Chapter 6 – Page 4 – The OM Blog by Heizer, Render, & Munson

OM in the News: Checklists as a TQM Tool in Hospitals

How can we use the TQM tools in Chapter 6 to reduce deaths in surgery? One tool is a kind of poka-yoke called a checklist (see p. 223). The Wall Street Journal (Dec. 13-14, 2014) quotes Dr. Atul Gawande describing how he worked with a team from the airline industry to design what emerged as just a checklist. Surgical blunders, says Gawande, are “most often basically failures of communications. The checklist had some dumb things—do you have the right patient ? But the most powerful components are: Does everybody on the team know each other’s name and role? Has the anesthesia team described the medical issues the patient has? Has the surgeon briefed the team on the goals of the operation, how long the case will take, how much blood they should be prepared to give? Has the nurse been able to outline what equipment is prepared? Are all questions answered? And only then do you begin.”

The result, after he tested in 8 cities around the world, was that in every hospital that used the checklist, complication rates fell. The average reduction in complications was 35%. The average reduction in deaths was 47%. The system has since been replicated in multiple places. Scotland has implemented it and taught it at the frontlines –and has now demonstrated that 9,000 people’s lives have been saved over the last 4 years.

“The hardest part,” says Gawande, “is to bring the culture that has the humility to recognize that even the most experienced people, even the most expert fail.” Doctors fear these kinds of checklist systems. When he surveyed surgeons 3 months after they adopted it and asked, “What do you think about this approach?” he found that about 20% really dislike it—“It’s paperwork, it’s a pain in the butt, I don’t want to do this.” But when he asked, “If you’re having an operation, would you want the team to use the checklist?” 94% did.

Classroom discussion questions:

1. How else can checklists be used in hospitals?

2. What other TQM tools can be employed in a surgery process?

OM in the News: Nurses, Ebola, and the Subject of Quality

With Ebola leading the news every day, I am reminded of the words of Dr. Edwards Deming: management needs to accept responsibility for quality in building systems. Deming believed an employee could not, on average, exceed the quality of a process’ capability. (His famous 14 points are summarized in Table 6.2 on page 212). Now with some nurses being blamed for the lax Ebola virus procedures in Texas, we are seeing a response from the leading nursing association.

Following news that the first U.S. nurse has now tested positive for the Ebola virus, National Nurses United (NNU, Oct.12, 2014) called for all hospitals to have in place the highest standard of optimal protections, including Hazmat suits, and hands-on training to protect all RNs, other hospital personnel to confront Ebola . NNU’s new survey of 2,000 nurses shows:

76% still say their hospital has not communicated to them any policy regarding potential admission of patients infected by Ebola
85% say their hospital has not provided education on Ebola with the ability for the nurses to interact and ask questions
37% say their hospital has insufficient current supplies of eye protection for daily use on their unit; 36% say there are insufficient supplies of fluid resistant/impermeable gowns in their hospital
39% say their hospital does not have plans to equip isolation rooms with plastic covered mattresses and pillows and discard all linens after use; only 8% said they were aware their hospital does have such a plan in place

Not having supplies; not having equipment; not educating employees; not having a plan. All of these are systems problems, not employee problems, Deming would say.

Classroom discussion questions:

1. Who is responsible for setting quality standards and processes for Ebola treatment and prevention?

2. Which of Dr. Deming’s 14 points particularly apply in this situation?

OM in the News: How Operations Management Improves Hospital Procedures

Swamped with tasks such as hunting for supplies, tracking down medications, filling out paperwork at the nursing station and looking for missing test results, nurses may spend less than two hours of a 12-hour shift in direct patient care, says The Wall Street Journal (July 22, 2014). But research has also found that the more time nurses spend at the bedside, the less likely patients are to suffer falls, infections and medication errors, and the more likely they will be satisfied with their care.

Now hospitals are changing traditional work practices, shifting more routine tasks to certified nurse assistants and other less highly skilled staffers. They are eliminating inefficient processes that make nurses walk as many as 5 miles around the hospital in a single shift. Some hospitals are aiming to triple the amount of time nurses spend with patients. That means locating supplies inside patient rooms and having pharmacists deliver medications to patient floors. As more hospitals adopt electronic medical records and place computers in patient rooms, they are enabling nurses to access information quickly and fill out medical charts while keeping close to patients.

