Pressure Ulcer Reduction Project. Reason for Action

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1 Page 1 Vol. 135 May 13, 2016 the daily NEWS UNC Health Care s Favorite Newspaper, established 25 August 2010 kai'zen change for the better Home Team Loree Kimball (BICU) and Jasmine Levy (8 Bdtwr) Visiting Team Carol Benge (NQ&R; Skin Committee), Sheena Hilton (CTICU), Kevin Brady (ISCU; Skin Committee), Lisa Jenkins (WOCN), John Bryson (PICU), Gigi Dube- Clarke (HBO), Sally Wood (Medicine Resident), Tiffany Estes (Medical Coding), Sarah Peters (SICU), Christa Seaman (4 West), JoAnne Moran (PreOp) Pressure Ulcer Reduction Project Sponsors Jacci Harden and Angela Overman Executive Sponsor Dr. Tony Lindsey Project Coach Linda Long (Primary) Erica Wolak (Secondary) For more information about Lean Six Sigma, contact Lisa Johnson at or visit our SharePoint site at Reason for Action UNCH experienced an unfavorably high rate of hospital acquired stage III/IV/unstageable pressure ulcers from July 2010 to July It is important to reduce the incidence of pressure ulcers, as they can lead to serious infections, including sepsis. Furthermore, pressure ulcers are a publically reported quality indicator which impacts an organization s reputation and finances. Project Scope Initial phase of the project will focus on implementing interventions in 2 pilot units, BICU and 8 Bedtower, prior to the larger implementation to inpatient acute and critical care nursing units in Medicine, Surgery, Heart & Vascular, Women s, Children s, Oncology, Emergency Department, and PreCare (OR). _Services/Operational_Efficiency /LSS/SitePages/Home.aspx

2 Page 2 Day 1 of 5 After a warm welcome from our coaches, our sponsors kicked off the week with excitement and anticipation of what the week would produce. The team took a moment to review the ground rules that we had created in our prework and quickly divided role assignments such as team leads and time keepers. We reviewed boxes 1-3 on the A-3, which had been completed during prior group work. Box 1 includes the Reason for Action, Box 2 includes the Current State, and Box 3 includes our Future State. Coach Erica Wolak facilitating a group review of the gap analysis before moving into identifying solution approaches. Day 1 continued Over the course of day 1 we were able to complete our Gap Analysis (box 4) and identify our Solution Approaches (box 5). We ended the day brainstorming experiments and giving our sponsors an update. The group wanted to thank Patt for ordering and delivering food and our coaches for staying mentally engaged during every conversation. The group also recognized Sally s summarizing skills! Team Member Jasmine Levy sharing some encouragement with Christa Seaman A-Ha! Moment: Did you know that pressure ulcers don t always progress sequentially in stage? Sally, Loree, Sarah, and John casting their votes to determine which gaps are the most critical.

3 Page 3 Day 2 of 5 On Day 2, we focused on building Box 6 (Experiments). The group started out the day by narrowing down potential experiments (we started with 70 different ideas for experiments!). From there, we created a PICK chart, which allowed us to see which experiments were the most favorable (lower effort and higher impact). We were then able to narrow it down further to only seven experiments. The group split into three teams to divide and conquer our experiments, which were to be trialed on our pilot units, BICU and 8 Bed Tower. We began preliminary experiments and were able to get feedback from the nurse managers and some staff nurses on each unit. A big thank you to John Motko (WOCN) for helping our group with experiments, Lisa Jenkins for sharing best practices, Michelle Apple and Kim Holloway- Shambo from 8 Bed Tower for providing algorithm feedback, and the BICU nurses who provided feedback on skin cart. Jasmine conducting an experiment on 8 Bed Tower, surveying a staff nurse. Day 3 of 5 Day 3 was filled with experiments! The group split back into our respective teams to refine the experiments further, then went back out to our pilot units to test them out for another round. The staff on 8 Bed Tower and BICU was very gracious to our Kaizen group; they were supportive and gave great feedback! After the initial testing, we re-grouped to finetune the experiments and went back out to the gemba ( the real place e.g. where the work happens) after lunch. A high note for the day was that we were able to move metrics favorably! We ended the day by reporting to our sponsors where our progress was in the testing phase. The teams drafting their plans for operationalizing experiments.

