Total Quality Improvement: An Example of an Effective Team

by Dean Miller, MS-HRM BSN RN Assistant Chief Nurse Prescoft Veterans Administration

Prescott, AZ Medical Center

The following authors are on staff at Carl T . Hayden Veterans

Phoenix, AZ Adminisf ra t ion Medical Cen f er

D.J. Smith, RN Psychiatric Coordinator, Nursing

Service

Marie Brophy, RN Nurse Manager

Marilyn Mollman, RN Staff Nurse

James Owen Laund y Supervisor

Gail Smith, RN Nurse Practitioner

Clarence More Health Supervisor

20 1 JHQ 1 January/February 1996 1 Vol.

Total quality improvement (TQI) advocates that all staff members in an organization develop their own ideas on job improvement about their own specific jobs. This process helps to improve staff performance and to build continually on those improvements. This article will describe how the TQI process was used successfully by quality management staff members at a federal medical center to investigate a problem with linen.

Background The healthcare system in the United

States is in the midst of unprecedent- ed change, in an uncertain climate. Much of the change is economically driven. Government, insurance com- panies, employers, labor unions, and the public all are exerting pressure on healthcare facilities to control spending and redirect healthcare dollars toward effectively meeting patients’ needs.

Industries, including the healthcare industry, have for years used economics to drive the decision-making process (Walton, 1986). Quantitative analysis usually provides the bulk of the data managers use to make decisions. In healthcare, however, the drive toward patient-focused care has helped to de- centralize the decision-making process (Peters & Waterman, 1982). This de- centralization is linked to the growing use of a new paradigm based on the to- tal quality management (TQM) system described in 1949 by W. Edwards Dem- ing (Walton, 1986). It is this focus on the customer that drove those who imple- mented the TQI process at the authors’ facility to develop a series of decisions that both improved patient care and also helped to provide an environmentally sound plan for the facility.

Introduction Carl T. Hayden Veterans Adminis-

tration Medical Center (VAMC) in Phoenix, AZ, is a 350-bed facility with two nursing intensive care units of 60 beds each. This medical center provides general medical and surgical care to vet- erans in middle to southern Arizona. The VAMC also provides a surgical and medical residency and internship pro- gram for medical schools throughout the country.

Opportunity to Improve The increasing cost of labor and sup-

18, No. 1

plies focused attention on a problem at the VAMC with the use of bed linens. Extra sheets folded in half width-wise were being used as pull sheets placed on top of regular sheets for patients throughout the VAMC (pull sheets are a means by which healthcare providers can move patients up in bed without in- juring the patient). This had been done for years and had worked well, ac- cording to the nursing staff. However, the medical center’s environmental management service (EMS) objected to the practice because it was hard for them to keep track of the amount of linen used and also because the practice caused un- necessary wear and tear on these sheets.

A lack of cooperation and commu- nication between services at the VAMC prevented the problem from being identified and resolved. It seems ob- vious that improving quality cannot be the responsibility of any one depart- ment, but for years, the VAMC, like most companies and healthcare orga- nizations, tried to do just that. The linen situation presented an opportunity for the VAMC to create an interdisciplinary team to study and resolve a specific problem according to the following TQI principle: ”Identify performance prob- lems and come up with solutions which, when implemented, will turn the situation around” (Blanchard & Johnson, 1983, p. 68).

Forming a Team To be effective in solving the problem

of linen use and its effect on patient care and comfort (which is an area that healthcare providers constantly seek to improve), the team had to include rep- resentatives from all affected services. Team members had to be willing to take the time to learn the TQI process and to take an active role in developing possi- ble solutions.

Members: The initial team included

the department chiefs for nursing ser- vice and EMS, nurses, building man- agers, health aides, and skin care spe- &hsts. After the first few meetings, team members decided the problem could best be resolved by using TQI, which was still new to the facility and had not been fully implemented. The interdis- ciplinary ”linen team” thus was one of the VAMC‘s first experiments in TQI.

Turf issues: The clearly defined di- visions between disciplines, depart- ments, and services in the medical cen- ter presented an initial challenge for the team. Each group carefully guarded its own turf. Laundry staff believed they were losing linen, nurses wanted the p d sheets, and building managers were concerned about the cost of using bed sheets as pull sheets. Team members openly discussed the turf problem in their meetings and committed them- selves to the importance of looking at the process rather than of maintaining boundaries.

