LEAN in a nutshell–Dave LaHote’s masterful diagram
The theme of our second day at Telluride was about reporting, risk management and quality improvement. We learned about the great examples that UIC and the University of Michigan Health System have set in adopting a policy of transparency and timely open and honest communication with patients when it comes to medical errors. The systems not only have resulted in improving direct communication between providers and patients, but have also led to significant cost savings (click here to learn more). The most important aspect of the system is that it allows a health system to engage in continuous quality improvement and learn from its mistakes.
However, as the discussion continued, we realized that while events at these health systems will trigger a process of error analysis and patient communication, many systems are severely lacking in a mechanism for medical students and residents to report errors and contribute to the process of continuous quality improvement for themselves and the system. Referencing LEAN manufacturing, what medical students and residents lack is an andon cord, a mechanism that “stops the line” and alerts management of a quality improvement problem. Without a process for safe reporting, medical students and residents become underutilized participants of the quality system.
The above diagram was drawn by LEAN expert, Dave LaHote. The diagram, while simple, wholly captures the essence of LEAN. What LEAN aims to do is align best practice standards with reality. If reality is different, then there is a process in place that allows individuals to “stop the line” and alert the need for a timely response of analysis and creation of a countermeasure to realign reality with the standard.
For those of you who do have a system for medical student error reporting, how does it work? Do you receive any feedback on errors that you report? Do these errors include only severe adverse events or near misses too? Are the reports anonymous? Is it a computer form or a trusted faculty member that you can report to? Tell me, describe your andon cord.