For decades, those of us involved in improving patient safety looked to Toyota Motor Corp. for guidance and inspiration in improving quality in healthcare. The Toyota Production System has been touted as the key to error reduction and consistency in product quality. The quest to build a “Toyota of healthcare” has been the mantra for many in medicine, spawning teams of healthcare executives on field trips to Japan and consulting groups touting the car company's “lean” industrial processes for healthcare.
Consider some lessons Toyota can learn from healthcare
The key to The Toyota Production System has been employee engagement in failure identification and empowerment to participate in continuous improvement. Toyota's performance improvement methods have been adapted by dozens of U.S. hospitals and have been reported as being successful in improving outcomes and efficiency. Given Toyota's recent quality issues, these are tough days for admirers of the company.
Since the 1999 release of To Err is Human, the Institute of Medicine's report on the prevalence of preventable medical errors in hospitals, American healthcare has been pretty hard on itself. Recognizing its responsibility for allowing these errors to occur, policymakers, researchers and healthcare leaders have been engaged in a number of important initiatives that have led to a safer environment for patients. Maybe it is now time for us to reciprocate and share some of what we've learned with Toyota.
When errors happen in hospitals, disclosure of the event to the patient and family is essential for effectively dealing with the problem. Hospital leaders have learned that failure to tell patients and families what has occurred leads only to further problems and builds institutional barriers to creating safe cultures. We have also learned that when mistakes are made, apologies are an important part of the process; accountability and saying “I'm sorry” can help patients, families and caregivers in the healing process.
Dealing with errors is rarely easy. When Jesica Santillan —a 17-year-old being treated at Duke University Hospital, Durham, N.C.—died after being given the wrong heart and lungs, the hospital responded with a candid acknowledgement of the error and a sincere apology from her doctor—actions that diffused public outcry over a horrific situation and immediately helped rebuild trust with future patients.
Hospitals have worked in recent years to create new systems for the rapid identification of problems when they occur. Healthcare workers are encouraged to report both errors and potential errors, using incident reports and other reporting systems. Medical staffs use peer-review processes to examine safety concerns or deviations from standard practices. Insurers have begun pay-for-performance systems that work with hospitals to monitor quality data and change payments based on improvements in quality data. Data on hospital quality is now increasingly reported to the public through government and private initiatives and is accessible on the Web through numerous commercial companies.
Toyota was slow to act in the face of its problems. The company first received reports of problems with its accelerator pedals in March 2007. On Aug. 28, 2008, a family was killed after the gas pedal got caught under the floor mat. On Sept. 26, 2009, Toyota first publicly revealed the potential problems with its gas pedals. It announced a vehicle recall on Oct. 6, 2009, and expanded the recall on Jan. 21, 2010, but it was not until Jan. 26 that it suspended sales and production. Since then, Toyota has been working to mechanically fix what it believes may be causing these problems in their cars. No doubt Toyota has been working tirelessly to identify and fix the problem, but customers want to know that they are being dealt with honestly and openly.
In April, Toyota paid a record $16.4 million fine to the National Highway Traffic Safety Administration for its slow response in the recall effort, and as of May 1 faced more than 320 lawsuits in federal and state court related to its sudden acceleration problems.
Toyota is paying a high price for its mistakes. Some estimate the direct cost in the billions. Most likely there will be additional economic damage as a result of deterioration in consumer confidence in the brand. Yet despite what can be seen only as a terrible tragedy resulting in numerous injuries and loss of life, Toyota has been working hard to respond responsibly. By issuing a recall, halting sales, engaging in large-scale public communications, and by acknowledging and apologizing for its errors, Toyota is on its way toward recovery and restoring confidence in its products.
As we have learned in healthcare, introspection, accountability and transparency of information is the best path toward healing. Sometimes, making a mistake, learning from it and implementing changes to make the system better is just what the doctor ordered.
David Shulkin, M.D.Professor of medicineAlbert Einstein College of MedicineYeshiva UniversityNew York
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