Presbyterian Medical Center, in Winston-Salem, N.C., found in a 2010 internal audit that nurses were involved in direct patient care at the bedside for only 2.5 hours every 12-hour shift. “Not only was that eye-opening, it was also completely unacceptable,” says its chief clinical officer. With a shift to a team-based model, the hospital hit 6.5 hours per shift at the end of 2013, with a goal to hit 8.5 hours by the end of 2015. Process changes helped save $20 million last year at Presbyterian, and the transfer to electronic records also reduced by 42 minutes the amount of time spent paging doctors, copying and faxing, and tracking down tests.

This is a good article to link to the video case studies on Arnold Palmer Hospital in Chapters 6 (Quality), 7 (Process Analysis), and 9 (Layout).

Classroom discussion questions:

1. What tools of TQM could be used to help improve hospital processes (see pages 218-222)?

2. Why is it important for nurses to spend more time with patients, and less time at their stations?

OM in the News: Best Practices at the Sanford Health System

In 2012, waste in the national health care system was measured at $750 billion annually. Driven by tightening margins and increased pressure for positive outcomes, health systems nationwide are looking for ways to maximize resources and trim costs, writes Argus Leader (May 7, 2014).

“It’s not just about cutting costs,” said the CEO of Sanford Clinic in South Dakota. “We do have to cut per-unit costs, but we have to look at standardization, best practices. We have a very fragmented health care system, and that’s where integration and coordination of care is so critical. It’s not just for efficiencies. It’s for best outcomes and eliminating errors and waste.” The clinic’s approach to becoming more efficient involves the approaches of Kaizen and Six Sigma, tools used in business for process improvement, but the greater goal is to integrate continuous performance improvement into the culture.

The Sanford Health System, of which the clinic is a part, set a goal of finding $100 million in efficiencies this year, with much of the savings coming through better supply chain management. “We looked at cost transformation opportunities, which is tying it back to product standardization; maybe some miscellaneous contracts we have from one region to another that we could consolidate,” added the President of Sanford USD Medical Center. As the system has grown, it has commanded better pricing options from vendors. Various Sanford locations have worked together to identify best practices and streamline products and pharmaceuticals to achieve more savings through buying in bigger quantities.

Agreeing to use a common spine hardware, for example, saved $2.5 million annually. Working with cardiologists to determine the pacemaker of choice across the system saved another $2.4 million. Further, a new asset management system is designed to further optimize staffing and supplies. It will monitor where patients and care providers are to manage patient flow and track equipment.

Classroom discussion questions:

1. Why is OM so important in hospitals?

2. What tools in Chapter 6 can be used to improve hospital quality?

Teaching Tip: Pareto Charts and Pork Processing

When Upton Sinclair published The Jungle in 1906, he hoped to shock readers about the mistreatment of immigrant workers in Chicago’s slaughterhouses. Instead, his book created outrage over the unsanitary conditions it described—how poisoned rats got swept into the sausage grinders; how tripe and cartilage were dyed and flavored with spices and sold as canned ham; how men in the cook room occasionally fell into open vats and sometimes went undiscovered for days, their flesh sold to consumers as lard. Sinclair groused that the book became a bestseller “not because the public cared anything about the workers, but simply because the public did not want to eat tubercular beef.”

Now 100+ years later, if you read the latest edition of BusinessWeek (Dec. 9-15, 2013), you will likely eat a lot less pork in 2014. The lengthy article, titled “The Truth About Pork,” documents how the US Dept. of Agriculture cut the number of inspectors on the pork processing line with the agreement that plants would hire their own quality assurance officers. Line speeds that are now “dangerously fast” and there are vastly increased violations of food safety requirements. A recent USDA Inspector’s General report states: “As a result, there is reduced assurance of inspectors effectively identifying pork that should not enter the food supply.”

The good news is that the data provided makes for a nice example which can be used to construct a Pareto chart when you are teaching Chapter 6. Using the 223 violations in 2012 at a sample plant (Quality Pork Processors, in Minnesota), students can construct an interesting chart. Here are the safety violations: Food contact preoperational sanitation–69 violations: Contamination such as fecal matter–60: Sanitation lacking–46: Nonfood contact surfaces unclean–20: Record keeping errors–10: Condemned carcasses–8: Inhumane hog handling, mislabeling, misc. violations–10.

