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2.5  Kaizen and change management


one of the six-sigma techniques that looks to make incremental small changes to
processes that will result in improvements to the overall process. It originated in
Japan and translates to mean change (kai) for the good (zen).  Often this is focussed on the process of
reducing waste and allows staff employed in the process to have ownership of
making changes.

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In a
healthcare setting waste could be movement
of samples or patients for no gain, time
waiting between processes (patients waiting for results prior to appointments),
defects (wrong result or
pharmaceutical preparations), over-processing
(reporting results to greater accuracy than required for diagnosis), variations giving non-standard
solutions when not required.



Human Factors in healthcare–


What are Human Factors in

“Enhancing clinical performance
through an understanding of the effects of teamwork, tasks, equipment,
workspace, culture and organisation on human behaviour and abilities and
application of that knowledge in clinical settings”.1



It is important to understand
that often failures are not just caused by individuals but are organisational.
The science of human factors in systems has developed greatly and learning has
included the often quoted “Swiss Cheese Model of organisational accidents”



Any system will have a number of
layers of control all of which will have minor gaps – when all the gaps line up
an incident occurs.



Developing healthcare systems founded
on human factors principles can have positive impacts on safety through:

reducing harm through better design of systems
and equipment
understanding why healthcare staff make
errors and how ‘systems factors’ have an impact on patient safety
improving the safety culture of teams
and organisations
improving communication and enhancing
teamwork between healthcare staff.
improving how we learn when things go
wrong by improving current approaches to incident investigation
predicting ‘what could go wrong’ in the
design of new hospitals and healthcare processes, for example, through,
prospective risk assessment tools, workload assessments etc


See “clinical human factors group”
(, “The Health Foundation”, MBJ Quality & Safety ( or NHS
sites for examples of learning in this area.


Catchpole (2010), cited in Department of Health
Human Factors Reference Group Interim Report, 1 March 2012, National Quality
Board, March 2012.?Available at:




2.7 Swiss Cheese Model


Dante Orlandella and James T.
Reason of the University of Manchester
were the first people to formally describe this model.


Any human based system contains multiple stages and safeguards all
of which have the potential for minor flaws. It is important to understand that
these flaws are shifting and not always recognised. These flaws are like the
holes in a slice of swiss cheese. If the flaws
(holes) in each stage (slice) line up at a given time you end up with a defect
that gets through all your safeguards and is reported.  


Historically the mistake was made to
just blame the operator and not accepting the fault may lie in the design of
the system. By considering the system as a whole you are able in effect
minimise the size of the holes and improve the system.



Include diagram


Further reading :

James (2000-03-18). “Human error: models and management”. British
Medical Journal. 320 (7237): 768–770.



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