Table 4

Allegheny General Hospital CIMO table (illustrating what about lean worked in a specific context and why)

Components of the interventionContextMechanismsOutcomes
  • A team headed by the Department of Medicine chair (with unit directors, physicians, infection control nurses, ICU nurses, and staff from Pittsburgh Regional Health Initiative) review charts of patients with central lines and translate epidemiological data into clinical terms (mortality, comparison with other patient categories, inclusion of femoral line infections, and microbiology of infections).

  • (Component IV: team approach to problem solving)

  • CDC guidelines for safe central line placement available. Despite this, the two ICUs report an average of 5.1 infections/1000 line days in 2002. Since femoral line infections were not included in the standard definition the problem was underestimated.

  • Management active and (we surmise) employees not adverse to achieving patient safety goals.

  • Realising that a problem exists and its magnitude and scope (by expressing the data in a comprehensible language, ie, clinical terms) motivates staff to engage in process redesign.

  • Active management participation may have also enhanced motivation

  • (Mechanism IV).

  • Management and staff engaged in process redesign and understand why (the reasons for change).

  • Team-based observations of line placement and maintenance

  • (Component I: process mapping)

  • (Component IV: team approach to problem solving)

  • Unclear clinical procedures and patient/family member communication.

  • Nurses in disagreement about techniques and physicians' choice of line placement.

  • Fierce adherence to physician autonomy.

  • Management active and (we surmise) employees not adverse to achieving patient safety goals.

  • Management and staff engaged in process redesign and understand why (the reasons for change).

  • Direct observations help staff (experientially) understand the variations in line placement and maintenance

  • (Mechanisms I and IV).

  • Staff find reasons for and identify opportunities to standardise and stabilise processes and systems, together.

  • Awareness of variations in central line practice.

  • Collaboratively develop new procedures.

  • Adopt standard operating procedures (single common line insertion kit, specify sterile techniques, standardise documentation and documentation review)

  • (Component II: specification of standard procedures)

  • (Component III: enhance adherence to standard procedures)

  • (Component IV: team approach to problem solving).

  • Unclear clinical procedures and communication with patients and family members.

  • Nurses in disagreement about techniques and physicians' choice of line placement.

  • Awareness of variations in central line practice.

  • CDC guidelines for safe central line placement available.

  • Fierce adherence to physician autonomy (which can conflict with standardisation).

  • Staff find reasons for and identify opportunities to standardise and stabilise processes and systems, together.

  • Management and staff engaged in process redesign and understand why (reasons for).

  • Collaborative development of context-specific countermeasures (not captured in CDC guidelines) facilitates their adoption.

  • Standard operating procedures clarify clinical procedures and obviate disagreements about how things should be done. The standardisation allows variations to be easily identified and dealt with.

  • More reliable processes yield waste reduction and more time for continual improvement and patient care

  • (Mechanisms II, III, and IV).

  • Positive sustainable results.

  • Real time investigations of individual infections carried out by a team composed of the infection control nurse, the physician of record, and the residents, fellows, and nurses caring for the patient.

  • A help chain was created to cut through the organisation's hierarchy. When necessary, the unit director and the chair of medicine were notified to address the defect.

  • (Component I: ‘5 Whys’)

  • (Component IV: team approach to problem solving and management system for rapid problem solving).

  • Hierarchy and status differences between nurses and physicians hinder communication about breaches in practice.

  • ‘Inconsistent’ team communication.

  • Nurses in disagreement about techniques and physicians' choice of line placement.

  • Fierce adherence to physician autonomy.

  • Management active and (we surmise) employees not adverse to achieving patient safety goals.

  • Management and staff engaged in process redesign and understand why (the reasons for change).

  • Awareness of variations in central line practice.

  • Each new CLAB occurrence interpreted as an opportunity for learning and improvement which counteracts and replaces a culture of blame.

  • Real-time investigations capture contextual factors which might otherwise be lost, enhancing learning.

  • Working in teams around events creates the feeling that learning and improvement is both possible and desired.

  • Management involvement in the help chain reinforces the importance of learning on the floor and mitigates the negative effects of hierarchy on drawing attention to defects.

  • Solving problems as they occur reduces the need to compensate for ineffective processes

  • (Mechanisms I and IV).

  • CLABs examined on average within 6 h.

  • Nearly all CLABs are discovered to be preventable when real-time problem solving is adopted.

  • Less compensation for ineffective processes.

  • Positive and sustainable results.

  • Development of a culture of safety and continuous learning.

  • Multidisciplinary task training for trainees (nurses and physicians) using patient simulator.

  • Residents and fellows reeducated in subclavian line placement technique

  • (Component III: enhance adherence to standard procedures).

  • Collaboratively develop new procedures and processes based on observations and real-time problem solving.

  • Fierce adherence to physician autonomy (which can conflict with standardisation).

  • Staff find reasons for and identify opportunities to standardise and stabilise processes and systems, together.

  • Management and staff engaged in process redesign and understand why (reasons for).

  • Management active and (we surmise) employees not adverse to achieving patient safety goals.

  • ‘Team members understand the work standardisation and their specific roles.’

  • Education helps reinforce and institutionalise the collaboratively designed solutions.

  • (Mechanism III).

  • Standardised practice deployed among all concerned actors for line placement and management which contributes to sustainable results.

  • CDC, Centers for Disease Control and Prevention, USA; CLAB, central line-associated bloodstream infection.