Adaptive Design
The Path to Ideal Care
Debra Shriver, MSN, RN
Chief Nurse Executive
Trinity Regional Medical Center, Fort Dodge
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 challenges, lessons learned, and
integration of core processes into an EMR.
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’
ability to deliver exactly what the patient
needs while simultaneously lowering the
cost of care.
John Kenagy, 2009
Adaptive Design:
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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
Allen Memorial Hospital
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Tami Jones, RN, MSN
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Clinical Director of Med/Surg and Nursing
Innovation
Christa Lerch, RN, BSN
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Staff Nurse on 4 Ortho
Frontline Design at AllenWhere we have been…
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4 Ortho
 Elisia Heidt-Penrod, RN, BSN
3 Medical
 Andrea Johnson, RN, BSN
Pharmacy
 Tim Schmidt R. Ph and Jeff Martin R. Ph
3 Surgical
 Rita Borrett, RN, BSN
4 NET
 Carmen Mundt, RN, BSN
Inpatient Therapy
 Molly Ehrig, OTR/L
Distribution
 Kari Beschorner
Frontline Design at Allen—
Where we are…
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Emergency Department
 Mike Tiedt, RN, BSN
OR
 Jenni Friedley RN, BSN,
 Missy Michaelson, RN, BSN
PACU
 Dana Clasen, RN, BSN
Ambulatory
 Vonice Hoffman, RN
Sterile Processing
 Janine Reuter, RN
Ambulatory Surgery Center
 Kim Prinsen RN, BSN
 Jenni Goos, RN
 Joe Randall, RN
Frontline Design at Allen
Where we are going…
Everywhere!!!!
Frontline Design at Allen
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Teachers
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Tami Jones, RN, MSN
Shari King, MPT
Jessica Lovrien, RN, MSN
Lynne Blythe, MBA
Denise Schult
Chris Clayton, PharmD, MBA
Marty Colwell, MA
Allen A3: Detox on 4T
Root Cause
Target Condition
Countermeasures
Allen Outcome Measure
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We are solving problems throughout the
organization.
376 A3’s in test as of April 1st!
Allen—What has this work
meant to me as a staff RN?
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Identifying 1st order problem solving and
using 2nd order to solve the problems so I can
spend time with patients
Decreased frustration with other department
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We get to learn about and honor their work
Gratifying to get to the root cause and really
solve problems
37 Bed Medical / Telemetry Unit
 Blueprint Team
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› Staci Olson, RN Nurse Manager
› Sue Niemeyer, RN Clinical Educator
› Sara Ladlie, RN Staff Nurse (days)
› Lori Hoover, RN Charge Nurse
› Jenna Matton, RN Staff Nurse (nights)
› Kim Bennett, RN Staff Nurse (days)
› Carol Archer, PCT (nights)
If one RN spends 5 minutes looking for an isolation
gown while the patient is waiting to go to the
bathroom and this happens to six nurses in 24
hours that would equal 184 hours of wait time for
the patient and wasted time for the RN
What could you do for your patients with 184 hours
in a year?
If we have 100 A3s that save 30 minutes (gown example) in 24
hours for the RN = 184 hours
184 (hours) x 100 (A3s)
=
18,400 hours / year
=
8.8 FTEs or 9.7 FT (72 hr)
=
$20.00 x 9.7
=
$194.00/hour x 72 hrs / pay period
=
$13,968 x 26
=
$363,168 / year
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Outcome Measures
Cost / Patient
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What this work has meant
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Improvement in our work
Saving time
Making things run more smoothly
Less running around
Problems don’t occur again
Reduction in waste
Changed the focus from the nurse to the
patient—hear more “what’s best for the
patient”
All about the patient; patient centered care
Staff work together as a team
What impact has this had?
