We have covered a great deal of material during the past seven weeks. I have been very impressed by your many insightful posts, as well as your idealism, passion, and energy. I have felt a sense of community, and I have very much enjoyed conversing with you over the Internet. I feel I know you better than if I had presented this course in a large lecture hall. There are not too many lecture halls that could have held 6,500 students. And it could have been quite expensive to bring students from 153 countries to one location. As I mentioned many times, these instructional videos and posts are only the beginning. It'll be important for you to practice what you have learned. Remember Kierkegaard's marvelous narrative about the newly educated ship captain. In week one, I presented Mary's frightening illness, and we outlined how our personal experiences exemplified the problems of modern healthcare. Preventable medical errors have now been estimated to be the third leading cause of death in the United States. And similar death rates have been reported throughout the world. It is very clear that our healthcare delivery systems need improvement. We defined a system as an interdependent group of items, people, or processes working together toward a common purpose. And modern healthcare consists of multiple interdependent processes or steps, making modern healthcare delivery systems highly complex. As noted by Don Berwick, every system is designed to produce the outcome it achieves. And in the IHI video, he describes the ideal characteristics of a healthcare system, STEEEP. Safe, timely, effective, efficient, equitable, and patient-centered. In week two, we discussed how manufacturing principles can be applied to healthcare. Some suggest that physicians don't like these analogies and feel they were imported from Japan. But the irony is that Toyota Production System, TPS, was developed by William Deming, an American. American car companies ignored Deming's ideas. As we discussed in week two, in 2008, Chrysler and General Motors went bankrupt. The key point is that TPS and other industries provide an extremely useful set of approaches that can increase the value and improve the safety of healthcare. We highlighted value streams, sequential and iterative. And we also discussed waste reduction, describing eight forms of waste. Remember, production = work- waste. We can improve output without increasing personnel if we focus on waste. Continually ask, is this of value to my patient? We also reviewed how to guard against PUSH medicine, a major problem in the United States. Thanks to TPS, defective new cars called lemons are now exceedingly rare. If we could apply TPS consistently in healthcare, deaths and severe injures could also be dramatically reduced. I selected representative posts that I liked from week two. I apologize that I could not include more of these insightful comments. Shazia Aman wrote, after attending week two of the course and learning the importance of value stream mapping and elimination of waste, I've realized the importance of time management in the clinical care process. Jamie Brydone-Jack wrote, staff resource cuts are the primary ways to achieve a better bottom line. There are better ways to reach those goals that aren't as apt to cause staff burnout, namely value streams. In week three, we discussed the vital importance of teamwork for orchestrating the many professionals required to manage a single patient. And I showed how teamwork can be taught by applying athletic principles that many of us learned when we were young. First playbooks, protocols, eliminating ambiguity and assuring that every task is being performed in a coordinated fashion. Remember, in our system, the patient is the team owner. Secondly, who is passing, and who is receiving? Customer-supplier relationships, they need to be clearly defined. And third, game films. We need to continually ask, what went well, and what could be improved? We also reviewed key fundamentals, the huddle. This flattens the hierarchy and creates a zone of safety that encourages everyone to share their ideas. Efficient communication, soap plus disposition and SBAR, they allow efficient and effective communication to take place. Disruptive providers destroy teamwork, just like a player who fails to follow the rules or work with others. Coaches call this bad sportsmanship. Referees can remove these players from the game, and hospital administrators need to consider the same strategy for chronically disruptive providers. Posts I liked in week three, Arthur Hamerschlag wrote, teaching teamwork, which I fully support, would be much easier if that was the norm and expectation that doctors, nurses, pharmacists and case managers had coming out of their professional training. Mary Littlefield, the risk that unchecked hierarchy will disrupt teamwork must be avoided and overcome. Tyra Howes, I think it is really important to have zero tolerance for physician disruptive behavior. It gives a new look to the hospital and the workers. In week four and five, we covered how to reduce and prevent errors. We reviewed conditions that increase human error, including lack of sleep, stress, and multi-tasking. We next discuss what to do when an error occurs, including root cause analysis, driver and fishbone diagrams, and asking why five times. With the help of Bob Lloyd of IHI, reviewed the