2006 OPEN FORUM Abstracts
Using Toyota Production System Methodology to Error-Proof Twice-Daily Monitoring of the Ventilator Bundle
Robert Hase, MS RRT-NPS, James
Hamilton RRT, Joe Streiff RRT, Jeff Suenaga RRT--Virginia Mason Medical Center,
Seattle, Washington
We applied Toyota Production
System (TPS) methods to error-proof the monitoring and recording of our
performance with the Institute for Healthcare Improvement (IHI) ventilator
bundle, for reducing ventilator-associated pneumonia (VAP). We developed a mechanism within our
electronic documentation system to provide the functions of visual control, warning-
and control- poka-yoke, self-check, and successive check. Our process change
was designed to achieve self-sustained monitoring that would comply with our
standard of 100% of all ventilated patients having all elements of the
ventilator bundle assessed twice daily. This process also places the recording
of data at the production site (the patient's bedside) and provides reference
standards within the audit process.
Background: Our
process of recording ventilator bundle audits consisted of Respiratory Care
Practitioners (RCPs) recording data on their work assignment sheets, then transferring
that data onto a department log. Logs
would then be transcribed onto a Microsoft Excel spreadsheet which would
maintain and tabulate the audit database. Three major kinds of process error
became apparent: first, data was not always recorded by all RCPs caring for
ventilated patients each day. Achieving
as reliable an audit process as possible required constant oversight and
reminding on the part of department supervisory staff. Second, incomplete data was not always
readily observable unless the ventilator bundle audit was cross-referenced to
the daily log of ventilated patients, a process also requiring a significant
time investment. Finally, the data
itself was suspected of reflecting a lower-than-actual defect rate (numbers of
audits with at least one bundle component out of compliance) because data was
recorded and compiled in the department.
Methods: We
improved this process via three components of our hospital's electronic medical
record and computerized physician order entry. First, we configured a
documentation screen within our electronic medical record that contained each
of our six bundle elements along with an input box allowing the user to assess
element compliance by clicking on an either/or bullet for Yes or No. The answer boxes were configured as required
fields, mandating each be answered before the record could be authenticated. Second,
we created a sub-order, "vent bundle data audit" that would attach to
ventilator initiation orders with a default frequency of Q12. Each time an RCP logs into the electronic
medical record, a summary list appears to show all pending orders and tasks,
now including the ventilator bundle audit.
Finally, a report was created to display the results for all audits
within a date range.
Results: Since implementation, we have seen 100% compliance
with twice-daily ventilator bundle audits for all intubated patients. The current process requires no maintenance
from supervisory staff to ensure compliance. Our process provides visual cues
and integrated reference standards to assist RCPs such as agency staff who may
be unfamiliar with our ventilator bundle process.