National Patient Safety Goals and Standard Work
The Joint Commission recently released the list of the 2009 National Patient Safety Goals. The NPSGs, as they are fondly known, promote specific improvements in patient safety by providing evidence-based guidelines on persistent patient safety issues to healthcare organizations.
Two of the 2008 goals were published with timelines to be met: teams put in place by April 1, work plans fashioned by July 1, piloting to begin by October 1 and full implementation by January 1, 2009. These two goals require an anticoagulation management program (3E) and selection of a method to directly request additional assistance from specially trained individuals when the patient’ condition appears to be deteriorating (Goal 16). Although the goal does not require a Rapid Response Team (known to many people as a Kaizen team), this is a common implementation strategy.
Three of the 2009 goals also come with the same timeline, with full implementation required by January, 2010: implementation of evidence-based practices to prevent healthcare associated infections due to multiple drug-resistant organisms, central line bacteremias, and surgical site infections.
How do these goals, as well as the other National Patient Safety Goals relate to “standard work?” The Joint Commission requires processes (procedure) and policies (which often reflect the process) as a measure of compliance with these goals. The Joint Commission is not prescriptive about what those processes are to be, however. Standard work, a Lean Healthcare cornerstone, establishes an agreed-upon method and procedure for the best sequence and timing to perform a process or step in a value stream. Standard work establishes the best method that we currently know, to perform a task which provides the best patient care and reduces waste.
3E, or the anticoagulation management goal, requires 3 key elements: approved, evidence-based protocols for warfarin, low molecular weight heparin and unfractionated heparin. Protocols are a form of standard work: dosing, timing, monitoring, target therapeutic ranges (of the INR). It also requires training for staff, providers and patients. The manner in which patients are educated should also be process-driven. Who does it? When? Where? Standardized content and a way to evaluate the patient’s understanding. If the patient is discharged from the hospital, but fails to understand that they must refill their prescription after 30 days, get ongoing monitoring, and follow a stable diet, all the best intentions of everyone may end in a negative and tragic outcome because of a stroke or bleed.
The new 2009 goal to prevent central line bacteremias follows work already being done by the IHI and various healthcare organizations. There are a variety of central line procedural checklists available already, which outline the process before, during and after central line insertion. Implementing a checklist at the time of insertion will help ensure that all processes are carried out for each central line placement, making the process reliable. This is another example of standard work, which is advocated as essential by Lean Healthcare champions.
The timelines (standard work for us) force us to be very intentional about what we are doing: establishing the best future state, mapping processes, development strategies and materials, building evaluation tools, piloting, revisions, final implementation and evaluation. These things take time, but because the approach it consistent, it is reliable. It is quite clear where Joint Commission is going with this; we can smile and understand. As we work with our teams, we can continue to stress the value of standard work and help with team members’ understanding of the structure of these initiatives.
Standard work: timelines, protocols, checklists, procedures and the NPSGs assist to promote ”IDEAL” patient care, that is defect-free and exactly as requested. Care can be customized to each patient, on demand as requested. Responses to problems or changes in condition are timely and appropriate. Standard work promotes safety for patients, staff and providers: physically, emotionally and professionally.
This week’s blog was written by Bill and Janice Lowstuter. Bill Lowstuter has been a Sr. Consultant with HPP since its inception, and has worked with healthcare clients throughout the USA. Bill previously worked with HPP’s parent company, The ACCESS Group (TAG) for seven years prior to joining HPP. Bill has overseen the implementation of Lean within numerous facilities and industries, and has a Bachelor of Science degree in Engineering from the University of Illinois. He has also conducted numerous seminars and conferences in Kaizen principles and Lean. Bill’s multi-disciplined background includes direction over functional organizations such as operations, quality assurance, materials management, purchasing, environmental, health and safety, and human resources. His experience in these areas provides a unique perspective that allows perfect complimenting between strategic and tactical plans. Janice Lowstuter is the Regulatory Readiness Coordinator at St. Anthony Central Hospital, a Level 1 trauma center in Denver, CO. Janice’s professional background includes critical care and post-anesthesia care nursing, staff education and performance improvement. She holds undergraduate degrees in home economics and nursing and an MBA in Health Care Administration from the University of Colorado.
Charles Hagood, a principal and President/CEO of Healthcare Performance Partners, LLC (HPP) has
overseen the implementation of
Cindy Jimmerson is a pioneer of lean healthcare, having initiated her work with a grant
from the National Science Foundation, 2001-2004. She is the founder and president of