use of the Plan-Do-Study-Act cycles as the simplest method for creating improvement plans. Finally, in week four, with the help of Steve Spear, we emphasized the importance of recognizing and avoiding workarounds. Don't simply step over the wire. In week five, we introduced you to William Deming's famous red bead exercise that demonstrates the tyranny of random or common cause variation. Under the present conditions, patients and providers too often can end up with a red bead, an error. With the help of Bob Lloyd, we next reviewed the use of the run chart, usually the best method for differentiating common cause, or random cause, from specific cause variation, a true change. Next I calculate the likelihood of a medication error when reliability is 99.9%, or one error per thousand. In the average 800 bed hospital, this reliability is estimated result in one death due to a medication error, every 80, 90 days. We need to aspire to Six Sigma, that is 3.4 errors per million. Next, we review tools that can be used to improve reliability. Forcing function being top on the pyramid of preventable tools, followed by computerization, and standardization and checklists. We also presented a new approach to patients who are harmed by medical errors that was developed at the University of Michigan. This approach is transparent and ethical and helps patients who have been inadvertently harmed. I want to thank IHI Open School and Michael Briddon for providing instructional videos and much helpful advice. I recommend that all of you attend IHI Open School. In preparation for this course, I completed all of the IHI Open School modules. And they complement and reinforce many of the lessons in this course. Some of the posts I liked in weeks four and five, Suzanne O'Brien, as hard as we may try, accidents and errors may still happen. Many times people refer to these events as dumb mistakes. When was the last time we encountered a smart mistake? Nancy Duffy, consider the workaround when it comes to infusion pumps, medication dispensing systems, alarm silencers, the electronic medical record, etc. Potential for negative outcomes is significant. I realize, quality and safety in healthcare is complex, but it can start at the bedside. Haresh Vachhrajani wrote, when I learned about the run chart, I plugged several weeks of retrospective data with the CL, central line infections. We realized that the variation was random, even without any shifts or trends. The data showed common cause variation. Using run charts for interpretation of some observations is very helpful. In week six, we discussed leadership. Too often in healthcare a command and control model of leadership is used. However, in order to improve healthcare quality, everyone needs to play a leadership role. Leadership teams are required to manage the complexity of modern healthcare. And a distributive leadership model that includes providers on the front lines, encourages effective change, and improves job satisfaction. As in no other field, leaders should never lose sight of their North star to improve the health and well-being of our patients. To bring about the changes required to significantly improve the quality and safety of healthcare, we will need to be adaptive leaders. It is important for everyone to differentiate technical from adaptive change. Remember, technical change is relatively easy to implement, while adaptive change creates emotional stress and must be carefully managed to maintain emotional disequilibrium in the productive zone. Those who want to truly improve the quality of healthcare will need to act like beekeepers. Adaptive leaders need to be rewarded and promoted. The lives of our patients depend on it. Finally, in week seven, we discussed how to campaign to bring about change. We should emulate Samuel Adams, the Founding Father who converted colonists from apathy to activism and was responsible for the American Revolution. First you must understand your constituencies in healthcare, that include patients, nurses, physicians, students, and administrators. One point I would like to add is that given the central role of physicians in directing patient care, for most campaigns, it will be important to recruit a physician champion. On the week eight landing page, I have included the web addresses for two IHI videos by Dr Don Goldmann and Steve Spear that discuss how to encourage physicians to become involved in improving quality and safety. These videos are optional, but if you are planning to recruit physicians to your quality campaign, I recommend watching these videos. We next reviewed how to use personal narrative. Emotions need to be aroused in order to encourage change. We need to begin with the story of self, followed by the story of us, and finally end with the story of now. One on one meetings are required to recruit a leadership team who will be responsible for agreeing on measurable goals and creating strategies and tactics that encourage action. An effective campaign's leaders train new leaders in this continual increase in leadership quotient that mimics the structure of a snowflake. Too often, leadership teams continue to plan and fail to act. They tip-toe around the pool. But to be successful, you must jump in. Remember, without action, there can be no change. In the next video, we will discuss how to use your new tools and understanding to act. Thank you.