Changes in our interactions with other
departments
 Staff involvement with solving the
problems that are signaled
 Increase quality time with the patient
 Cost savings, reducing waste
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The Finley Hospital Adaptive
Design Information for Leadership
Symposium
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Chris Wilson, RN MSN- Director of 4
Med/Surg and Inpatient Acute Rehab Unit
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Sarah Bader, RN BSN, Staff nurse 5 Med/Surg
and Clinical Adjunct Instructor for Clarke
College Nursing School
Our two 20 bed med/surg units plus the 21
bed 5 North Med/Surg/Peds. units are
engaged in adaptive design process. Blue
Print team members include:
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Diana Batchelor, RN MSN, CNO Finley
Teresa Neal, RN MS – Six Sigma Black Belt/ Blue Print
lead facilitator
Pat Lehmkuhl, RN MSN- PI Coordinator and Blue Print
team facilitator
Chris Wilson, RN MSN, Director 4 M/S
Cheryl Haggerty, RN, MSN, Director 5 M/S and 5 North
Londie Brauer, RN BSN, Educator 5 M/S and Rehab
Dee Maahs, RN, BSN, Educator 4 M/S
Sarah Bader, RN BSN, Staff RN 5 M/S
Melissa Shannon, RN, BSN Staff RN 5 M/S
Julie Beyer, RN, Charge RN 4 M/S
A3’s
Outcome Measures that we
are proud of:
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Redesigned the supply process on both floors to
apply LEAN concepts and to ensure that supplies
are readily available for the nurse so that the patient
does not wait for care. Since redesign we have
seen a significant drop in the number of calls to
Purchasing for missing items.
Outcome Measures that we
are proud of:
● We identified a significant issue with IV push for
large doses of Lasix. Blue Print team worked with
pharmacy to develop process to piggy back
medication so that the nurse is free to monitor the
infusion and attend to other needs instead of
having to remain in the patient room for a long
period of time pushing the medication.
● Since beginning Blue Print in October 2009 we have
completed 55 A3’s for 2009 and 44 A3’s are in
process or completed as of April 2010.
Staff Nurse Perspective: What has this
work meant to you and/or your unit?
What impact has it had?
● Working with Blue print has been exciting because it
has given us the opportunity to really look at ideal
care and what that means to the patient. I have
enjoyed developing the definition of ideal care and
working with the staff and the patients to identify
and work signals. We have learned to think
differently about problems and the process has
opened our eyes to recognizing “work arounds” as
problems that we can fix.
Iowa Health Des Moines
N3 Blueprint Unit
IH-DM N3 Blueprint Unit
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24 bed Cardiovascular Unit
6.7 Admits per day
5.8 Discharges per day
32% Patient Turnover per day
58 Staff on Unit
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Blueprint Team Members
Jennifer Early (Director of Adult Behavioral Services)
Pat Busick (Quality Improvement Coordinator)
Sharon Henry, RN, BSN
Toby Riddle, RN, BSN, Unit Based Educator
Kathy Quick, Nurse Manager
IH-DM Ideal Care
The patient and family will say, “I
receive the care I need and want
safely, on time, with respect and
compassion”.
Senior Leader/Executive
Director Experience
● Purpose:
- To learn and honor the work of the
staff in a 2 hour experience
- Assist leaders to identify with us the
barriers in providing ideal care
Reflections
● Senior Leaders
- Quotes
● Blueprint Team
- Culture Change
Last but not least:
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Adaptive design guides work in identifying
steps in core processes.
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5.
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Admit (Jan.)
Discharge (Feb.)
Medication administration/reconciliation (Mar.)
Care of the Patient (April)
Orders (pending)
In terms of content-sequence-timing i.e, admit
 hx present illness
 Patient profile (ht, wt, allergies)
 Med Rec
 Physical Assessment
 Screenings
 Advanced Directive
 Documentation of immediate – non immediate care
Last but not least:
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Timing
1. Direct admit: 60 minutes or less
2. ED admit → nursing unit – 30 minutes
uninterrupted
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IT Enabled: A few examples:
1. Order sets automatically generated from data
entered
2. CPOE
3. Work list for physicians/eliminate “sticky” notes
4. Template data from previous admission, ED,
clinics, pharmacies
5. Work list of incomplete handoffs.
6. Single sign on.