Adaptive DesignThe Path to Ideal Care

Mary Ann Osborn RN, MSNVP/CNO St. Luke’s Hospital, Cedar Rapids

Panel Members from Quad Cities, Cedar Rapids & Sioux City

IHS Symposium

April 2010

Objectives for the day

Review the IHS Vision Provide overview for Adaptive Design Share examples of Adaptive Design and the

scientific methodology to solve problems (A3) Outcome measures at various affiliates Describe the borrow forward process

challenges, lessons learned

GOAL: Ideal care that achieves best outcome for every patient every time

• Patient Centered• Based on best practice/evidenced based• Efficient/adds value/enhances the patient

experience• Electronic medical record enables care• Professional practices nurtured/effective work

teams

GOALS (not an all inclusive list)

• 95% of patients willing to recommend• 0 codes on med/surg units• Less than 5% readmissions within 30 days• Achieve 90% or above in all quality measures (HF,

MI, Pneumonia, Infection Preventions, etc.)• No patients fall• No skin breakdown• Increase caregiver time at the bedside to 60-70%

Adaptive Design is an improvement methodology developed by John Kenagy. It is an enabling technology that continually improves an organizations’s ability to deliver exactly what the patient needs while simultaneously lowering the cost of care.

John Kenagy, 2009

Adaptive Design:Blend of 2 innovative concepts

Disruptive Innovation Encourages leaders to look for effective, simpler,

less costly ways to provide better service Gives permission to look at other industries for

ideas or answers Toyota Production System

How people work and manage How they think about their work How they learn and work together to improve

What is Adaptive Design? The foundation of the work is observation

Honors the work of the front line staff Allows observer to ‘see’ the whole picture—eliminates

assumptions Detailed observations provide opportunities for problem

solving All the improvement work is based on the point of

view of the patient Creates a culture of improvement that uses the

creativity, knowledge and problem solving ability of frontline staff to solve problems whenever care is not ideal.

Problem Solving

First order Solving the problem for this patient and this

clinician at this time (work around) Second order

Get at root cause and solve the problem for future patients and clinicians

Adaptive Design sets Direction: Ideal Patient Care

“My family and I get what we want and need, safely and without waste and without having

to wait.”

Rules of Adaptive Design

Strive for Ideal Patient Care Ideal Patient Care is a test to see if we are

delivering the best outcome for every patient, every time. It can be answered with a yes or no. Did the patient get what he wanted, and needed safely without waste and/or having to wait?

Rules of Adaptive Design

There are 4 rules in Adaptive Design that are used to assist us with achieving ideal care

Rules 1-3 guide the work that is being done Rule 4 guides us through problem-solving

Rule 1—How People Work-Activities All work shall be highly specified as to content,

sequence, timing, and outcome.

If work is highly specified, it does not allow variation in the way employees do their work.

Too much variation in a work process can lead to Poorer quality Lower productivity Higher costs Hinders learning and improvement in the organization

because the variations hide the link between how the work is done and the results.

ACTIVITY

Rule 2- How People Connect-Connections Every customer-supplier connection must be direct,

and there must be an unambiguous yes-or-no way to send requests and receive responses.

The connection should not have any gray areas. The connection should provide who, what, when, where,

and how. When a person needs assistance, there is no confusion

over who will provide it, how the help will be triggered, and what services will be delivered. (Help chain)

This rule encourages employees to ask for help at once.

Rule 3-How the Production Line Is Constructed-Pathways Every product or service flows along a simple, specified

path

There should not be any deviation from the pathway No forks or loops Care and services do not flow to anyone, but to a specified person or

equipment The care we provide is a series of different pathways

(services): Admission Medication Administration Discharge

Each pathway has several different activities (Rule 1) and connections (Rule 2)

Those not connected to the pathway do not need to be there (Eliminate wastes and reduces repetition)

Rule 4-How to Improve-A3 Problem-solving

Any improvement to production activities, to connections between workers or machines, or to pathways must be made in accordance with the scientific method, under the guidance of a coach, and at the lowest possible organizational level.

Encourages management to mentor frontline staff and be facilitators

Develops staff members into a community of learners who participate in the problem solving

Problems, as signaled by staff, are solved using a scientific method Tackles specific problems or failures rather than generalize

or assume the issue. The countermeasures are solutions developed based on

the particular cause.

What is the Adaptive Design process?

