Mistake Proofing for Lean Healthcare  book cover
1st Edition

Mistake Proofing for Lean Healthcare

ISBN 9781439837436
Published September 3, 2015 by Productivity Press
111 Pages 146 B/W Illustrations

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Book Description

The principles of mistake proofing, long used to eliminate errors and defects across a range of industries, are now being applied in healthcare organizations around the world to help ensure patient safety, improve services, and eliminate waste.

Mistake Proofing for Lean Healthcare
is based on the definitive mistake-proofing philosophy and system developed by Shigeo Shingo. This reader-friendly book introduces the main concepts and benefits of mistake proofing in healthcare and highlights common reasons that errors and defects occur. It also explains how to catch errors before they become defects, using the concept of "source inspection," so you can ensure quality before a process is performed instead of afterward. When systematically used, the mistake-proofing approach explained in this book will help you:

  • Create safer, more reliable, and more effective healthcare services for both patients and staff
  • Establish a culture in which mistakes and the conditions that cause them are readily surfaced so they can be corrected
  • Lay the foundation for processes that flow smoothly, without disruption
  • Eliminate rework, waste, and the need for extra resources and supplies

Presenting real-world healthcare examples, the book shows different types of mistake-proofing devices and methods (poka-yoke) that provide feedback quickly and automatically to prevent errors and defects.

The book is part of the Lean Healthcare Series and is designed for individual or group learning. Each chapter includes reflection questions to facilitate understanding and stimulate discussion and action.

Table of Contents

Getting Started
Purpose of This Book
What This Book Is Based On
Two Ways to Use This Book
How to Get the Most Out of Your Reading
     Become Familiar with This Book as a Whole
     Become Familiar with Each Chapter
     Using a Reading Strategy
     Using the Margin Assists
Overview of the Contents
     Chapter 1: Getting Started
     Chapter 2: The Production Processes and Operations of Healthcare
     Chapter 3: Introduction to Mistake Proofing
     Chapter 4: Basic Elements of the Mistake-Proofing System
     Chapter 5: Using Poka-Yoke Systems
     Chapter 6: Examples of Poka-Yoke Applications
     Chapter 7: Reflections and Conclusions

The Production Processes and Operations of Healthcare
The Industrial Origins of Lean Healthcare
Production, Process, and Operation
Principles of Lean Healthcare Management
     Standard Work
     Flow Production
     Socratic Method

Introduction to Mistake Proofing
What Is Mistake Proofing?
Why Focus on Zero Defects?
How Mistake Proofing Makes Work Easier
What Causes Defects?
     Communication Errors
     Cognitive Errors
     Red-Flag Conditions
Controlling Conditions So Defects Do Not Happen
     The Traditional Quality Improvement Cycle
     Integrating PDCA in the Mistake-Proofing Approach

Basic Elements of the Mistake-Proofing System
Quality at the Source
The Four Elements of Mistake Proofing
Three Approaches to Inspection
Judgment Inspections Reveal Defects
Informative Inspections Reduce Defects
     Statistical Quality Control
     Successive Checks
Source Inspection Keeps Errors from Becoming Defects
100 Percent Inspection Catches All Errors
A Short Feedback Loop Means Quicker Action on Problems
Poka-Yoke Systems Catch Errors We Might Have Missed

Using Poka-Yoke Systems
About Poka-Yoke Systems
Poka-Yoke Systems in Source Inspection and in Informative Inspection (Self-Checks and Successive Checks)
How Poka-Yoke Systems Regulate the Process
Types of Poka-Yoke Systems
Method Poka-Yokes
     Checklists in Healthcare
     Using Checklists Effectively
     Stop the Line—Stop the Process
Physical Poka-Yokes
     Contact or Identification Techniques
     Fixed-Value or Number Techniques
     Motion-Step or Sequence Techniques
Poka-Yoke Sensors
Devices that Link to Poka-Yoke Sensors

Examples of Poka-Yoke Applications
Learning from Examples of Poka-Yoke Applications
Method Poka-Yoke Examples
     Thoracic Surgery Checklist
     Red Event Safety Alert, Incident Command Checklist
     Chart Preparation Checklist
     Rounding Checklist
     Clinician Previsit Checklist
     Electronic Health Systems
Contact or Identification Poka-Yoke Examples
     Integrated Color-Coding Systems
     Other Color-Coding Poka-Yokes
     Wristbands with Bar Codes or Radio-Frequency Identification Tags
     Tactile Signals on Wrong Buttons
     Throat Pack Identification
     Shrink-Wrapping on Dangerous Medications
Fixed-Value or Number Poka-Yoke Examples
     Surgical Sponge-Counting Systems
     Automatically Timed Processes
     Automated External Defibrillator
     Bed Angle Visual Aid
     Pulse Oximeter
Motion-Step or Sequence Poka-Yoke Examples
     Oral Care Pegboard
     Glucose Test Reminder
     Hand Hygiene Monitoring Systems
     Sheathed Needles

Reflections and Conclusions
Reflecting on What You Have Learned
Applying What You Have Learned
     Possibilities for Applying What You Have Learned
     Your Personal Action Plan
     Opportunities for Further Learning

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Tom Jackson is the former CEO of Productivity, Inc. and Productivity Press and member of the influential Ford Lean Advisory Group.