FEATURED CLIENT STORIES
Surgical Site
Client: Large Ontario Hospital
Process: Operation/Surgery
Goal: To perform all surgeries on the correct area of the human body.
Current Plan
In order to perform surgery on the correct area of each patient, the Operating Room nurses complete a checklist of items to ensure the correct site is identified for the intended procedure. This includes asking the patient to confirm the correct site of their surgery.
What’s Not Working
There are still a significant number of surgeries being performed on the wrong site. Naturally this has serious negative effects for patients, staff and healthcare organizations.
SJC Solutions Analysis
After breaking the process down into all its steps, it was found that one of the root causes is related to the surgical orders displayed on the video screen in the OR. The surgeon uses this screen for operational direction and could potentially display the wrong patient's information, or display the incorrect site for surgery on the correct patient.
It was found that the controls in place were ineffective because:
- OR nurse checklists are often rushed due to the short turnaround time between surgeries, and because of the shortage of nurses.
- Patient verification of the site for surgery is sometimes unreliable as they are sedated and nervous.
Result
The SJC Solution was to disable the surgical lights in the OR until a new patient ID bracelet barcode is scanned. This will display the correct patient’s surgical images and enable the surgical lights to be turned on.
This solution prevents the root cause as opposed to the current human inspections being used.
Construction Material Handling
Client: Building Construction Contractor
Process: Receiving Materials
Goal: For all materials available for use to be received undamaged.
Current Plan
Materials for this particular client are transported to site packed in protective materials to prevent against movement, crushing and vibration. The transportation of these materials is by way of air ride suspension equipped trailers, by an approved trucking companies.
What’s Not Working
Transported materials are unloaded from the air ride suspension trucks and found to be damaged. Ultimately, all of these materials were rendered unusable, which slowed down our client's client.
SJC Solutions Analysis
The process of receiving materials on site has several variants. These were not all considered before SJC Solutions investigated the situation. Many times, the materials cannot be unloaded for several days, and are left in the truck trailers.
In the summer, the temperature in the sealed trailers can exceed the maximum for the materials. Adhesives and high thermal expansion materials are especially susceptible to failure.
This process step had not been considered and isolated, and therefore, was identified as the root cause for failure.
Result
SJC Solutions suggested including trailer dwell time and ambient temperature in the materials management plan, tailored to each shipment. This addition to the project planning process eliminated the cost and project delays associated with the unrecognized root cause.
Information Flow
Client: Store Fixture Designer and Manufacturer
Process: Sending Design Files to Customers
Goal: To correct the iteration of design files being sent to customers.
Current Plan
A computer-aided design (CAD) software file management system is supposed to open the most recently revised iteration of any design in the storage vault. This feature is dependent on employee-specific settings for the file management system.
What’s Not Working
A development CAD file (not the most recent iteration) for printing store display artwork was sent to the customer. The artwork did not fit the store display, resulting in a delay for the customer's product launch.
SJC Solutions Analysis
In analyzing this failure, it was discovered that there was a well defined procedure for training new CAD employees, with the “most recent file open at start up” feature turned off. When the new designer is ready to work on current projects, this feature is activated by the system administrator.
However, another person had administrator rights and set up a new designer with the feature turned off - this was during a period of office reorganization. This allowed an older version of the CAD file to be sent to the customer. The individual who set up the new designer incorrectly was trying to help, but had not been involved with the CAD department for several years.
Result
The system administrator rights were distilled down to a few people, which could not be changed without leadership approval. The documented procedure for both setting up a new CAD employee and who has system administrator rights were reviewed and updated every six months going forward.
The new controls actually highlighted that there was no checklist of items when a person’s job description changes. This exposed other instances of out of date rights, including former employees who still had software administrator rights. There have been no issues with the correct (most recent) CAD files being sent to customers since.
Food Packaging
Client: Toronto-Based Muffin Bakery
Process: Packaging Muffins into Plastic Containers
Goal: To create a continuous flow with reduced labour requirements and failures related to human error.
Current Plan
New equipment to close the lid of a filled muffin container, seal it, and turn it 90 degrees was designed and prototyped. This was meant to achieve the goal of removing an operator (annual savings of $100K) from the production line and continue to operate continually at the line rate.
What’s Not Working
The new equipment suffered from multiple unforeseen failures. These failures would force the producer to shut down the line, therefore negating the intent of the change to the process.
SJC Solutions Analysis
The closing and turning of the muffin container by the new equipment was isolated as a process. This process was broken down into its energy state steps. A definition of success was identified for each step, allowing our team to identify all possible root causes for each failure mode.
The controls and recommended actions generated by the Failure Mode Analysis (FMEA) produced changes to the design of the equipment (preventive control). Several problems which had not yet occurred were pre-emptively avoided by the analysis-driven design changes to the equipment.
Result
The revised muffin container lid-closing and turning station on the packaging line has permanently removed an operator, and works problem-free at line rate. Duplicate equipment was installed at several other plants to realize efficiencies too.
Patient Alarm Fatigue
Client: Cardiac Integrated Unit within Toronto Hospital
Process: Responding to Patient Monitor Alarms
Goal: To decrease the total number of alarms by 30% and decrease the response time to critical alarms by 50%.
Current Plan
All telemetric monitors in the Cardiac Integrated Unit (CIU) produce audible alarms when a patient's vitals reach dangerous zones. These alarms go off without any coordination of urgency or prioritization.
What’s Not Working
For nurses and doctors around these alarm often, they experience
alarm fatigue, which is a workplace occupational hazard. This causes critical alarms to be ignored or not promptly tended to, which seriously compromises patient safety.
SJC Solutions Analysis
A detailed list of process steps was created to encompass the admission of a patient, all the way through to being placed in the CIU, to alarm response. Next, a rigorous FMEA was performed, which generated several new controls and recommended actions.
The significant changes implemented based on the analysis were:
- Customization of monitor settings based on patient condition
- Detailed procedures and training on skin preparation for lead attachment and lead changing
- Staff training on battery replacement
- Posting of alarm and response metrics to engage staff
Result
Over a six month period, the number of alarms was nearly cut in half, from an average of 10,275 per week to 6,203 per week. Over the same period, average response time went from 10 minutes to under three.
Software Algorithm
Client: Diagnostic Software Provider
Process: Brain Magnetic Resonance Imaging (MRI) Tumour Detection
Goal: To identify brain tumours on MRIs more quickly and reliably.
Current Plan
When a patient is given an MRI, the image is inspected and documented by a radiologist based on their individual experience.
What’s Not Working
The time it takes to analyze and identify masses, including tumours, varies greatly depending on the imaging and the radiologist selected to review the MRI. This means the accuracy of analysis is dependent on the selected radiologist's experience and workload, and therefore not always consistent in its level of thoroughness.
SJC Solutions Analysis
Upon review of the situation, we broke the computerized digital manipulation of the MRI image into very finite process steps. We also defined success for each step, and then performed a rigorous FMEA on this process.
The FMEA produced a full set of preventive and detection controls, which were implemented into the MRI program. Several recommended actions for further refinement were also created.
Result
The new program manipulates the MRI brain scan to detect tumours far more quickly and accurately than manual inspection.
Commercialization and implementation of this program could then move forward.