~~

The team had to include representatives f rom all afiected services.

Trust and respect: Because team members were able to share ideas and experiences and discuss how their jobs intertwined, they developed mutual trust and respect, became more cohe- sive, and started to make progress. At this point, the service chiefs left the team, thus allowing those remaining the au- tonomy and freedom to work without supervisory pressure. (The normal pro- cess at the VAMC would have required managers to directly supervise the TQI team from start to finish. In a more tra- ditional TQI approach, a steering com- mittee, which would provide guidance and direction to the team, would ap- prove each step of the process.)

The team ultimately comprised two nurse managers, a nurse practitioner, a staff nurse, an enterstomal therapy nurse, a nursing coordinator, a laundry supervisor, and a health aide supervi- sor. The team elected one of the nurse

managers and the nurse practitioner as team leaders and chose a representative from psychiatric services as their facil- itator to help with the TQI process. The team was now ready to begin to iden- tify and resolve the problem.

Planning Brainstorming sessions: The team

discussed the process in a brainstorm- ing session, which helped the members develop the following questions:

What are the reasons for using pull sheets? What patient benefit is derived from their use? What staff benefit is derived from their use? Are p d sheets needed for every pa- tient? If not, for which ones? How are the sheets moved through the system in between each laun- dering? Is there a viable option to this pro- cess?

Brainstorming and planning sessions (four or five over a period of 1% months) helped team members to better under- stand each other’s roles in the overall linen-handling process.

Team charter: When each member of the team was comfortable with the linen-handling process, the facilitator helped the team develop a charter to clearly d e h e the team’s boundaries and express the group’s desired outcomes (see Figure 1).

In addition to the problem with pull sheets, the team also needed to deter- mine how to decrease the use of dis- posable absorbent bed pads (which commonly are placed underneath pa- tients to protect them and the sheets from blood and other body fluids).

The Process Additional questions: As team mem-

bers continued to study the linen prob- lem, they developed the following ad- ditional questions:

What products are being used as disposable pull sheets? What products (such as absorbent pads, medications, and therapeutic mattresses) are being used to pro- tect patients from fluids and skin breakdown?

Figure 1. Teamucharter

Process Owners Chief, building management service and chief, nursing service

Goal To reduce use of disposable pads and increase efficient use of linen

Process Boundaries Project must be accomplished within

Project must be accomplished with cur- current budget

rent personnel Recommendations will be based on TQI philosophies and analyzed according to a data-driven approach Recommendations will be in compliance with Joint Commission on Accreditation of Healthcare Organizations require- ments The team will seek input from all ser- vices involved in the implementation of recommendations

Strategies to Define Process Review current amount of usage of

Review current methods used to make

Get input from staff who make the beds

Get input about alternatives and poten-

Survey representative units Determine process flow

Use of disposables will decrease Nurses will be able to move patients in

disposable pads

patients’ beds

and use the products

tial costs

Desired Outcomes

beds safely as determined by staff report and to provide documentation in employee injury forms Patients will suffer no ill effects (e.g., number of pressure sores will remain stable or will decrease) User satisfaction will be maintained

What alternatives are available? What is the extent of product usage? What is the cost of current practice? How should current practice be

Data collection: Data collection be- came a priority to help answer these questions. The team initially looked at the medical center’s use of the dispos- able pads. Team members and several other nurse managers in the medical, surgical, teaching, nonteaching, and nursing home (extended care) units in- ventoried stock levels and studied dai- ly usage. They found that the VAMC had approximately 6 disposable pads per patient in stock on each unit and

changed?

JHQ 1 January/February 1996 1 Vol. 18, No. 1 1 21

Total Quality Improvement

I Disposable $111,960/2 yr.

used an average of 3.5 disposable pads per patient per day. One ward had more than 1,000 pads in stock and was be- ing resupplied on a daily basis. The VAMC was spending $30,000 to $32,000 per year on the disposable pads, in ad- dition to approximately $24,000 to dis- pose of them, either by burial in a land- fill or by incineration.

