Commentary: "Who was caring for Mary?" revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement.

Over 15 years have passed since Mary's near death (Annals of Internal Medicine. 1993;118:146-148). Disappointment in the care by fellow academic physicians persists; however, a reanalysis of her case through the lens of complex systems design and performance yields a more accurate and actionable perspective.

Using real-time problem solving to eliminate central line infections.

Background: An estimated 200,000 Americans suffer central line-associated bloodstream infections (CLABs) each year, with 15%-20% mortality. Two intensive care units (ICUs) redefined the processes of care through system redesign to deliver reliable outcomes free of the variations that created the breeding ground for infection.

Methods: The ICUs, comprising 28 beds at Allegheny General Hospital, employed the principles of the Toyota Production System adapted to health care--Perfecting Patient Care--and applied them to central line placement and maintenance.

Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients.

There is a marked gap between the potential of medical science to treat illness and injury and the performance of the health care system in which hard-working, intelligent, well-trained people put that science to work. Care is available to too few, and costs and risks of injury are too high. This is avoidable.

Operational failures and interruptions in hospital nursing.

Objective: To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care.

Data Sources: Primary observation, semistructured interviews, and surveys of hospital nurses.

Study Design: We sampled a cross-sectional group of six U.

Fixing health care from the inside, today.

Today, you are about as safe in a U.S. hospital as you would be parachuting off a bridge or a building.

Ambiguity and workarounds as contributors to medical error.

Why are some organizations error-prone-regularly subject to interruptions and inconveniences, some of which periodically coalesce catastrophically-whereas other organizations, although similar in the products and services they generate and the process technologies they use, are reliable, adaptable, and continuously self-improving, relentlessly learning from experience to get ever better? Analyzing medical error reports and studies of high-performing, non-health care organizations reveals 2 differences. High performers know how to prevent problems from producing further consequences once they occur and how to prevent their recurrence. They do this by specifying how work is expected to proceed-who will do what for whom, with what purpose, when, where, and how-before work is actually done.

Medical education as a process management problem.

With complaints that new doctors are less prepared for residency and practice than expected, are burdened with debt, and then take even longer to complete their specialty training, the authors ask whether medical education can be designed more effectively. Curriculum redesign and pedagogical reform efforts to date address fragments of medical education-the content of particular courses or clerkships or the way in which the courses or clerkships are conducted. However, these reforms do not typically address the relationships among the various elements, that is, in what order skill sets should be sequenced, how communication should occur between disciplines, and by what mechanisms skills or knowledge should be mastered and assessed by the end of one phase so students are prepared adequately for the next.

Learning to lead at Toyota.

Many companies have tried to copy Toyota's famous production system--but without success. Why? Part of the reason, says the author, is that imitators fail to recognize the underlying principles of the Toyota Production System (TPS), focusing instead on specific tools and practices. This article tells the other part of the story.

Driving improvement in patient care: lessons from Toyota.

Nurses today are attempting to do more with less while grappling with faulty error-prone systems that do not focus on patients at the point of care. This struggle occurs against a backdrop of rising national concern over the incidence of medical errors in healthcare. In an effort to create greater value with scarce resources and fix broken systems that compromise quality care, UPMC Health System is beginning to master and implement the Toyota Production System (TPS)--a method of managing people engaged in work that emphasizes frequent rapid problem solving and work redesign that has become the global archetype for productivity and performance.