1. Read the case study below
2. As you read the case, jot down in your notes the information you would use for each section: Background, current conditions, objectives. Come to tutorial prepared to discuss and initiate an A3.
3. Remember: It doesn't matter, if you have never worked in a hospital! As a Project Manager/Lean Six Sigma practitioner, often we work on processes where we do not have the operational background! For this week we are looking to document the current state and get approval to work on this project before performing root cause analysis or Six Sigma principles

CASE STUDY

Inoue Hospital in Osaka, Japan, specializes in hemodialysis. It has 22 doctors and 420 staff. Its hemodialysis division has 127 beds for hospitalized patients and 180 beds for visiting patients. The hospital sees approximately 12, 522 patients per year.

This is another case in which the collection of data (scare reports) has proved to be a crucial step toward improvement in the hospital environment.

Scare Reports as a Quality Tool

In 1985, the hospital's director, Dr. Takashi Inoue, learned about scare reports being used in the manufacturing industry. The system requires that every time an operator ingembawitnesses a potentially hazardous situation, they must submit a scare report, which is then used as a basis for correcting the conditions that allowed the situation to arise. As the hospital was not immune to accidents Inoue liked the idea of collecting data on scares to prevent an accident from actually taking place.

Often, scares happen as a result of somebody else's careless handling of the preceding tasks, and filing a scare report is tantamount to pointing the finger at someone else's mistakes. In introducing scare reports at the hospital, Inoue made it clear to everybody that the purpose of the report was to assure the safety of the customers (patients), not to accuse colleagues who had made mistakes. Improvement of quality assurances was the main goal, and to do it, he said, everybody must be frank enough to admit mistakes. Otherwise, there would be no hope for improvement.

The hospital staff learned Heinrich's Law on Safety, Heinrich found that out of every 330 industrial accidents, 300 are accidents causing no damage, 29 are accidents causing minor damage, and 1 is an accident of grave consequences. See Figure 1 below.

To avoid 1 serious accident, Heinrich argued, both the total number of minor accidents and the total number of accidents causing no damage should be reduced.

Inoue Hospital classified its scare reports according to the categories in Heinrich's model, and standards were established. Scare reports at the hospital are now required in the following instances.

1. Air: If air has entered a patient's body during dialysis
2. Hemorrhage:If any hemorrhage over 10 ml has occurred
3. Blood Coagulation: If the dialyze circuit has had to be exchanged
4. Leakage: If any rupture has taken place
5. Wrong medicine or wrong shots: If any incident in which the wrong medicine or solution has entered a patient's body has occurred, even if it has not caused any harm
6. Wrong Sequence in withdrawing the needles: If the needle has been withdrawn completely from the body, even when hemorrhage has not resulted
7. Circuit malfunction: If the dialyzer has needed to be replaced
8. Water release: If water has been released in any amount 500 grams more or less than the stipulated amount, or if it has taken 30 minutes longer than expected

Scare reports must be submitted every day, and this tool has greatly enhanced the safety awareness of the nurses and paramedical staff.

In the early days, the people responsible for causing the scare would ask, "Who reported it?" Sometimes doctors themselves were heard asking this question. But over time, everybody at the hospital has come to accept the scare report as a daily routine and a way to review and improve everyday work processes. Most problems arise from a failure to follow the correct procedures. Scare reports, therefore, help staff to review their own working procedures.

For instance, a nurse once tried to give a hemostatic shot to a patient. The patient said, "I don't usually get any shots." When the nurse checked the record, she found that the patient was right. This scare happened because this was the first time the nurse had worked on this particular patient, and she did not get all the pertinent information from the previous nurse. Normally, mistakenly giving a shot of a hemostatic agent does not constitute a serious accident, but at Inoue Hospital, it must be classified as an accident. A scare report must be submitted, and a measure to prevent recurrence must be devised.

The reports are assembled at each nurses' station and submitted to management every day. Every month, management compiles the reports andsends a summary to the staff. Each department must implement countermeasures right away and report them. If the solution is more complicated and will require more time, the subject must be taken up by the hospital's quality circles as a joint task.

In 1993, the hospital had a total of 839 scare reports in the following categories:

Category of Scare Report	% of Total Scare Reports
Wrong medicine or injection	41%
Water release	23%
Blood coagulation	17%
Air inclusion	10%
Hemorrhage	8%

QUESTION:

	A3 Report
	Project Title:		Team Lead:	Team Members:
	Date:		Key Stakeholders:	External Support:
PLAN	Background:	DO	Future State:
Current Conditions:	CHECK	Impact:
Objectives:
	ACT	Follow Up:
Root Cause Analysis: