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2.5  Kaizen and change management Thisone of the six-sigma techniques that looks to make incremental small changes toprocesses that will result in improvements to the overall process. It originated inJapan and translates to mean change (kai) for the good (zen).  Often this is focussed on the process ofreducing waste and allows staff employed in the process to have ownership ofmaking changes.  In ahealthcare setting waste could be movementof samples or patients for no gain, timewaiting between processes (patients waiting for results prior to appointments),defects (wrong result orpharmaceutical preparations), over-processing(reporting results to greater accuracy than required for diagnosis), variations giving non-standardsolutions when not required.

  2.6Human Factors in healthcare–  What are Human Factors inhealthcare? “Enhancing clinical performancethrough an understanding of the effects of teamwork, tasks, equipment,workspace, culture and organisation on human behaviour and abilities andapplication of that knowledge in clinical settings”.1   It is important to understandthat often failures are not just caused by individuals but are organisational.The science of human factors in systems has developed greatly and learning hasincluded the often quoted “Swiss Cheese Model of organisational accidents”   Any system will have a number oflayers of control all of which will have minor gaps – when all the gaps line upan incident occurs.  UpdatesDeveloping healthcare systems foundedon 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” health., MBJ Quality & Safety ( or NHSsites for examples of learning in this area.  1Catchpole (2010), cited in Department of HealthHuman Factors Reference Group Interim Report, 1 March 2012, National QualityBoard, March 2012.?Available at: http://www.england.nhs.

uk/ourwork/part-rel/nqb/ag-min/   2.7 Swiss Cheese Model Dante Orlandella and James T.Reason of the University of Manchesterwere the first people to formally describe this model.  Any human based system contains multiple stages and safeguards allof which have the potential for minor flaws. It is important to understand thatthese flaws are shifting and not always recognised. These flaws are like theholes 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 defectthat gets through all your safeguards and is reported.    Historically the mistake was made tojust blame the operator and not accepting the fault may lie in the design ofthe system.

By considering the system as a whole you are able in effectminimise the size of the holes and improve the system.  Include diagram Further reading : Reason,James (2000-03-18). “Human error: models and management”. BritishMedical Journal.

 320 (7237): 768–770.  

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