Applying Lean methodology to medical-surgical care.
The delivery of high-quality, safe, efficient and affordable care requires a shift in the paradigm for problem solving. Traditional top-down, management-driven process improvement initiatives are slow to create change. Adopting an approach that empowers frontline patient care staff to examine and recreate productive care delivery models supports change from the bottom up-with iterative, rapid improvement cycles to test that the new models work.
This article describes how frontline patient care staff applied Lean methodology to redesign and launch a new team nursing model in medical-surgical units. The “SharedCare” model has increased the quality of care and improved patient and staff satisfaction.
Lean in Healthcare
Members of the executive leadership at a 769-bed regional teaching hospital in southeastern North Carolina (New Hanover Regional Medical Center in Wilmington) recognized that the shifting healthcare environment would require a more agile approach to process improvement. Although the organization had been meeting quality goals, maintaining an impressive operating margin, and managing to avoid layoffs, it was becoming evident that its existing delivery of care model might not be able to support the long-term strategic goals of the organization. Additionally, mounting pressure from external forces in the form of value-based purchasing (pay for performance) and healthcare reform spurred change. To prepare the organization, executive leadership embarked on a cultural transformation by making a commitment to use Lean methodology in 2010.
These leaders speculated that traditional top-down, management-driven process improvement initiatives were unlikely to result in long-term change and that any change in care delivery would require overwhelming buy-in and enthusiasm from frontline patient care staff. They made the bold decision to put creative power in the hands of the staff. The task was to recreate a care delivery model that would meet quality, safety and clinical needs and would be financially sustainable.
Lean methodology, rooted in the foundations of Toyota Production Systems, and the concept of “Kaizen” or continuous change, is not new to healthcare. As a result of using Lean methodology, many health systems have realized major improvements in quality, safety and efficiency. Lean has led to cost-saving initiatives, as well as others that avoid costs. It is an innovative and easy way to engage frontline staff to understand issues and create better ways to work.
Lean offers a set of tools and concepts that can improve healthcare for patients and clinicians alike. However, before attempting to use a new set of tools to drive change, it is imperative to first understand what customers value. Value-added services are essentially anything the customer is willing to pay for. Examples may include time spent with a physician, having a diagnostic procedure, or receiving a pain-reducing medication from a nurse. Each of these activities, or processes, represents a value the healthcare system provides to the patient. Activities such as providing redundant information multiple times to multiple clinicians, waiting for test results, having clinicians walk excessive distances during a 12-hour shift, or treating infections that result from poor technique do notrepresent value for the customer. This can be defined as “waste,” or non-value added activities.
The easiest way to see waste is to go where the work is done (the “gemba”) and observe processes or “value streams” in their current state. Observation is a powerful tool that allows the observer to see when tasks or procedures are performed in varying ways by different people or different standards. Observation also shows when connections or communication processes between people are broken or occur in silos, and when service pathways are indirect and inefficient. Once a process has been observed and is understood, the value stream mapping (VSM) tool provides a way to visualize a broken process and identify better ways to work. A VSM can act as a roadmap for future process improvement. A Lean system strives to remove waste and identify the best way to provide value to the customer while meeting organizational goals.
Care Delivery Issues
The first step in creating a better way to work, or a new care delivery model, is to identify the problem or issue to be addressed. In spring 2013, feedback from patients indicated that their expectations about communication and responsiveness to their needs were not always met by patient care staff and clinicians. Additionally, nursing staff members were frustrated with interruptions in workflow and the mounting number of “tasks” that prevented them from spending time at the bedside and practicing at the top of their license. Patients rated “responsiveness of staff” in the second percentile and the fall rate on the most challenged medical unit was 7.5 per 1,000 patient days, or more than double the acceptable goal. RN turnover rates were greater than 20% .
