Toyota Production System Methodology Leads to Improved Peri-Operative Care
The Toyota Production System (TPS) industrial engineering approach to improve manufacturing quality originated in the automobile industry and is now being applied to quality improvement (QI) in healthcare delivery systems. In TPS, front-line work groups identify problems, experiment with possible solutions, measure the results, and implement strategies to improve quality, resulting in a "ground-up" rather than "top-down" approach to solving system problems. Beginning in 2001, one VAMC instituted TPS methods to reduce Methicillin Resistant Staphylococcus Aureus (MRSA) infections on a general surgical floor. The intervention then evolved to address other areas for QI on the surgical unit, such as increasing appropriate prophylactic peri-operative antibiotic therapy. The aims of this study were to determine: 1) whether the QI intervention for peri-operative antibiotic therapy was associated with improvements in selection and duration of prophylactic therapy; and 2) if the overall MRSA prevention initiative was associated with decreased hospital stay (LOS). Investigators used VA data to identify patients undergoing five types of surgical procedures (neurosurgery, vascular, gastrointestinal/biliary, genitourinary, orthopedic) and examined changes in appropriate antibiotic therapy and LOS from 2000 to 2004.
Findings show that use of the TPS methodology resulted in a QI intervention that was associated with an increase in appropriate peri-operative antibiotic therapy among surgical patients. The proportion of all surgical admissions in this study (n=2550) receiving appropriate peri-operative antibiotics was significantly higher in 2004 after initiation of the TPS intervention (44.0%) compared to the previous four years (range 23.4% to 29.8%). The increase was due primarily to improvements in compliance with appropriate antibiotic duration rather than appropriate antibiotic selection. However, while appropriate antibiotic therapy significantly improved for neurosurgery, vascular, and orthopedic procedures between 2000 and 2004, higher rates of compliance with guideline recommendations for the selection of agents were limited to neurosurgical admissions. The proportion of Veterans receiving appropriate antibiotic therapy for gastrointestinal/biliary procedures was significantly lower. Results also showed no statistically significant decrease in LOS over time. This study adds to the growing body of literature demonstrating the effectiveness of a TPS approach to improve quality in a healthcare setting.
Burkitt K, Mor M, Jain R, et al. Toyota production system quality improvement initiative improves peri-operative antibiotic therapy. American Journal of Managed Care September 2009;15(9):633-42.
This study was partly supported through VA's Office of Research and Development. Drs. Burkitt and Mor are part of HSR&D's Center for Health Equity Research and Promotion in Pittsburgh.