Trial period: Because of the high us- age rate and the high cost of the dis- posable pads, the team decided to search for alternatives to the pads, as well as for different suppliers. Four ven- dors were contacted; two could provide disposable absorbent pads and two could provide reusable absorbent pads. Each vendor agreed to provide the VAMC with samples and the nurses with in-service education on the use of its product. The initial trials of the dif- ferent products were carried out in the two intensive care units because they are large and usually full and because the staffing level (one nurse for every two patients) would permit a sigruhcant level of nurse involvement.

During the 4-week trial period, an- other linen problem became evident. If there was no pull sheet tucked under the sides of the bed, the bottom bed sheet had a tendency to loosen at the head and foot of the bed. This caused patients and their families a great deal of concern; the simple act of sitting on the side of the bed was displacing the linens and giving the bed an unmade appearance.

Trial results: Several vendors had fit- ted sheets available, but only two were willing to provide the VAMC with sam- ples. Sample fitted sheets were given to each ward; nurses tested them exten- sively on almost every bed and in al- most every patient situation. There was unanimous agreement that fitted sheets should be used on patients’ beds. In a second trial, held on two medical units and in the intensive care areas, nurses determined that fitted sheets with 18- in. wells were the best option. The re- sults of the second trial were brought to the nurse manager committee. The nurse managers agreed that this type of sheet was best because it did not bunch under the patient or sag when the head of the bed was raised, it was soft to the

Figure 2. Cost Comparison of Disposable and Reusable

Absorbent Bed Pads

Disposable Reusable

Cost per year $32,000 $60,260/2 yr.

Disposal $23,980 $0 Laundering $0 $13,000/2 yr.

Total $55,980 $73,260/2 yr.

Reusable $73,260/2 yr.

Difference in Cost $38,700/2 yr. (Savings by using reusable absorbent bed pads)

I

touch, it did not require ironing or fold- ing, and it reduced the time needed to make and maintain beds (thus reduc- ing nurses’ and health aides’ risk of in- jury). The laundry supervisor concurred with the nurses’ assessment and re- ceived the EMS chief‘s approval to pur- chase the fitted sheets.

Decisions Reusable pads: After the bottom

sheet issue was resolved, the team re- turned to evaluating disposable and nondisposable absorbent pads. The team concluded that staff nurses pre- ferred one vendor’s reusable pads for the following reasons: one pad is large enough to cover the bed, the pads pull moisture away from a patient better than disposable ones, the pads can be used to move a patient up in bed and to transfer a patient from bed to gurney, nursing time is saved because fewer bed changes are required, and the pad’s un- dersurface moves easily across the sur- face of the new fitted sheets.

There were other important reasons for choosing these particular pads, as opposed to the competitor’s reusable pads. Using reusable pads instead of disposable ones reduces waste and therefore is environmentally responsi- ble; each pad has a 2-year warranty, but is expected to last longer because of the new material used; these reusable pads, because of their composition, are less likely than the competitor’s to stain; and

using the pads will reduce the need for using full-size sheets as pull sheets.

The laundry supervisor and the med- ical center’s acquisition and material management service agreed to reassign the $30,000 per year that had been spent on disposable pads to laundry service for the reusable pads.

Team Concerns and Questions After the team reached consensus on

which products to use, it needed to ad- dress the future costs of procuring and maintaining these pads and to gain management approval. The team also needed to decide if its solutions fit the strategies and the desired outcomes set out in the team charter at the beginning of the process.

The team also addressed issues such as how the VAMC would appropriate the funds to purchase reusable pads, in addition to the $30,000 already bud- geted for the purchase of disposable pads, and whether the VAMC should continue to provide disposable pads for outpatient use if they were no longer available for inpatient use. (Outpatient use was estimated at 46 cases [1,380 pads] per month, costing $20 per case.)

To address these issues, the team de- veloped a breakdown of the involved costs (Figure 2). Disposable pads are purchased on a yearly basis. Reusable pads wear out and must be purchased every 2 years. Their warranty requires that the VAMC purchase a 2-year sup-

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ply (based on an estimated daily us- age of five pads per patient). The team estimated that the cost of sending used disposable pads to a landfill or to a med- ical waste incinerator had been about $23,000 a year. The cost to launder the reusable pads would be about $6,500 a year. Labor costs were not factored in either for this process or for removal of the disposable pads, because the team believed the labor expense would be about the same for each.