Sinclair predicted that the industry would make sure inspection addressed only the barest concerns about the deadliness of a product. Repeatedly he warned against letting meatpackers carry out their own inspections. His warnings still resonate.

OM in the News: Kaizen at San Francisco General Hospital

Kaizen team leader at SF General Hospital

At San Francisco General Hospital, clinicians, executives and staff are peppering their conversations with Japanese words like kaizen and muda. This “Toyota Way”, writes the San Francisco Chronicle (Oct. 14, 2013), is an effort to infuse the Japanese automaker’s management philosophy and practices into the way the hospital delivers medicine to its patients.

To make the system work, a team of employees is assigned to analyze a particular area targeted for improvement. The group immerses itself in a weeklong, hands-on session, and emerges with a plan to make specific changes designed to have a big impact on costs or the patient’s experience. One recent kaizen focused on the number of minutes it takes from the moment a patient is wheeled into the operating room to when the first incision is made. A team spent a week trying to come up with ways to whittle 10 minutes off the hospital’s average “wheels in” to incision time of 40 minutes. Another targeted the Urgent Care Center and dropped the average wait from 5 hours down to 2.5 by adding an on-site X-ray machine–instead of forcing patients to endure a 15 min. walk to the main radiology department.

Toyota’s production system has been increasingly adopted by hospitals trying to improve medical quality and increase patient satisfaction. Here are some of its Japanese terms, many of which do not have a direct English translation: Gemba: the place where work is performed. Hansei: a period of critical self reflection. Heijunka: a level production schedule that provides balance and smooths day-to-day variation. Jidoka: using both human intelligence and technology to stop a process at the first sign of a potential problem. Kaizen: continuous improvement. Kanban: a visual card or signal used to trigger the fulfillment of need, such as restocking supplies. Muda: anything that consumes resources but provides no value. Poke-yoke: a mistake-proofing device that prevents errors.

(Ironically, the day before this flattering article about quality appeared, NBC News reported that SF General lost a 57-year old female patient for 2 weeks–she was just found dead in a hospital stairway.)

Classroom discussion questions:

1. Why are hospitals adopting the “Toyota Way”?

2. Which of the many Japanese terms above could have prevented the lost patient?

OM in the News: Air Berlin’s Service Implosion

How could a passenger plane take off without a single piece of luggage? That’s the question from 200 Air Berlin passengers on flight AB 8109, whose bags were left sitting at the airport when their flight took off, and then apparently vanished. Nearly a month later the airline still doesn’t know where all the bags are, reports Slate.com (Sept.4, 2013).

Passengers’ inquiries were met with endless redirects. One email to Air Berlin reads: “ NONE of the checked luggage was loaded on the airplane—almost 200 missing pieces missing among the passengers. We filled out forms and were given baggage service numbers to call, but the phone line has no answer. Days later, still no information whatsoever, nobody to call, not sure what to do. Baggage company says to contact airline; airline says to contact baggage company. Why did the captain decide to take off before any pieces of luggage were loaded? We need support from Air Berlin. This isn’t one lost bag, it’s a whole plane of lost bags!”

And, in a separate event, here is twitter bot over a 2-day period earlier this month between a frustrated passenger and the airline:

@5Foot1: “Arrived in Dusseldorf without my bag. @airberlin are useless. No apology, no idea. What happened to German efficiency?”

@airberlin: “We’re sorry for the inconvenience caused. Did you contact the Lost & Found?”

@5Foot1: “Of course. Bag left in LDN. No assurance it will be on the next flight. I’m here for business meetings with no clothes.”

@airberlin: “We understand how annoying this is and apologise! Unfortunately we can’t help you right now. Lost & Found will contact you.”

@5Foot1: “Do you have a number I can call and speak to a human being. The tracking number is giving me no information.”

@airberlin: “Unfortunately there is no number I can give you. Lost & Found will get in touch as soon as they found your bag.”

Concludes Slate: “Air Berlin’s total inability to transport a suitcase from point A to point B can’t be a good sign”.