4 Page 4 Day 4 of 5 On day 4, our group continued the hard work of progressing in our 7 experiments! Lots of time was spent in the field collecting data and finalizing experiments. A great deal of progress was made in a short amount of time. We finalized 3 algorithms (Staff Nurse Pressure Ulcer Prevention, Manager Pathway and ICU Unstable Patient Pathway), the skin carts on 8 Bed Tower and BICU were completed along with their respective visual aids, and algorithms for preventing pressure ulcers in pre-op, ED, and PACU areas were started. We ended the day by reporting out to our sponsors and showing them some of our completed products. Our team would like to send a special thanks to Mr. Bell on 8 Bed Tower for ordering all supplies needed for the skin cart and providing boxes, as well as Erica and Beth for their fantastic Visio work - we couldn t have done it without you! Working on some finishing touches to the 8 Bed Tower Skin Cart! The group helping Team Sheena complete the skin carts by creating visual guides to assist nursing with accurate staging for pressure ulcers.!

5 Page 5 Day 4 continued. Below are some of the different visual aids the team created in order to define standard processes for preventing pressure ulcers, documenting accurately, and notifying correct personnel:

6 Page 6 Day 5 of 5 Tick-tock the final countdown! All team members spent the morning working vigorously fine-tuning and polishing their experiments. Team Sheena got a surprise visit on 8BT from the other teams who had finished their work and assisted with the final touches on the Wound/Skin Cart. Process Owners Loree and Jasmine worked with Beth to finalize their Managing for Daily Improvement (MDI) Boards. The MDI Boards are hung on each pilot unit and assist in ensuring sustainability of process changes as well has monitoring for defects in the new process. Upon completion, the team headed back to the war-room (aka BICU Conference room) for final discussions. Coach Linda coordinated an all-inclusive Completion Plan (Box) to ensure tight connections over the next month. Prep for final report out to Sr. Leadership included assigning team members a part of the A3 to present to the Sponsors and guests. After a power lunch of pizza a dress rehearsal of the report out took place. Promptly at 2 o clock, the team presented the Pressure Ulcer Reduction Project to Sr. Leadership. We were proud to share our results: Box 8. Confirmed State - True North Metrics # TNM Metric Unit Current 1 Q&S Matching RN/Provider pressure ulcer documentation (staging) % matching Target 22% 50% Event May'16 ~100% *if dot.phrase is adopted 30 day 60 day 90 day 2 Q&S (survey) Correctly staged pressure ulcers % 63% 80% 81% 3 P 4 Q&S 5 Q&S 6 Q&S (survey) Positive level of confidence about ability to accurately stage pressure ulcers ( agree/strongly agree ) reported (survey) Understand need to page LIP upon pressure ulcer discovery (survey) Understand need two RNs for admission skin assessment (survey) Understand WOCN do not assess all pressure ulcers % 46% 75% 67% % 54% 75% 73% % 27% 60% 77% % 32% 60% 73% 7 Q&S BONUS METRIC! 5S Skin Cart % 43% - 8BT 28% - BICU 83% - 8BT 83% - BICU 8 Q&S BONUS METRIC! Find & Fix a Safety Issue (We found two! 1. Skin cart did not have adequate supplies 2. Lack of standard process for accurate documentation) # 0 1 2

7 Page 7 Day 5 continued The efforts and hard work of the team and coaches were praised by the Sponsors (Jacci Harden and Angela Overman), as well as guests Dr. Cathy Madigan, Glen Spivak, Eric Wolak, Erin Burgess, Nikia Smith, Cheryl Stewart, and Dr. Tom Ivester. A small celebration with cake (and gluten-free and vegan cupcakes!) was enjoyed by all. The team departed with plans to meet again in 30 days to review the progress of the Pressure Ulcer Reduction Project. Sheena, Jasmine and Lisa presenting at the Final Kaizen Tollgate. Kudos to the entire team for all your hard work and dedication last week! Way to go Linda great job coaching this MASSIVE project! Thank you to our sponsors for all of your support! And a big thanks to the staff and managers on 8BT and BICU for being so helpful and flexible throughout the week!