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What Do Cars and Cancer Care Have in Common? More Than You Might Expect

Andrew Jacobs, MD

When ASCO and the National Coalition for Cancer Survivorship partnered to form the Cancer Quality Alliance, one of its intentions was to adapt approaches to quality from a variety of settings.¹ Yet even the most visionary among the Alliance organizers might not have thought to apply to cancer therapy the same quality initiatives used by automobile manufacturers.

Nevertheless, that is exactly what leaders at Virginia Mason Medical Center (Seattle, Washington) have been doing for the last 4 years, and with considerable success. Their approach is modeled after the Toyota Production System—a highly disciplined methodology developed over the last 50 years to achieve zero defects in the production of Toyota automobiles.^2,3 The system examines a process that determines where and why errors occur, and then challenges those who carry out the process to redesign it to prevent future errors.

Andrew Jacobs, MD, Chief of the Department of Cancer Care Services at Virginia Mason, notes that the first big hurdle to implementing the system in a health care setting is the culture shift that must take place. Physicians, nurses, and others in health care believe that it is different from other businesses. Achieving zero defects might be possible when building a car, but not when you are treating patients. For example, a certain percentage of patients will develop infections after surgery. Mishaps are inevitable.

"Even patients seem to accept the concept that ‘stuff happens' in health care," says Jacobs. "No other business would survive if it accepted that a certain percentage of its products would fail."

Jacobs and others at Virginia Mason believed that this assumption that mishaps are inevitable in health care was incorrect. And they have shown it to be so, as over the past 4 years they have implemented the Toyota system in both inpatient and outpatient units throughout the medical center, including cancer care services.

"There are thousands of processes in health care that are somewhat random, lacking structure. That's how mistakes are made. Yet a lot of what we do is predictable and capable of being standardized."

"When we are confronted with a medical error or bad outcome, we pose the question ‘How do we redesign the process so there won't be errors?'" explains Jacobs. "We've found most errors are process failures, not the result of incompetence."

Often the problem is miscommunication or a lack of clarity about one or more person's role.

During the last 4 years, Virginia Mason has implemented hundreds of process changes using the system, including about 16 in the cancer care department. One change involved one of the most commonly performed procedures in the department—installation of a vascular access device. In reviewing the 300 to 400 installations performed at the center each year, Jacobs' team found that many patients had to undergo the procedure twice because the wrong model had been installed or because the catheter tip (and thus the catheter itself) was not positioned well. After careful process analysis, the team made the following changes:

1. The variety of catheters available was reduced to those most commonly used, thereby decreasing the chances that the wrong model would be installed.
   
2. The team developed an order sheet, which includes specifications for the type of catheter and its location; the sheet must be completed and available before surgery can begin. The patient does not enter the operating room unless the surgeon has done so.
   
3. Agreement was reached on the standard to follow for tip placement, based on research and standards set by the Oncology Nursing Society. The patient does not leave the operating room until correct tip placement has been confirmed by fluoroscopy.
   

In 12 months of follow-up, not a single patient had to return to the operating room to correct the type or location of a catheter.

Fundamental to the success of the system is the Rapid Process Improvement Workshop, the mechanism by which a process is evaluated and revised. As Jacobs describes it, all the stakeholders involved with the process under review are locked in a room with the mandate to review provided data, redesign the process, test it, and get the surgeons (or others who actually perform the process) to agree to the changes, all in less than 5 days. The following week, the new process is implemented.

"People can see the power of the method when they see the results," says Jacobs. "The system has two significant benefits. First, it improves quality of care and reduces patients' suffering. At the same time, it has lowered costs of care by eliminating waste."

Toyota has shown with automobile manufacturing that it is possible to lower costs without sacrificing quality. As the American health care system struggles to rein in costs of care, the lesson that quality can rise even as costs fall is an important one.

	References

Top References

 

1. Organizations collaborate to improve the quality of cancer care. J Oncol Pract 2:116-119, 2006[Free Full Text]
2. Ohno T: University Park, IL, Productivity Press Inc, Toyota Production System: Beyond Large-Scale Production. 1988
3. Womack JP, Jones DT: Lean Thinking: Banish Waste and Create Wealth in Your Corporation (revised and updated), Free Press, New York, NY, 2003

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This Article Extract Full Text (PDF) Submit a response to this article Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Alert me to new issues of the journal Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Social Bookmarking                            What's this?