The journey to redefine the model of care began by developing a current state VSM of the inpatient medical-surgical care delivery model from the time of admission through discharge. To capture the amount and type of work provided to patients, a collaborative group of stakeholders, consisting of staff nurses, nursing managers, case managers, physicians, nursing assistants, physical therapists, dietitians, pharmacists, and patients was assembled. Their charge was to identify the step-by-step patient care processes within the adult inpatient medical-surgical patient care units to understand how the work actually occurred. The team created a VSM of the path the patients took from the beginning to the end of hospitalization, to identify the interconnectedness of care delivery processes and identify all non-value added waste.
After the VSM was created by the team, participants were briefly trained on observation techniques and dispersed to seven medical-surgical units. The goal was to gain an understanding of issues within the care delivery model from the perspective of patients and staff members. Patients were interviewed about their experiences with the care delivery model, and staff members were asked to identify what prevented them from easily, safely and efficiently completing their work on each shift.
All issues, barriers and challenges were captured in red Kaizen bursts on the current state VSM to represent waste within the care delivery model. Major themes of waste included fragmented communication, unclear and poorly communicated plans of care, constant interruptions during care delivery, siloed work practices by all disciplines, and a lack of top-of-license practice. Waste was identified across the VSM.
A New Care Model
Once the issues were identified within the care delivery model, the team was challenged to conceptualize an ideal, waste-free, better way to provide healthcare to patients in the future. Improvements in care delivery, or in Lean terms, “countermeasures,” were captured on a future state VSM and represented as blue clouds. The team realized that standardized processes would be necessary in the future care delivery model. Variation in practice based on personal preferences or individual care providers practicing within silos prevented effective communication among providers and patients. Major countermeasures included:
- Care provided by teams of nurses and nursing assistants with defined roles and responsibilities.
- Frequent and standardized communication huddles to ensure that the patient’s care was coordinated and communicated clearly among all disciplines.
- Mechanisms to identify when staff members were overloaded and needed assistance.
The team believed a successful model would result in an increase in the quality of care delivered to patients, improved communication between care teams and patients, and improved patient satisfaction scores. The proposed future state also would create an environment in which work was equitable, manageable and satisfying for staff.
The SharedCare model was tested using the scientific method known as Plan, Do, Study, Act (PDSA). Multiple PDSA trials occurred during summer 2013. These iterative PDSA trials, or small cycles of change, provided the opportunity to test the proposed countermeasures to determine if the process changes resulted in the improved outcomes the team had hypothesized. The initial trials involved one or two nurses and their nursing assistants with their assigned group of patients. SharedCare underwent numerous adjustments before implementation on the entire 42-bed Medical-Surgical Hospitalist unit in September 2013.
Standardized work is considered a foundational tool in Lean organizations, so it was a key component in the creation of the SharedCare model. Standardized work is considered the best way to safely complete a task or activity to achieve the highest level of quality and desired outcome with the fewest possible resources. Historically, many problems within healthcare can be traced back to the lack of standardized processes. Without standardized processes, a risk for tremendous variation in practice exists, along with the likelihood that desired outcomes will not be achieved consistently.
A standardized process informs care providers about an expectation for how to perform work, and it creates an opportunity to continuously and efficiently improve processes in dynamic and changing systems such as healthcare. Standardized work identifies the necessary steps to complete an activity or task and provides the rationale for why the step is essential. The most effective standardized work is created by the people who do the work and, therefore, understand it best. In addition, when implementing standardized work, it must be supported and monitored by organizational leaders to achieve optimal results for patients.
The SharedCare model was built on a foundation of standardized work created by direct patient care staff. Identifying roles and responsibilities within the new nursing team model was essential because it required a mindset different from the primary nursing model. Clear role delineation, outlined in a standardized work document, helped staff perform the right work at the right time for each patient. It also increased the opportunity for staff members to consistently work at the top of their license and reduced the number of interruptions care providers experienced.
Standardized work also provided a mechanism for structured communication for team huddles that occur three times during every 12-hour shift. During each huddle, key points are addressed to ensure that all team members have pertinent patient information throughout the shift, that patient-specific goals and plans of care are identified and achieved, and that successful loop closure of delegated tasks or escalation of patient-related issues occur well before the end of the shift. Huddles, guided by standardized work, created communication connections that had been lacking in the previous model of care.
