The Science Journal of the American Association for Respiratory Care

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.

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