Toyota way of risk assessment for safe hospitals

Deepak Venkatesh Agarkhed, GM, Engineering, Facilities & Quality, Sakra World Hospital, Bengaluru, explains how Anzen philosophy can be applied to maintain safety within hospitals

The housekeeping person nearly suffered injury as he was about to accidentally touch the exposed live motor of scrubber unit due to dislodged cap of motor.

The post knee replacement surgery vulnerable patient had fall resulting into hip injury while going to rest room as there was uneven gap between rest room and patient room.

The above examples illustrate one among few examples of accidents or near miss in hospital. The healthcare delivery system consists of various clinical and non-clinical processes involving various members from clinicians, nurses to ward boys. Unlike manufacturing or aviation industry, the process varies frequently based on patient disease and treatment related to same. Inspite of various checks and balances in system, there are incidents of breaches in standard operating processes resulting into various levels of harm. The current approach in any quality accredited hospital is to act on reported incidents which have resulted in harm to patient or hospital staff through mechanism of incident report analysis. Unfortunately, most of the incidents are not reported by functional team out of fear of them being penalised on account of reporting. Although corrective actions for that particular incident are taken, mostly the preventive aspects are completely overlooked. The hazard identification and risk assessment (HIRA) using technique like FMEA (failure mode effect analysis) are not yet popular in high-risk clinical area like operating theatres, intensive care units. The risks to patients and even hospital staff can be minimised using proactive techniques like KYT (Kiken Yochi Training) and Anzen first (safety first) risk assessment methodology.

There is a tendency to get confused in understanding English syntax of harm, hazard, risk and accident. The hazard is a potential source of harm like exposed insulation sleeve of live electrical power chord from electrosurgical unit inside the operating room during surgery. Harm is physical injury or damage to the health of a person, or damage to property or environment, like a surgeon getting an electrical shock after touching the live electrical power chord. The risk is the combination of the probability of occurrence of harm and the severity of that harm. In case of improper maintenance of hospital medical equipment, the risk will be high in this case as oxygen rich environment operating room and patient under saline irrigation i.e. wet environment. The safety is freedom from unacceptable risk i.e. from medical equipment inside the operating room in this example. The accidents will happen when unsafe conditions like exposed insulation sleeve of live electrical power cord and unsafe acts like surgeon touching power chord take place.

The term Anzen means safety in Japanese language. Safety first is the philosophy of Toyota automobiles plants across the world. The risk identification, assessment and arriving at counter measures to mitigate can happen in any hospital wherein top management is supportive on this initiative and good work relation exists between the ground staff and mid-level management like managers.

The Anzen, Toyota way suggests the following four steps to be adopted to improve safety at hospital workplace.

1. First step is to keep the workplace clean and lean using 2 S methodology. First S i.e. Sort means that not needed items of current workplace are removed .This directly results into efficient utilisation of space. Second S i.e. Set in order means results in arranging all needy items with proper labelling and good visualisation in order to retrieve right item at right time from the right place.
2. The second step uses simple and yet effective proactive risk identification through KY (kiken yochi training). It has been noted that number of work related errors can be reduced by pointing and calling while doing certain activity like checking medicine in medication cart. Pointing and calling KY adopts technique wherein one person will point out target objects (eyes) by stretching arm (arm and finger) and stating out loud (mouth) and listen own sound (eye) like example “Medicine stock is OO… OK”. Other person acknowledges it by saying ‘OK’ after verification. The risk identification using KY leads to next anzen step of risk measurement and adoption of countermeasures.
3. The risk assessment includes identification of hazards at workplace, estimation of the degree of hazard, possibility and severity of accident, evaluation of risk level, risk reduction measures for higher priorities and finally implementation of risk reduction measures. The degree of   risk evaluated based on hazard is calculated by referring to following risk evaluation table (A), (B) & (C).

The risk evaluation point is summation of frequency of work, degree of accident, occurrence possibility. After calculation of risk evaluation point, the possible control measures to reduce risk need to be worked out. In continuation of earlier example of operating room, electrosurgical equipment is potential source of harm i.e. hazard. The medium risk is obtained through calculation of risk evaluation point (5 + 6 + 4) i.e. 15. Based on risk rank given in table shown, the following are the possible hierarchy of control.

• Risk elimination
• Risk substitution by changing the working method
• Isolation of hazards like physical barrier, lockout
• Using engineering like guards
• Administration like signages,work instructions
• Usage of personal protection equipment

According to each case, it is possible to arrive at appropriate measures using risk control methodology. The quick implementation of counter measures for high rank risk should be priority for any hospital to achieve safe environment. In the example of electrosurgical unit inside OR it is possible to reduce the risk to (5 + 6 + 1) i.e. 11 through regular preventive maintenance of unit including accessories, establishing checklist for each equipment.The KY technique before start of surgery can be answer to quickly check the safety of operating room.

4. Once the appropriate measures are implemented on ground, the work instruction (standards operating procedures) need to be changed so that all the concerned members can get trained not only in that particular area but across all other places within hospital wherever conditions are applicable.

In a high stress hospital environment, anzen technique is perfect answer for patient and staff safety. The hospital functional heads should look at work environment risk aspects besides employees, operations and equipment. The continuous education on risk mitigation and using tools like KYT, FMEA will reinforce safe culture at hospital.