Classroom discussion questions:

1. In Chapter 6, Managing Quality, we list the 10 Determinants of Service Quality (see Table 6.5). On which of the 10 service determinants did Air Berlin fail?

2. Why did the pilot of AB 8109 leave without any baggage?

OM in the News: Need a Poka Yoke at San Francisco’s Baseball Stadium?

$99 batter's box template — $99 batter’s box template

Though it doesn’t take long for them to get destroyed and disappear, the batter’s boxes originally drawn in for this week’s Reds-Giants baseball game at San Francisco’s AT&T Park “may be the most crooked and awkward looking we’ve ever seen,” reports Yahoo Sports (July 25, 2013).

Of course that also means they were not up to Major League Baseball standards — or sandlot ball standards, for that matter — but no one on the field seemed to notice or care — most notably home plate umpire Chris Guccione — as the game started and carried on without the lines being corrected. The umpires collectively missed it or ignored it.

Most hitters, like Miguel Cabrera, can sense when a line is an inch too long or too close to the pitcher’s mound. A lot of that is based on routine. A lot of that is based on instincts. But, in this case the errors weren’t even marginal. Both sides were angled so noticeably. The cure is a poka yoke like the one shown here, available for less than $100 on-line. (For more on poka yoke, see Chapter 6, Managing Quality).

Discussion questions:

1. Why does the crooked batter’s box make a difference?

2. Name some other popular poka yokes.

OM in the News: Quality Problems in Hospital Internship Training

Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research, says Time (March 26, 2013), shows that’s not the case. Since 2011, new regulations restricting the number of continuous hours 1st-year residents spend on call cut the time that trainees spend at the hospital from 24 to 16 hours. Excessively long shifts were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided.

But in a large new study that compared interns serving before the 2011 work-hour limit was implemented with interns working after the new rule, the number of medical errors the post-2011 doctors reported was higher than those among previous trainees. In the year before the new duty-hour rules took effect, 19.9% of the interns reported committing an error that harmed a patient, but this percentage went up to 23.3% after the new rules went into effect.

How could fewer hours lead to more errors? For one, interns were still expected to accomplish the same amount that previous classes had, so they had less time to complete their duties. This “work compression” increases the risk of errors or mistakes if residents don’t have as much time to make and recheck patient-care decisions. And the reduction in work hours has not been accompanied, for the most part, by increase in funding to off-load the work, so current interns have about 20 fewer hours/week to complete the same work. Another source of errors came as one intern going off duty handed his cases to another. With fewer work hours, the number of handoffs has increased from an average of 3 during a shift to as many as 9. Anytime a doctor passes on care of a patient to another physician, there is a chance for error in communicating complications, allergies, or other aspects of the patient’s health.

Discussion questions:

1. Relate this issue to the 10 determinants of service quality in Table 6.5 in the text.

2. What can be done from an OM perspective to improve the intern situation?

OM in the News: J&J’s Hip Implants Run 40% Defective

For a great case study in OM ethics and quality, the New York Times (Jan. 26, 2013) reports that an internal analysis conducted by Johnson & Johnson not long after its 2010 recall of a troubled hip implant (called the A.S.R.) estimated that the all-metal device would fail within 5 years in nearly 40% of patients who received it. J&J never released those projections for the device. And at the same time that the medical products giant was performing that analysis, it was publicly playing down similar findings from a British implant registry about the device’s early failure rate.

The company’s analysis also suggests that the implant is likely to fail prematurely over the next few years in thousands more patients in addition to those who have already had painful and costly procedures to replace it. The J&J analysis is among hundreds of internal company documents expected to become public as the first of over 10,000 lawsuits by patients who got an implant goes to trial this month. The episode represents one of the biggest medical device failures in recent decades. Last year, the company took a $3 billion special charge related to medical/legal costs associated with the device.

The A.S.R. belongs to a once-popular class of hip implants in which a device’s cup and ball component were both made of metal. Surgeons have largely abandoned using such devices in standard hip replacement because their components can grind together, releasing metallic debris that damages a patient’s tissue and bone. Hip implants, which are generally made from metal and plastic, often last for 15 years before they wear out and need to be replaced. The early replacement rate is typically 1% after a year, or 5% at five years.

