"We learned early on that much of the focus in infection prevention was on how you place the catheter. What we learned through our observations (and borrowing the processes from Toyota) was it was in maintaining the catheter. Once it was in, how do you take care of it? And what we initially discovered was, there weren't reliable processes in place by which nurses and others took care of catheters. So now it's very unambiguous, very clear to everybody where the catheter is in the person's body, what the condition of the catheter is every day. There's a specific person responsible each day for looking at that catheter site and making sure it's intact. And any time there's a question, that's immediately kicked up to a higher-level person who can make a decision about whether the catheter needs to come out or not.
"So identifying a highly-reliable, unambiguous process in which everyone's responsibility is made clear creates a much more likely defect-free process during the course of that catheter being in place."
"A highly-reliable, unambiguous process in which everyone's responsibility is made clear." Damn right.