Urgent ( Lean Management A3 project presentation)
nstructions –
Please be prepared to present a 10-minute pitch
You are free to choose your own PowerPoint template, develop an A3, and/or include any other Lean tools in your pitch, but ensure the panel can visualize everything
The presentation has a time limit of 10 minutes (the panel will cut you off at 12 minutes) Straight to the point please . Cannot exceed 10 minutes
A brief question & answer session will follow the presentation
The content and delivery of the presentation will be scored
SCENARIO- Hypothetical
The facility had three safety events involving a patient receiving blood transfusions of the wrong blood type. All three patients died. Two (2) patients received their transfusions on a medicine unit and the other patient received his transfusion on a surgical unit. After a root cause analysis, it was found that transfusion orders for each patient were meant for other patients. Additionally, it was found that in two of the cases there were blood specimen labeling errors.
In the six (6) months before the deaths of these three patients, the facility had received ten (10) patient safety event reports (JPSR) related to blood labeling errors, but all were caught before a patient was harmed. When staff were interviewed about the event, many reported that communication between clinical staff has always been an issue. Several of the physicians interviewed stated that it is not uncommon for the Laboratory to make errors because nothing is ever done to correct them. The Medical Center Director has met with the staff members. They all report feeling really bad that this happened. They believe in the care they provide and only want to do a good job.
MUST INCLUDE NEED Graphs and visual aid
1. Identify an interdisciplinary team-based improvement project based on the root cause analyses of the safety events. During the pitch, identify why you selected the project and which safety issues are addressed.
2. Include a draft of the problem statement you plan to share with the Medical Center Director, which also discusses two (2) associated high reliability principles.
3. Discuss how will you manage and lead these projects through to completion.
4. Identify the improvement methodology you plan to use to address and track the safety failures.
5. Is there any data that you need? Discuss which databases you plan to pull it from.
6. Identify any tools and/or resources you will you need to implement your plans and manage the activities of your team. Include how you plan to train the teams to carry out the improvements.
7. Discuss how will you ensure sustainability once the project deliverable are deployed and implemented.
8. Explain how you would use change management to prepare the Care or Service Line to accept, implement, and sustain the improved processes.
9. Discuss how you plan to incorporate dashboards and graphical reports into your tracking and sustainability plan.
10. Finally, discuss how you plan to close out the project. Include how you will confirm that all project requirements have been met and how your project benefits the experience of the veterans at MEDVAMC.
Time-Sensitive Will pay top dollar
DUE BY: Wednesday, AUGUST 12, 2020 by 9am CST (NO EXCEPTIONS)
Systems Redesign & Improvement
By: Andrea Ware
August 10, 2020
The Michael E. DeBakey VA Medical Center
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Overview
Wrong-patient errors in blood transfusion have an adverse impact on the quality of patient care.
Errors linked to blood transfusion in a health care setting should be prevented to minimize the risk for preventable deaths (Hensley et al., 2019).
Accurate patient identification and correct labeling of blood for transfusion in every healthcare setting is indispensable to efforts to address patient safety issues in healthcare.
Purpose: To identify an interdisciplinary team-based improvement project based on the Root Cause Analyses (RCA) of the safety events.
Aim: To decrease the wrong-patient errors in Blood Transfusion by the 25% at the end of the 1st Quarter/ FY 21. Eliminate barrier for the facility moving toward High-Reliability Organization (HRO) to deliver value to the veterans it serves.
The Michael E. DeBakey VA Medical Center
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Draft Problem Statement
The Problem is that there is poor communication between the Interdisciplinary Team, with a preoccupation failure and reluctance to simplify.
Preoccupation with failure is a principle that applies to the presented situation since the staff feel that nothing is ever done to correct the errors.
Reluctance to simplify the complexity in the organization has been attributed to poor communication between clinical staff.
The Michael E. DeBakey VA Medical Center
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Proposed Project
An interdisciplinary team-based improvement project proposed based on the RCA of the safety events at MEDVAMC involves the use of BARCODES and Offering Communication training.
Barcoding will help improved the accuracy of labels on blood and minimize the RISK of patient receiving blood of the wrong blood type.
Communication training will equip clinical staff with the knowledge, skills and abilities needed to reduce errors arising from inadequate communication between the staff.
The Michael E. DeBakey VA Medical Center
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Managing & Leading the Project
The main Objective is incorporating Barcoding System.
