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Hospital CEO support crucial to quality, safety efforts

September 4th, 2012

by Kevin L. Shrake

The easiest initiative for a CEO to commit to and the hardest to execute is the culture change required to truly impact quality and safety in hospitals.

Lean techniques utilize a plan-do-check-act (PDCA) process to determine if a particular task should be performed. Six Sigma utilizes a define-measure-analyze-improve-control (DMAIC) process to determine the most efficient method of carrying out a task once it has been determined necessary.

Many top organizations in and outside of healthcare have adopted a process called the Toyota Production System (TPS) that blends Lean and Six Sigma techniques into a unique quality and safety program that is more employee-focused and tends to offer a more specific, actionable path to move toward perfect. Although the scientific, data-driven method used by Six Sigma may be very attractive to engineers, it has a tendency to be project-oriented rather than globally-focused on improving quality and it is less exciting to the front-line staff.


There is an old adage in change management called the "20 foot rule." If you truly want to know how to make a change to improve quality, engage the people who are within 20 feet of a task or process. Not only do they know the answers, but having their commitment to making improvements is an essential element of success.

Problem: Waste is everywhere in healthcare, with some estimates being as high as $1 trillion annually. Although every healthcare executive will say our primary customer is the patient, our systems and processes are largely built around the providers. After careful analysis, we can find an unlimited amount of waste in key areas such as time, errors, motion, transportation, inventory and processing, to name a few.

Executives often feel they have "done more with less" for so long that there is simply not much more that they can do to be more efficient and cost-effective. The reality is that proponents of the TPS believe there is still 40 percent to 50 percent waste in our healthcare systems!

Solution: A commitment to perfection must start with the CEO and permeate every employee of the organization with a unified approach to eliminate waste and, therefore, improve quality and safety. Although it may seem counterintuitive, it has been proven over and over that high quality also produces lower costs. Top organizations now are reaching out to companies and expert consultants who can assist in making perfection the goal of everyone's day. The TPS model blends all current best practices into a culture change that becomes the defining characteristic of an organization.

Healthcare organizations have not set the bar high enough in our pursuit of perfection. Many of our quality benchmarks should be 100 percent, not something less, for standards such as operating on the correct leg! The highest levels of quality and safety are not achieved through a "campaign" or a directive from the C-suite. It must become a part of everyday life for each employee. This requires leadership and not directives.

Results: The TPS process sets the standard of driving down incident and error rates to zero. This is accomplished by empowering employees with the skills and authority to solve every problem that can cause harm to patients and workers. To be effective, there has to be a commitment from the C-suite to encourage and reward a culture of reporting. Once this commitment has been made, it is often shocking to organizations to learn what their true error rate is for events such as medication errors.

You can simulate high quality by having a culture based on punishment and fear, which encourages employees to under report. Only when you know what your true error rate is for a particular aspect of care can you really quantify the results and drive the error rate toward zero. We must adopt the philosophy that we cannot be perfect, but our pursuit of perfection should be relentless.

Hospitals whose CEOs have led the pursuit of perfect safety using the ideas of TPS have realized between 50 percent and 67 percent reductions per year in incidences of harm reaching workers and patients!

There is an employee safety metric in the industry that defines the number of employees per 100 who miss at least one day of work per year due to an incident at work. This standard metric averages 3.6 lost workday cases per 100 employees across the healthcare industry. Two different hospitals pursuing zero lost workdays have driven their rates well below one, or three to four times better than the average.

To put this in perspective, applying these improvements at a 10,000-employee health system would prevent 300 staff injuries per year! These improvements have a profound impact on productivity and workers' compensation costs.

A patient related success story is illustrated via the results of a major 1,200-bed academic medical system in the eastern United States. Its baseline of central-line infections on an annual basis was 383. By engaging the TPS process, it reduced that rate to single-digit infections per year sustained for multiple years. It has not achieved perfection, but its pursuit of perfection through empowering staff to solve the root causes of infections resulted in drastic improvements.

Take-home Thought: To improve quality and safety, CEOs must first recognize there is huge opportunity in their organizations. Then they must make a commitment to a process that inspires employees and comforts those they serve. If every organization made a commitment to eliminate waste, reduce errors, improve efficiency and, therefore, lower cost, we may well find our solution to the healthcare crisis in our country after all.

Kevin L. Shrake ( is a 35 year veteran of healthcare, a Fellow in the American College of Healthcare Executives and a former hospital CEO. He currently serves as the Executive Vice President/Chief Operating Officer of MDR™, based in Fresno, Calif.


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