Adaptive Design
The Path to Ideal Care
Mary Ann Osborn RN, MSN
VP/CNO St. Luke’s Hospital, Cedar Rapids
Panel Members from Quad Cities, Cedar Rapids & Sioux City
IHS Symposium
April 2010
Objectives for the day
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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
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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)
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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
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Disruptive Innovation
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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
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How people work and manage
How they think about their work
How they learn and work together to improve
What is Adaptive Design?
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The foundation of the work is observation
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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
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First order
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Solving the problem for this patient and this
clinician at this time (work around)
Second order
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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
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Strive for Ideal Patient Care
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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
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There are 4 rules in Adaptive Design that are
used to assist us with achieving ideal care
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Rules 1-3 guide the work that is being done
Rule 4 guides us through problem-solving
Rule 1—How People WorkActivities
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All work shall be highly specified as to content,
sequence, timing, and outcome.
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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
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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 ConnectConnections
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Every customer-supplier connection must be direct,
and there must be an unambiguous yes-or-no way to
send requests and receive responses.
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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.
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Rule 3-How the Production Line
Is Constructed-Pathways
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Every product or service flows along a simple,
specified path
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There should not be any deviation from the pathway
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The care we provide is a series of different pathways
(services):
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No forks or loops
Care and services do not flow to anyone, but to a specified person
or equipment
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 ImproveA3 Problem-solving
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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.
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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.
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What is the Adaptive Design
process?
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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
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Is a disciplined approach
Creates a culture change in how to solve problems
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Removal of barriers of ideal patient care
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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
No “work-a-rounds”
No communication gaps
Eliminates repetition and redundancies
Increase quality
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Increases nurse time on patient care
Increases patient satisfaction
Increases employee satisfaction
Trinity Quad Cities
6 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
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Staff no longer feel threatened by change;
they feel empowered to look for things
that need changing!
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It’s no longer “They vs. Us”, now it’s “We”
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It’s a “can-do” environment
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Staff have begun to challenge
their own status quo
St. Luke’s Hospital-Cedar Rapids
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5 East-Medical
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Diane Pfeiler, RN-Adaptive Design Coach
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Blueprint Unit
25 beds
Manager, 5 East-Medical
Connie Bulman, RN-Adaptive Design Coach
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Lead RN, 5 East-Medical
Areas involved with Adaptive Design
at St. Luke’s-CR
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5 East-Medical
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Emergency Department
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Sandi McIntosh, MSN, Director
Admission Process Committee
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Diane Pfeiler, RN, Manager
Carmen Kinrade, MSN, Chair
Medication Reconciliation Committee
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Carmen Kinrade, MSN, Co-Chair
Pat Thies, RPh, MS, FACHE, Co-Chair
St. Luke’s-Cedar Rapids DNR orders A3
DNR orders A3
Background
DNR orders A3
Current State
DNR orders A3
Root Cause
DNR orders A3
Target Condition
DNR orders A3
Countermeasures
DNR order A3
Test Question
St. Luke’s-Cedar Rapids
5 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
Fall Rate
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Jan- Feb Mar
09
Apr May Jun
Fall Rate
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Jul
Aug Sep Oct
Nov Dec Jan- Feb
10
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?
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Problems/Issues are dealt with right away
Able to spend more time with frontline staff
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A3 are useful learning tools for my staff and
hospital
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Staff give their input related to signals to me
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?
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Adaptive Design is now my work
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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?
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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
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“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 Pishek
Vikki 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.