Spotlight on Clinical Problem-solving

When Small Changes Have Big Impact

Objectives

• Describe Ideal Patient Care

• Discuss what a barrier to Ideal Care is

• Explain the impact of workarounds in everyday patient care

• Describe how making small changes one at a time impacts bigger processes

Adaptive Design Emergency Services

Daphne Willwerth, RN, BSN, CENManager, Emergency ServicesTrinity Regional Medical Center

Fort Dodge, Iowa

Training

• Began training core Adaptive Design Group in June of 2010

• Core Group consisted of ED Charge RNs and EMS Supervisors

• Began training 8 hours per week and then decreased to 4 hours scheduled training time per week

Ideal Patient Care

The patient and family’s physical and emotional needs are met with compassion in a safe and timely

manner.

4 Rules of Adaptive Design

1. All work shall be highly specified as to content, sequence, timing, and outcome

2. Every customer-supplier connection must be direct, and there must be an unambiguous yes or not way to send request and receive responses

4 Rules of Adaptive Design

3. The pathway for every product and service must be simple and direct

4. Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization

Observations

Activities

Connections

Pathways

Work of an individual

Communication between individuals

Processes (activities + connections)

Observations

• 1 Hour patient pathway observations completed by core group

• 1 Hour patient pathway observations completed by all ED and Ambulance staff with assistance of a coach

• Began work with A3s

Adaptive Design Process in the ED

Signal Log

• Completed by staff when patient does not receive Ideal Care

• Coach uses to start A3

Communication A3

• One of our first problems was how do we communicate all of our counter measures

Pre-Shift Huddles

• Used every shift to communicate problems and counter measures

• Charge nurse to all staff

Monthly Newsletter

Spreading Adaptive Design• Improvements in Signal Form

• Pulling more staff into our scheduled Thursday training days

• Working A3s with staff involved in the signal

• Posting A3s in break room and discussing counter measures with each huddle

• Coming in on night shifts to train night staff

A3s to Solve Problems• All Peminics• All core measures that fall out for pneumonia

and STEMI• All signaled problems• Performance measures not met on Stroke and

Trauma patients• Staffing issues if they impact our ability to give

ideal patient care• NDNQI survey results that were lower than

comparative data

Increase Staff Involvement

• Coaches assigned to specific staff

• 1 hour classes on Thursday morning during shift changes

• Work department A3s during ED and EMS Unit meetings (e.g. ED Noise levels)

Impact on the ED

Vitality Survey

Vitality Survey

Mean Trends Emergency Department - Acute

Trinity Regional Hospital

Displayed by Discharged Date

Overall

Acute Emergency Department Overall

Mean Trends Emergency Department - Acute

Trinity Regional Hospital

Displayed by Discharged Date

Question - Likelihood of recommending

Acute

Mean Trends Emergency Department - Acute

Trinity Regional Hospital

Displayed by Discharged Date

Question - Staff cared about you as person

Acute

Mean Trends Emergency Department - Acute

Trinity Regional Hospital

Displayed by Discharged Date

Question - Overall rating ER care

Acute

Lessons Learned

• One patient, one problem at a time

• Focus on Ideal Patient Care

• Observe for opportunities to solve problems with the A3

Using Adaptive Design to Improve Admission Core

Process Work

Jim Abel, RN, BSN

Cathy Hunt, RN, BSN

St. Luke’s Cedar Rapids

Admission Core Process

• Set Direction

• Observations

• Document Current State

• Identify workarounds and barriers to Ideal Patient Admission (signals)

• A3 problem-solving

Ideal Admission Process“The admission process

accommodates the wants and needs of my family and me

safely and without waste and it provides my caregivers

with the information necessary to care for me.”

Admission Core Process• Observations

– Direct and ED Admissions– Adult and Pediatrics– Patient– ED pod RN, ED charge RN– Physicians (ED, admitting)– Bed Placement– Admission Center RN– Inpatient charge RN, bedside RN,

secretary• Documented current state• Identified barriers to ideal care and

workarounds (signals) – Patient Family Advisory Council– Frontline staff

A3 problem-solving• Signal: I was not an appropriate patient

for the room I was assigned– Root cause: ED charge nurse who provides the

information to bed placement does not have a full picture of the patient and is a loop in the connection between the customer who has the full picture (ED pod RN) and the supplier (bed placement)

– Countermeasure: Remove ED charge nurse from process and have direct connection between ED pod RN and bed placement

Adult transfers-1st 24 hours

A3 problem-solving• Signal: My home medication list wasn’t

ready for my admitting physicians when he/she wrote my admission orders which resulted in many workarounds– Root cause: There was no specified process for

getting a complete and accurate home medication list prior to physician writing orders

– Countermeasures: • Admission nurses now work out of the ED• Prioritize completion of the home medication

Percent of home medication lists (210) that have standardized documentation

(n = 40/month)

0%10%20%30%40%50%60%70%80%90%

100%

Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11

Per

cent

of

210s

tha

t ar

e de

fect

-fre

e Adaptive D

esign

Home Med Documentation

Change Process to

Team Ownership

Leaders Communicate

to Organization

Teams Understand

Teams Adopt

Teams Own

Leaders Set

Direction

Most difficultpart of process

Countermeasures

• Train med/surg managers and supervisors in Adaptive Design using four week “cohorts”: Twelve 5 hour days of learning

• Develop Standard Work Process Guides• Encourage real-time coaching of new work

processes

The real key to stabilizing and sustaining work is……

Patience and Perseverance

My Patient StoryCultural Diversity & Fall

Aimee Derby

Assistant Nurse Manager- 5A

St. Luke’s Hospital- Sioux City

Story Dialogue Utilized by Adaptive Design Methodology

Elderly Hispanic gentleman hospitalized on Surgical/Oncology floor.