Standardized bedside handoff processes also were created. The standardized nursing shift report ensures that relevant and pertinent information is always exchanged between off-going and oncoming nurses. Information is organized so that nurses participate in a standardized process that is thorough and captures key quality and safety concerns, as well as patient-specific goals and discharge planning information. It is also efficient. While at the bedside, nurses update each patient’s “Roadmap to Discharge,” or communication whiteboard, so that the patient is aware of the plan.
“Andons” are defined signals or triggers to alert staff members or leadership to problems in a process or workflow. The use of an andon in the SharedCare model has created a safe way for staff members to verbally identify when their current workload has exceeded their ability to complete work in a safe or timely manner.
Multiple times throughout the shift, staff members declare their workload status as green, yellow or red. Green signals that the staff member is caught up and has the ability to help others if needed. Yellow identifies a staff member who is able to complete his or her own work but is unable to assist another team member. Red signifies a need for assistance. The use of the red, yellow and green andons has promoted direct and clear communication and fostered teamwork and camaraderie.
The shift to the SharedCare model has been a cultural change for patient care staff and has required nursing leaders to work differently as well.
The sustainability of SharedCare has been achieved through the use of Lean Management System (LMS) tools, including a unit-based Huddle Board and a verification/validation process to monitor standardized work. The unit huddle board focuses the staff’s attention on the unit’s “plan of the day,” including any safety, equipment or workflow issues. The huddle board also promotes a dialogue about progress with unit-based problem solving initiatives. SharedCare units track specific daily indicators that align with organizational strategic goals.
Daily indicator results are displayed on the unit, updated every shift and are reviewed during huddle every 12 hours to provide a real-time snapshot of unit performance. This helps staff members recognize the impact of their work on goals.
Verification and validation of standardized work occurs daily on all SharedCare units. Verification is the process of ensuring that staff members perform work according to the standard. It provides an opportunity for unit leadership, usually the charge nurse or manager, to coach staff members to the standard when it is not being followed. Validation of standardized work occurs when unit leaders perform standard work themselves to ensure accuracy and make adjustments as needed.
Each LMS tool promotes effective communication and problem-solving. This has created a safe environment for staff members to be coached by making expectations clear and maintaining focus on meeting these expectations. Through LMS tools, staff members are acutely aware of the nursing unit’s measures of success and are engaged in ensuring that goals and targets are met.
SharedCare has led to improved quality of care and overall patient experience and satisfaction. It has also resulted in financial savings. Quality improvements achieved with the SharedCare model on the pilot unit included a reduction in the fall rate from 7.5 in FY13 to 2.5 in FY14.
Patient satisfaction, as measured by responses to the “Responsiveness of Staff” question on the HCAHPS survey, saw significant improvement from less than the 10th percentile in FY 13. “Communication with RNs” scores continue to trend upward and have been higher than the 70th percentile in FY15.
Financial outcomes included reductions in RN turnover, overtime and salary expenses per unit of service.
SharedCare has been implemented on 10 additional inpatient units since January 2014. While SharedCare continues to stabilize and become the care delivery norm throughout the organization, overall improvements have occurred in the fall rate, nurse turnover and staff engagement scores.
The organizational fall rate has plummeted from higher than 4 to less than 3.2 since the third quarter of FY14. Responsiveness of staff members continues to improve and has averaged above 50% since the first quarter of FY15.
Staff members consistently rate their daily workload in SharedCare as “green,” or manageable, and are able to assist other team members.
As a result, nurse turnover rates have improved. The 2015 organizational employee engagement scores also increased significantly over 2013.
Putting Patients First
Healthcare leaders across the nation have recognized the need to redesign care delivery models. SharedCare has demonstrated sustained improvements at a time when many organizations are struggling. Rooted in structured communication, standardized processes and team nursing, SharedCare puts the needs of the patient first.
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