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, CEN
Manager, Emergency Services
Trinity 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
Overall
Acute
Displayed by Discharged Date
Emergency Department Overall
Mean Trends
Emergency Department - Acute
Trinity Regional Hospital
Question - Likelihood of recommending
Acute
Displayed by Discharged Date
Mean Trends
Emergency Department - Acute
Trinity Regional Hospital
Question - Staff cared about you as person
Acute
Displayed by Discharged Date
Mean Trends
Emergency Department - Acute
Trinity Regional Hospital
Question - Overall rating ER care
Acute
Displayed by Discharged Date
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)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Adaptive Design
Percent of 210s that are
defect-free
Home Med Documentation
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Teams
Own
Most difficult
part of
process
Teams
Adopt
Teams
Understand
Leaders
Communicate
to Organization
Leaders Set
Direction
Change Process to
Team Ownership
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 Story
Cultural 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 up
Created 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%
Number
of
Med Recs
Percent
of
Total
Sioux City
Population
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
34
0.3%
4.9%
M MULTIRACIAL/UNKNOWN/DECLINED/OTHER
5
0.1%
0.0%
P
RACE
AMERICAN INDIAN/ALASKA NATIVE
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
• 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
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Principles
• Basic Principles for Shift Report
• Shift report should:
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»
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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