J&J decided in 2009 to sell off its A.S.R. inventories just weeks after the F.D.A. demanded safety data about the implant. But the F.D.A. said J&J could not dump the device in the U.S. because of concerns about “high concentration of metal ions” in the blood of patients who received it.

Discussion questions:

1. Ask students to follow and report on the current status of the lawsuit.

2. What are the ethical implications of J&J continuing to sell the implant after British and F.D.A. studies warned of its dangers?

OM in the News: Toyota and “The Cost of Quality”

In our Chapter 6 discussion of the cost of quality (COQ), we note the external costs that occur after delivery of defective products (such as rework, liabilities, lost goodwill, etc.). Philip Crosby, author of Quality is Free, wrote that the cost of poor quality is understated and “there is absolutely no reason for having errors or defects in any product or service.” The New York Times (Oct. 10, 2012) article that Toyota just announced the recall of 7.4 million vehicles worldwide, including 2.5 million in the U.S., to repair power-window switches that can break down and start a fire , certainly brings Crosby’s ideas to the forefront for your class.

It was only 2-3 years ago that the company recalled more than 11 million cars to replace floor mats and sticky accelerator pedals. It has been seeking to reassure consumers about the quality of its vehicles since then. The recall could surely set back its efforts.

The vehicles affected in the U.S. include more than a million Camrys. Eight months ago, the National Highway Traffic Safety Administration opened an investigation into reports of smoke and fire coming from doors. During its investigation, the safety agency collected reports of 161 fires and of 9 injuries. In its news release, Toyota said there were “no crashes related to the recall,” but did not mention fires or injuries. Toyota said it originally wanted to conduct a “customer satisfaction campaign” but decided to pursue the recall after discussions with the agency. Toyota described the recall as voluntary, but under federal regulations once a manufacturer learns of a safety problem it must, within 5 business days, tell the safety agency of its plan for a recall or face a civil fine.

Discussion questions:

1. Will such recalls impact your students’ images of Toyota’s quality?

2. How does this compare to GE’s dishwasher recall several years ago in which the cost of repairs exceeded the value of all the machines?

OM in the News: Quality Control in Intensive Care Units

If you want an example of how the tools of OM can result in major improvements in the field of health care, read The Wall Street Journal (Sept. 11, 2012) article on the use of checklists in hospital intensive care units. A national patient-safety program, sparked by the death a decade ago of an 18-month-old child, reduced the rate of a deadly bloodstream infection by 40% in hospital ICUs.

The initiative, led by Johns Hopkins’ VP-Quality, Dr. Peter Pronovost, was implemented in more than 1,100 ICUs in 44 states. It took aim at bloodstream infections associated with catheters used to deliver drugs directly into patients’ major veins. The result of the effort was a reduction in the rate of infections to 1.137 per 1,000 days of catheter use, from 1.903, over the first 18 months that hospitals implemented the program. This cut represented at least 2,000 infections avoided, more than 500 lives saved and $34 million in health-care cost savings.

One professor who helped with the rollout of the program in Rhode Island, said the results are “dramatic.” Though the ideas in the program weren’t new, its developers “figured out how to bundle those best practices and insert them into the daily practice of nurses, physicians and other health-care professionals.”

Mortality for central-line infections in the U.S. is 12% to 25%. The CDC estimated there were around 18,000 of the infections in ICUs in 2009, down from 43,000 in 2001. The entire program is built on checklists like pilots use. Key practices on the checklist include hand washing, properly covering up care givers and patients when a catheter is inserted, and using the right disinfectant at the site of insertion. But equally important, according to Dr. Pronovost, were cultural changes, such as authorizing nurses to ensure that doctors adhere to the lists.

Discussion questions:

1. How else can operations management tools be used in ICUs?

2. Ask students to report on Dr. Pronovost’s book, Safe Patients, Smart Hospitals, which we described in this blog last year.

Good OM Reading: Big Medicine vs. The Cheesecake Factory

It was back in January, 2011 that we blogged about Dr. Atul Gawande’s excellent book on health care quality called The Checklist Manifesto . Gawande’s newest piece, “Big Med,”‘ which appears in the New Yorker (August 13, 2012) is an amazing read as you prepare to teach quality management in Chapter 6. He argues that healthcare can must learn from all high-reliable industries, from aviation, to pit crews, to construction, to the Cheesecake Factory.

