organization. Are easily seen, and are truly necessary. Watch out, too many visual controls can cause confusion. You don't want to create visual overload. Not only should you focus on the visual cue, but also make sure those who see the cue respond appropriately. Responses need to be prompt and there should be a clear expectation of a standard response. Standard work. Without a meaningful response, the Andon is useless. Ineffective or unreliable responses will reduce trust and lack of trust will reduce compliance, endangering our patients. You may end up causing harm rather than helping improve the condition. Visual controls can improve patient care because they can convey, at a glance, the status of a work process, make waste easier to identify, and help to standardize countermeasures. Implementation requires strong leadership, commitment and discipline, there must be a consistent and reliable response. When properly implemented, visual controls can save lives. Thank you.