Benefits The team’s choice of reusable pads fit

w i h the budgetary constraints set forth at the begiruung of the process. Once the process has been set in place, the other desired outcomes will be determined by the management team, which reviews all TQI recommendations.

The linen team also found other, in- tangible benefits to using reusable pads, including the following:

They are more comfortable for pa- tients and, therefore, patient satis- faction and compliance with bedrest orders should increase. They draw moisture away from the patient, so skin integrity improves (and they do not need to be replaced as often as the disposables). They are more environmentally sound and meet industry norms for hospital waste disposal. (It is esti- mated that in 5 years, hospitals and other healthcare organizations may be required to handle all waste in an environmentally sound manner [Sullivan & Decker, 19921. This pro- gram gives the VAMC a head start on any future requirements.) Employee injuries should decrease, because nurses now have a sturdy pad to help them in moving patients in bed.

Lessons Learned There were two primary lessons

learned from this TQI experience. The first is that the TQI process works. It takes time to change processes, but em- powering all levels of staff to make de- cisions helps managers and staff accept new processes more easily. The second lesson, which probably is as important as the first, is that by going through the

TQI process, each member of the team can get a new perspective on his or her job. By sharing ideas, procedures, and expertise, team members learned more about each other’s positions and about how each person is expected to perform his or her duties and responsibilities.

A lack of cooperation between ser- vices serves only to widen the gaps of understanding and to make interde- partmental communication formal and potentially ineffective. By sharing with each other, the services begin to merge and communication improves. With improved communication, daily oper- ations run more smoothly.

Recommendation The TQI process takes time, effort, and

support from management. It provides an opportunity for staff from all areas of the medical center to share ideas and concerns, to work productively togeth- er toward a solution, and to present that solution. The TQI process develops and improves the lines of communication. When communication is improved and strengthened, employee satisfaction and retention should improve. The recom- mendation from this TQI team is this: Give TQI a try!

References Blanchard, K., &Johnson, S. (1983). The one-

minute manager. New York: Berkley Books.

Peters, T., & Waterman, R. (1982). In search ofexcellence. New York Harper and Row.

Sullivan, E., & Decker, P. (1992). Effective management in nursing (3rd ed.). Red- wood City, CA: Benjamin/Cummings.

Walton, M. (1986). The Derning management method. New York: Putnam.

Suggested Readings AT&T Steering Committee. (1989). Process

quality management and improvement guidelines. Indianapolis, IN: AT&T Lab- oratories.

Berkley, G. (1984). The craft ofpublic ad- ministration (4th ed.). New York: Allyn and Bacon.

Boissoneau, R. (1986). Healthcare organi- zation and development. Rockville, MD: Aspen Publications.

Harris, P., & Moran, R. (1989). Managing cultural differences. Houston: Gulf.

Roberts, W. (1990). Leadership secrets of At- tila the Hun. New York Warner Books.

Acknowledgment The authors give special thanks to Nancy Claflin, MS RN CPHQ CCRN, for her editorial guidance.

Dean Miller is assistant chief nurse at the Prescott V A M C in Prescott, A Z . He was the nurse man- ager of a surgical unit at the Carl. T. Hayden V A M C in Phoenix, A Z , at the time this article was written.

D.J. Smith is psychiatric coordi- nator at the Phoenix V A M C . He is a clinical specialist in adult psychi- atric/mental health nursing.

Marie Brophy has been the nurse manager of the acute medical unit at the Phoenix V A M C for 12 years.

Marilyn Mollman is a staffnurse assigned to the Phoenix VAMC’s nursing home care unit.

James Owen is the laundry su- pervisor at the Phoenix VAMC. He provides laundry coverage for the three VAMCs in Arizona.

Gail Smith has been a nurseprac- titioner in enterstomal therapy at the Phoenix V A M C for 10 years.

Clarence More was the health su- pervisor for the Phoenix V A M C at the fime this article was written.

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