Gawande writes: “In medicine, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of 2 or 3, even within the same hospital. Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Wal-Mart the most successful retailer on earth.”

Physicians, though, have been mostly self-employed, working alone or in small private-practice groups. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. Only 1/4 of U.S. doctors are now self-employed—an extraordinary turnabout from a decade ago, when over 50% were independent.

Enjoy Gawande’s description of his tour of The Cheesecake Factory’s kitchen and the disheartening comparison to a hospital’s medical operations. It’s a good 15 minute investment of your time.

Teaching Tip: Teaching Quality Inspection Using Chickens

In Chapter 6, our favorite line when discussing inspection is: “Quality cannot be inspected into a product.” What better way to discuss this important topic with your students than the controversial move by the USDA last week to streamline chicken inspection by cutting by 75% the number of government inspectors who eye chicken carcasses for defects. The Los Angeles Times (June 6, 2012) reports that the USDA move to let chicken slaughterhouses run production lines 25% faster is angering food safety advocates and poultry plant workers.

The USDA says it can eliminate 800 inspector positions and save the federal government $30 million a year. Consumer advocates said the rising rates of salmonella infection in recent years should give pause to any plans to cut the number of inspectors. But in testing its relaxed rules at 25 poultry slaughterhouses, the USDA found little difference with conventional plants in the instances of salmonella and other diseases. “The test plants performed exceptionally well”, the department said. (In other words, more inspection did not equal more quality.)
Under existing rules, the production line can move as fast as 140 birds a minute. Four federal inspectors positioned along the line inspect carcasses and remove those that have visual defects. No single inspector inspects more than 35 birds a minute. The relaxed rules allow lines to speed to 175 birds per minute while relying on plant employees to spot defective carcasses and pull them from the line. They then move past a single line inspector.

The CDC estimates that there are 1.2 million incidents of salmonella illness each year–and growing. When Consumer Reports tested 382 broiler chickens bought from grocery stores, 14% were found to contain salmonella. The union that represents poultry workers said the new rules would mean “more danger on the job.” The industry’s worker injury rate already is about a third higher than the average for all manufacturing industries. They often are prone to back problems, and 59% of line workers already have carpal tunnel syndrome — at line speeds of 70 to 91 birds a minute.

This story can make for a good Ethical Dilemma exercise as well.

OM in the News: Hospital Quality Rising–But 1 in 20 Patients Gets a Dangerous Infection

“Nationwide,” writes The Wall Street Journal (June 5,2012), ” about one in 20 patients entering a hospital will get a potentially deadly infection, accounting for some $33 billion in preventable costs.” Dangers lurk not only in vulnerable places like operating rooms, but from sink faucets and TV remote controls, which can harbor the most deadly bacteria. (By the way, it is not just hospitals that transmit deadly germs. TV remotes are now being sanitized and plastic-wrapped in 2,200 Best Western Hotels).

For decades, US hospitals have based room cleaning quality on visual checks. These “are no longer sufficient,” says the infection prevention director at New Jersey’s Hunterdon Medical Center. That hospital conducts random audits of 300 surfaces a month with a new swabbing device (shown in photo). Over 95% of checks get a passing grade, up from only 75% 3 years ago. Hunterdon also cut its rate of C. diff (Clostridium difficile) infections by 79% and reduced MRSA infections by 66% in the past 5 years. A bug called VRE that was on the rise for several years dropped 23% at Hunterdon last year. (C.diff is linked to 14,000 US deaths a year.)

Helping to spur action, the US government has set a goal of reducing hospital infections and other preventable problems by 40% by next year from 2010 levels. Medicare has stopped paying to treat some infections acquired in the hospital. And facilities with the highest rates of hospital-acquired conditions will face reduced federal payments starting in 2015.

What are hospitals doing? We now know that C. diff can survive for weeks on a doorknob, alcohol-based sanitizers don’t kill it, and hand washing is not sufficient. Cleaning crews need to use bleach and hydrogen peroxide, rooms have to be scrubbed carefully (even in corners), and “high-touch” surfaces carefully disinfected.

Discussion questions:

1. Why haven’t hospitals mastered quality control of cleaning?

2. How can the tools in Chapter 6 be used in this process?

3. Is 95% cleaning quality sufficient?