Improving the Communication, between the Nurses and Physicians
First Step: Weekly Team Meeting should be initiated
Develop communication FRAMEWORK from weekly meeting Structures, processes and outcomes
Use the FRAMEWORK to guide the teams communication.
The Michael E. DeBakey VA Medical Center
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Improvement Methodology
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To address and track the safety failures, the failure mode and effect analysis (FMEA) will be used.
Failure Potential Lack of Communication; labels in error
Mode Types, Ways, & Possibilities –
Effect Negative Effect on process under study
Analysis Study RISK and Reduce it
.
The Michael E. DeBakey VA Medical Center
Data
Patient Safety Report (Joint Patient Safety Reporting (JPSR) Hospital Administration
Regardless, data on the effectiveness of barcoding when it comes to addressing blood labeling errors will be considered.
The data will be used to evaluate the effectiveness of the proposed solution.
Interviews that have been conducted by the organization will also be used to identify the specific issues that the project will address.
The Michael E. DeBakey VA Medical Center
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A3 Tool
1. Reason for Action 4. Gap Analysis 7. Completion Plans
Improve Communication & Add New Barcoding System Communication Barriers Lack of Spirit Making Sure Completion plan is on Track
2. Initial State 5. Solution Approach 8. Confirmed State
Poor Communication. Led to medical errors.
Three patients died Increase Staff Interaction through meetings. Improve communication. Provide sustainable solution. Confirmed State metrics should be in place. Like the Final Reports.
3. Target State 6. Rapid Experiments 9. Insights
Proper Coordination & Communication Between the Teams Checking whether the solution s are working Using the FMEA. Key Lessons will be documented and Future Opportunities Identified.
The Michael E. DeBakey VA Medical Center
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Required Resources & Tools
A3 is the suitable tool
It will document learning, decisions and planning
Automated error-proofing tools will also be indispensable to efforts to minimize laboratory errors that contribute to erroneous labeling.
E-learning platforms will be used to train the teams to carry out the improvements.
Training programs will be designed and implemented in collaboration with trainers and subject matter experts.
The Michael E. DeBakey VA Medical Center
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Ensuring Project Sustainability
Develop partnership.
Involve Key Stakeholders
Ongoing Training
Regularly evaluation of project
Avoiding Mission Drift
The Michael E. DeBakey VA Medical Center
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Using Change Management
Used to prepare the service line to accept, implement and sustain improved processes.
This will happen through the following five levers:
Communication Plan
Sponsor Roadmap (for the MCD)
Coaching & Training Plans
Change Management plan
The Michael E. DeBakey VA Medical Center
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Incorporating Dashboards and Graphical Reports
Data Dashboard will be instrumental
Visually tracks, analyzes and display Key Performance indicators to monitor the process.
Robust Barcoding System for data support
These tools will be helpful in making the organization sensitive to operations and committed to resilience.
Dashboards and graphical reports are interactive data VISUALS, which will provide feedback toward sustainability
The Michael E. DeBakey VA Medical Center
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Project Closure
The project will be closed by
Gaining Stakeholder Acceptance (Medical Center Director)
Collect and present Outputs (Project Documents; Final Reports)
Final Report & Presentation to the Senior Management.
Tracking the Results will help confirm if the project goals are met.
The Michael E. DeBakey VA Medical Center
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Benefit of Project to MEDVAMC Veterans
Improve communication
ADD -Robust Barcoding System (Minimize Errors)
More Coordination of the TEAMS
Improve/rather revamp the reputation of Facility
Decrease barriers from becoming HRO
Overall restore confidence of the Veterans
The Michael E. DeBakey VA Medical Center
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References
Hensley, N. B., Koch, C. G., Pronovost, P. J., Mershon, B. H., Boyd, J., Franklin, S., … & Stierer, T. L. (2019). Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.The Joint Commission Journal on Quality and Patient Safety,45(3), 190-198.
Kaufman, R. M., Dinh, A., Cohn, C. S., Fung, M. K., Gorlin, J., Melanson, S., … & Degree, L. (2019). Electronic patient identification for sample labeling reduces wrong blood in tube errors.Transfusion,59(3), 972-980.
Weick, K. E., & Sutcliffe, K. M. (2015).Managing the unexpected: Sustained performance in a complex world. Hoboken: Wiley.
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The Michael E. DeBakey VA Medical Center
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