Mr. Potato Head: A LEAN, Mean Quality Improvement Teaching Machine!

Submitter Information

Author: Beth Murphy, MD, Department of Medicine
Title: Medical Doctors
Institution: University of Massachusetts Memorial Hospital and University of Massachusetts Medical School
Coauthors: Eric Alper, MD and Eric Dickson, MD (*Inventor)

Competency Category(s)
Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration

Learner Level(s)
Continuing Education, Graduate Students, New Graduates/Transition to Practice, Pre-Licensure BSN, RN to BSN, Staff Development

Learner Setting(s)
Classroom, Skills or Simulation Laboratories

Strategy Type
General Strategy

Learning Objectives

Strategy objectives:

1. Participants will understand concepts of Lean Process Management including “waste”, non-value added work, elimination of non-value added tasks in a work process, role of “the system” in quality, and importance of team based care.
2. Participants will understand steps in a PDSA cycle.
3. Participants will understand that with small changes in system, both quality and efficiency can be improved.
4. Applying insights gained from this interactive and fun exercise, participants will be energized to bring new Quality Improvement skills and knowledge back to their clinical settings to begin or enhance improvement efforts.

QSEN graduate competencies:

1. Describe strategies for improving outcomes at all points of care.
2. Identify useful measures that can be acted on to improve outcomes and processes.
3. Demonstrate leadership in affecting the necessary change.
4. Value the contribution of standardization and reliability to safety.
5. Analyze self and other team members strengths, limitations and values.
6. Value the influence of system solutions in achieving team functioning.
7. Understand the roles and scope of practice of each interprofessional team member including patients, in order to work effectively to provide the highest level of care possible.

QSEN pre-licensure competencies:

1. Describe examples of the impact of team functioning on safety and quality of care.
2. Identify system barriers and facilitators of effective team functioning.
3. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice.
4. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals.
5. Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families.
6. Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act).
7. Value own role in preventing errors.
8. Understand the roles and scope of practice of each interprofessional team member including patients, in order to work effectively to provide the highest level of care possible.

Strategy Overview

This is a simulation teaching strategy used to illustrate Quality Improvement. This strategy can be used with:

1. Medical Students, Residents, Faculty, Nurses, other health care providers and team members
2. Anyone! Has been done successfully with 9 year learners at summer camp, as well as industrial engineers!

Number of Participants Needed:

1. Ideal number is 7-8 members per team
2. Has been done with as few as 4 participants, or 125 students in teams of 8-10 members.

A bus filled with 16 Potato Head family members is in a terrible crash! At the scene of the accident, Emergency Medical Services arrives to find only scattered body parts. Luckily, one of the family members was carrying a photo album with a photo of each family member. There are men, women, children, and pets on the bus. A health care team is waiting in the emergency room to correctly assemble as many family members as possible in 7 minutes. On the health care team, two of the members are designated “Implantation Specialists” (a.k.a. trauma surgeons). Only they can “implant” the parts into the potato bodies. The number of correctly assembled Potato Heads and the number of errors are tracked through each PDSA cycle.

Submitted Materials

Additional Materials

Evaluation Description

During the debrief, students should identify the following points:

1. The system is a critical determinant of performance; usually more significant than the skills or efforts of the people.
2. Good communication is essential for a high-functioning team.
3. Good ideas for improvement can come from anyone on the team.
4. Data is essential to drive improvement efforts.
5. Repeating PDSA cycles is a valuable process in Quality Improvement.
6. Efficiency is enhanced when waste is reduced.
7. All steps should add value. Strive to eliminate all steps that do not add value.
8. With very simple changes in system, you can improve both quality and efficiency!