Do You Use This Antidote To Painful System Issues?

By:  DM Kashmer MD MBA MBB FACS (@DavidKashmer)


Healthcare colleagues:  have you ever felt like you’re running in mud? We have a term for when multiple small elements create resistance to inhibit you from getting done the work that needs to be done. That term is “friction”.  Friction is the accumulation of all those little things that add up to slow you down (or stop) you from imposing your will upon the disease process.  Well, colleagues, here is the antidote:  poka-yoke.


What Does Poka-Yoke Mean?


Poka-yoke is a design philosophy that, simply put, means “make it easier to do the right thing”. Want the physician to get charts done on time?  Make the computer work.  Make it accessible from anywhere.  Make the charts not come to his/her inbox in the eleventh hour with only one minute remaining before they expire such that they violate hospital staff bylaws (!)


Charts aside, want doctors to be on time for trauma?  Make a call room (and work hours) so attractive that they’ll want to stay there.  Make it physically harder to make a mistake.


A related description of poka-yoke is “poka-yoke as error-proofing”.  At its heart, the concept is the same:  make it more difficult to make a mistake.  This means either setup the system for success (as above) or create a better way to detect defects before the next step in a process.  Add inspection to a step before moving onto the next step.  Create a device that beeps if the water level in the tank I’m filling gets too high, etc. etc.


Error detection and inspection seem, to our team, to be somewhat more challenging to implement in healthcare than the “make it easier” approach described above.  We joked around at a process re-design meeting recently:  hire someone to stand outside the call room and knock or yell “beep” if we don’t wake up to the pager.  Possible?  Yes.  As practical as other choices?  Not really.


Each of the cases above may remind you of challenges with your own system, and (by no means) is the list above representative of what will work for you or all your unique factors involved.  Your data will guide you to your issues (if you let it).  However, the point here is that a workable solution is often not:  “doc work harder and just get it done”, penalties for not working hard enough, or chastising a colleague or entire service line at a meeting.  In fact, a healthy, workable solution may involve some poka-yoke type thinking that is very different than those other listed (more pathologic) interventions.


It boils down to this:  when I’m on the administrator side of the table, and when I need a system to function, I try to make sure it is easier for the person at the tip of the spear (the person awake at midnight, etc.) to obtain the desired outcome.  It needs to be as easy as we can make it given our available resources and what is within the realm of possibility for our system.  In other words, if there is a certain outcome that we want to obtain in quality control, we must make it easier to do the right thing.  That’s the poka-yoke design philosophy that accompanies Six Sigma and, often, Lean.  When was the last time you saw that used in healthcare?


Friction Is So Common & Overwhelming That We’re Trained To Accept it…Yet We Shouldn’t


For physicians, and particular trauma surgeons, we have all experienced that running-in-mud feeling of daily friction. When issues come up that are minor, additive, and problematic, I often jokingly ask “is this just the routine level of friction?” meaning is this just the routine level of friction we see every day or somehow even more than the norm. The facts about friction are so common and known that, well, friction has become a joke…but it shouldn’t be one.


People who speak up are often worried they’ll be labelled as “complainers”.  The truth is (as we all know in healthcare) if we started complaining we may never stop, so it’s easy to try and avoid falling into that bottomless pit.  Training seems to teach some that there’s no upside to complaining.  However, sometimes (just sometimes) the person who has the (often minority) viewpoint of the complainer may be a sign that something is amiss.  Collecting some data about the system can show whether that person’s view is trying to help signal you that there’s an issue or whether the system feels bad to them yet works just fine.


Although we may joke about it, the routine level of friction is often completely unacceptable and mis-aligned with the outcomes we want. Again, in quality control, if we want a certain outcome we need to make the design of the system line up with that desired outcome. That means it greatly helps the person performing the action when it’s easier to do the right thing.  That’s where poka-yoke is so valuable.  Magically, when the system makes it easier to get a desired outcome that’s often what you get.


The poka-yoke design philosophy helps grease the wheels, or gets the wave moving in a way so as to make it easier to surf to shore.  Imagine an environment that makes it easier for us to surf along and achieve a great outcome.  Think of that environment that actually supports our ability to be effective.  There aren’t many that I’ve seen in healthcare, yet the ones that do function that way are truly amazing in terms of quality and provider satisfaction.


Caution:  clearly we can’t spend millions of dollars on each project.  Resources are limited and constrain available poka-yoke solutions.  However, often, the costs associated with poor quality (the COPQs) are MUCH higher than we realize, so some reasonable expenditures on the preventative measures seen with poka-yoke may often work better for our system.  By the way, prevention (as you recall) is the only type of expenditure on quality that has a positive return on investment.  More here.


Have You Ever Seen A Healthcare Quality Project That Decreases Paperwork?


Consider more about how poka-yoke finds its application in healthcare. Have you ever been part of a quality control initiative or similar healthcare project where your paperwork burden is decreased? Probably not, because it just doesn’t seem to happen.  (It can, my colleagues, be done!) Maybe, after reading this entry, you’ll start to look for ways to reduce forms at your next quality improvement meeting.


Next time you are in a quality improvement meeting, remember to look at what the improvement would look like (and how it would feel) to the person on the front line. (Maybe even get the end user’s input in designing the solution!  Dare we ask the residents how to design the specifics of the solution we choose?) Consider how the job of the people on the front line can be made easier and more aligned with the outcome you want. Involve them in the decision making.


Creating alignment may involve removing obvious obstacles, improving resources available, or implementing a solution that just works better for everyone. The bottom line, in any event, is that you should remember “poka-yoke” to make it easier to get the outcome you want. Remember, in the next quality improvement meeting, the idea of friction and its antidote:  poka-yoke.