Married with adult children- wife and son visiting, present in patient room.

Patient and wife spoke Spanish only, adult children bilingual.

Patient and family had been previously instructed to call for help with ambulation.

Current State: Patient attempted to ambulate without help and fell while wife and son sat in room and watched.

Nurse arrives in room and assists patient back to chair.

Patient had no apparent injuries.Nurse spoke to adult son who explained in his

culture, children are expected to be obedient and respectful toward parents; therefore, he is not comfortable telling his father not to get up alone.

Traditionally, father is head of household and holds ultimate decision-making authority.

Action Plan

Applied personal alarm to patient when upCreated a sign in Spanish that stated “Call

Don’t Fall” to hang in the room as a visual reminder

Reinforced with staff in daily huddle the cultural implications of Hispanic family dynamics and safety

Reinstructed patient and family to call and wait for staff assistance before attempting to get up

A3

Hospital Admit vs Population Diversity

01/01/2010 - 12/31/2010

Hospital Admits

9,748 100% 100%

Numberof

Med Recs

Percent of

Total

Sioux CityPopulation

RACE

135 1.4% 2.6% A ASIAN

266 2.7% 2.2% B BLACK

7,692 78.9% 78.5% C CAUCASIAN

1,107 11.4% 10.0% H HISPANIC/LATINO

509 5.2% 1.8% I AMERICAN INDIAN/ALASKA NATIVE

34 0.3% 4.9% M MULTIRACIAL/UNKNOWN/DECLINED/OTHER

5 0.1% 0.0% P PACIFIC ISLANDER/HAWAIIAN NATIVE

Decrease in Fall Rates

First Quarter (Jan-Feb 2010)- 7.41 falls per 1000 patient days

First Quarter (Jan-Feb 2011)- 3.21 falls per 1000 patient days

Why the Decrease?

Reliable Rounders Program (initiated in March 2011)

Communication (shift huddles, bedside report, white boards, fall signage)

Safety Devices (personal alarms, bed alarms, low beds, fall mats)

Patient-Family Centered Care (engaging the family)

Bedside Shift Report

Sarah L. Scott, B.S.N., R.N.

Allen Hospital

To begin…

• A problem was signaled involving shift report

• The patient was not being kept informed

• The nurse wasn’t receiving the information needed to care for his/her patients

• Thus, observations were made and an A-3 was completed

Observations

• Observations were completed by nurse managers and staff nurses

• It was observed that shift report was not consistent

• The current state was: shift report was occurring at the nurse’s station, hallway, outside of the patient room, and at the bedside

• A consistent tool was not being utilized across the medical-surgical units

What we learned

51

• Nurse managers and staff nurses met to discuss common themes throughout their observations

• As a group, we identified what we learned• We discovered that shift report was variable• Varied from nurse to nurse-unit to unit• Not always at the bedside• Needs some degree of variability• Patient not always engaged

Principles

• Basic Principles for Shift Report• Shift report should:

» Tell the patient story

» Keep the patient engaged

» Patient focused

» Consistent

» Needs to be specified

» Utilization of the white board

» Accountability from giver to receiver

» Any “I don’t know” should have an answer before the off going nurse leaves and the answer should be relayed

Content/Sequence

• As a group, we developed what the content and sequence to shift report should consist of:

• Introductions• Reason for admission• Medical History• Precautions/Safety• Course of hospital stay• Plan of Care• Closure

CareCast Report

• A report was being utilized by some of the units, but not all

• Required the nurse to hand-write the patient’s diet, activity, IV, intake and output, vital signs, labs, and assessment

Old Shift Report Tool

Shift Report Tool

• A new shift report tool was developed from the Trinity Quad Cities Patient Care Tech report

• The new RN report was developed by IT with feedback from staff

New Shift Report

Tool

Shift Report Tool

• The new shift report tool was implemented on medical-surgical units

• A poster was created to remind staff of items to include in report and was placed at the head of the patient’s bed

• Report was to occur at the patient’s bedside

Shift Report Poster

Another Signal

• A patient signaled that report was not occurring at the bedside

• Another A-3 was created

• As a result, the content was re-specified• It was found that nurses were reading off of the

report tool which was redundant

Re-specified Content

• The needs of shift reporting at the bedside• Introductions• Course of hospital stay (high-lights)• Plan of care• Closure

Work in Progress

• A new poster was created for the patient’s room with the re-specified content, placed above the head-of-the-bed to remind nurses of what report should consist of

• Report tool was standardized across all medical-surgical units at Allen Hospital

• This is a continual work in progress to ensure that nurses are practicing report at the patient’s bedside

New Poster with Re-specified content

Questions?

Thank you for your attention