Observations of the current state Look for “signals” when patient care is not

ideal Problem-solve using a scientific method (A3s) Implement and Test Countermeasures quickly Continue with Countermeasure, until failure is

signaled by frontline staff

Adaptive Design Transformation

Is a disciplined approach Creates a culture change in how to solve problems

Every solution is a “test” and we expect it will fail---but we will learn more about the issue and come closer to the ideal

Every employee becomes a problem solver Removal of barriers of ideal patient care

No “work-a-rounds” No communication gaps Eliminates repetition and redundancies

Increase quality Increases nurse time on patient care Increases patient satisfaction Increases employee satisfaction

Trinity Quad Cities6 North Unit – Surgical/Ortho

Background:

Post-op surgical inpatient population. 30 - bed unit with 25 private rooms. 9 Ortho Certified RNs

Core Blueprint Team:Kathy Yadon RN, MS, CMSRN – Manager 6North

Kim Chant RN, ONC – CAP III Staff Nurse

Megan Neal RNC, BSN – Clinical Nurse Educator

Lauren Monks BA, CPHQ – PI Champion

Jewels Stark MBA, MS, BSN, RN – Director, Acute Care Services

Current State of Blueprint

Blueprint fully implemented. Staff “get it”. Blueprint has become a living entity.

We’ve gained momentum

We’re working on sustainability

Call light A3

Call Light A3 – Root Cause

Call Light A3 – Counter Measures

Our Proudest Outcome: Unit-Based Shared Decision Making

Staff Perspective

Staff no longer feel threatened by change; they feel empowered to look for things that need changing!

It’s no longer “They vs. Us”, now it’s “We”

It’s a “can-do” environment

Staff have begun to challenge

their own status quo

St. Luke’s Hospital-Cedar Rapids

• 5 East-Medical• Blueprint Unit• 25 beds

• Diane Pfeiler, RN-Adaptive Design Coach– Manager, 5 East-Medical

• Connie Bulman, RN-Adaptive Design Coach– Lead RN, 5 East-Medical

Areas involved with Adaptive Design at St. Luke’s-CR

• 5 East-Medical– Diane Pfeiler, RN, Manager

• Emergency Department– Sandi McIntosh, MSN, Director

• Admission Process Committee– Carmen Kinrade, MSN, Chair

• Medication Reconciliation Committee– Carmen Kinrade, MSN, Co-Chair– Pat Thies, RPh, MS, FACHE, Co-Chair

St. Luke’s-Cedar Rapids DNR orders A3

DNR orders A3Background

DNR orders A3Current State

DNR orders A3Root Cause

DNR orders A3Target Condition

DNR orders A3Countermeasures

DNR order A3Test Question

St. Luke’s-Cedar Rapids5 East Medical Outcomes

Total Number of A3s completed 179

Total Number of A3s related to Pt. Safety 29

Total Number of Departments Involved 31

Total Number of Frontline Staff Completing A3s

16

% Staff Overtime Pre AD = 2.36%

Post AD = 0.82%

Improving Patient Safety

5 East Fall Rate

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Jan-09

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan-10

Feb

Fall R

ate

Fall Rate Median

• 12 A3s related specifically to patient falls since October 2009

St. Luke’s-CR: What has this work meant to me as a Manager?

Problems/Issues are dealt with right away Able to spend more time with frontline staff

Staff give their input related to signals to me A3 are useful learning tools for my staff and

hospital Builds staff members’ experiences and

knowledge bases It’s not extra work, it’s how I do my work

St Luke's-CR How has this impacted my work as a Lead RN?

• Adaptive Design is now my work• Incorporated with frontline staffing duties

• Utilizing Adaptive Design in committee work • Increased connection with other departments• Constant interaction with frontline staff

St. Luke’s-CR: How has this work impacted the frontline staff?

• They come to us with things that get in the way of Ideal Care

• They are involved in developing countermeasures

• They think differently about the problem solving process• “Working through the A3 helped me to evaluate

what the real problem was. It helped me see that there are other solutions that would be safer for the patient.”—Angela, RN, 5 East

•

St. Luke’s Blueprint Work

Began Jan 5,2010 4A Surgical/Oncology Unit

Team members include: Lisa PishekVikki Bridgford

Wendy Hamblen Laurie McCurry

Blueprint Team

Impact on our work

“It has impacted everything!"“Everything has changed---it’s

wonderful having what you need right in the room.”

Michaela Nesbit (RN 3yrs)

“It shortens the time spent going and running to get things.”  Megan Fick (RN <1yr)

4A’s Favorite A3 (so far)

Departments working together

Conclusion

We are excited because: The patient is the focal point of our work. Frontline staff are driving the process. Managers are coaching and mentoring. We’re back at the bedside and finding joy in

our work.