If Toyota ran your trauma program: How to improve trauma care using poka-yoke

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Many healthcare leaders look to Toyota and other world-class manufacturers for ideas on how to improve quality. But few healthcare organizations have adopted one of Toyota’s most important quality concepts — poka-yoke. This powerful design philosophy can help trauma leaders improve system performance without adding new layers of process and new penalties for poor performance.

Poka-yoke is Japanese for “error-proofing.” Many system designers focus on the negative aspect of this philosophy — making it impossible to make a mistake. But according to David Kashmer, MD, chair of surgery at Signature Healthcare in Brockton, Massachusetts, the heart of poka-yoke is a positive goal — making it easier to do the right thing.

“Poka-yoke is a design philosophy that is used infrequently in healthcare,” Dr. Kashmer said. “In fact, we seem to have a lot of systems that conspire to make it difficult to achieve the desired outcome. Poka-yoke gets us thinking about how to make a process easier for physicians, nurses and others. It’s a really big shift, but the results can be amazing.”

Conventional PI vs. poka-yoke
Conventional approaches to process improvement are often additive. The solution to a problem is to develop more protocols, create more penalties and usually create more paperwork. In contrast, the goal of poka-yoke is to improve outcomes by removing the obstacles that make a process difficult for users. Recently, Dr. Kashmer discussed how poka-yoke thinking can be applied to trauma care.

“Say we look at our data and we find that we are not diagnosing low-grade renal contusion as much as possible,” Dr. Kashmer said. Trauma leaders using a conventional process improvement approach might solve the problem by creating a new protocol. The protocol might outline new clinical indicators for identifying at-risk patients and a new process for ordering urinalysis. However, this adds to staff work rather than simplifying it.

According to Dr. Kashmer, the better approach is to create a system that requires little or no intervention. “Depending on your data, it may make sense to create a standing order for UA on every trauma patient and just allow the user to opt out if appropriate.”

Another example: Say a trauma program has problems getting accurately labeled lab specimens from the OR to pathology in a timely manner. The team’s current specimen process comprises ten steps, including filling out three forms. A conventional solution might be to create a checklist to help the nurse execute the steps more quickly and accurately.

Poka-yoke takes a different approach. “If the problem is too much paperwork, then adding a checklist is not always the correct solution,” Dr. Kashmer said. “A checklist can be just another sheet of paper lying on top of a process that is already terrible.”

To make the process more effective, make it easier for users. “If you want this process — getting specimens to pathology — to happen quickly and without defect, you need to design it so that the user has to do less. You need to find some way to cut down the steps and ideally push all the paperwork together into a single form.”

Using tech to simplify
Electronic medical records often make documentation harder and more time-consuming for clinicians. But Dr. Kashmer believes that poka-yoke thinking can help make EMRs more usable.

For example, trauma surgeons are often unable to fully document critical care services. Poka-yoke can help improve documentation by making the EMR experience more fluid. “To make it easier for the physician user, you could create an auto-fill text within the EMR that reads, ‘I saw this patient for X minutes for Y diagnosis.’ The template could include a drop-down menu with your eight most common critical care diagnoses.”

When creating auto-fills, let your data guide the solution. “It’s common for trauma physicians to be unable to get a review of systems, either because the patient is unconscious, drunk or some other reason. But you might realize from your data that physicians are frequently forgetting to document the fact that they can’t get that review.”

A poka-yoke solution, Dr. Dr. Kashmer said, could be to create EMR template language that reads: “Could not perform review of systems due to patient mental status.” The language would auto-fill into a free text field, and the user would have the ability to opt out. (Consult your hospital billing/coding department for specific guidance on the acceptable use of auto-filled text in your EMR.)

Systems thinking is essential
To use poka-yoke effectively, trauma teams must have a true system view. “A classic challenge for us in trauma is getting physicians to respond to an activation within a certain amount of time,” Dr. Kashmer said. The question often becomes, “What is wrong with Dr. Smith?” But from a system perspective, the question should be, “What aspects of the whole process make it difficult for physicians to respond within the timeframe?”

The answer could include financial issues. “Let’s say the surgeon’s compensation package is aligned with him or her being in the office and generating RVUs, and let’s also say the surgeon’s office is 15 minutes away,” Dr. Kashmer said. “Frankly, the system lines up so that the surgeon will probably not respond within the target timeframe.”

In this example, “making it easier to do the right thing” could involve changes to reimbursement, in the form of either physician employment or supplemental call pay. However, solving problems with money is not the primary strategy of poka-yoke.

“From a system perspective, one factor might be that the call rooms in your hospital are terrible,” Dr. Kashmer said. “The question would then become, ‘How can we design our call rooms so that it is easier for the surgeon to stay there while on call?’ The answers might be investing in comfortable beds, installing nice showers, and providing physicians on call with a change of scrubs.”

Resource constraints can limit poka-yoke solutions, Dr. Kashmer noted. “However, the costs associated with poor quality are often much higher than we realize, so some reasonable expenditure on preventive measures like these may ultimately work better for the system.”

Less friction Subscribe to Trauma System News
According to Dr. Kashmer, conventional performance improvement efforts often fail to remove the “friction” with a system that makes it hard for people to do the right thing.

“That’s where poka-yoke is so valuable,” he said. “Magically, when the system makes it easier to get a desired outcome, that’s often what you get.”