Applying Lean Principals to the Environment of Care

Transcription

1 Applying Lean Principals to the Environment of Care Russ Harbaugh, CHEP Accreditation Coordinator EOC/Life Safety/Disaster Preparedness St. Luke s Health System Boise Idaho EOC Purpose The environment of care is a broad term for a wideranging group of factors in the healthcare environment; however, it encompasses a large body of checkpoints that accrediting bodies use to determine a facility s quality. We talk about the environment of care as referring to the elements and factors that contribute to creating the way the environment works for the patient, family, staff and others in the healthcare delivery system, in terms of certain key elements. 1

2 Environment of Care Some important aspects of the environment addressed in the standards include the following: Safety and Security Hazardous materials and waste Fire safety Medical equipment Utilities Objectives: This presentation is organized around the concepts of planning, implementing, and evaluating, and evaluation of results. Also to hard-wire compliance with Environment of Care regulations and standards. Environment of Care 2

3 Environment of Care Background The Hospital s Environment of Care program previously has not been effective in ensuring a continual state of regulatory readiness. Internal surveillance as well as findings from on-site surveys consistently revealed opportunities for improvement in the following areas with organizational performance for October 2010-February 2011 as indicated below: Under sink storage (73%) Expired supplies (65%) High dusting (77%) Clean vs. dirty separation (89%) Linen supply carts (80%) Wall mounted sharps containers (86%) Multi-dose vials (90%). Develop a Core Team for Support Executive Sponsors Team Leader EOC/ Life Safety Accreditation Infection Prevention Employee Safety/ IH Consultant Document Management 3

4 Goals Implement an effective Environment of Care framework to improve compliance with EOC regulations Hard-wire compliance with Environment of Care regulations and standards. Providing a Safe Environment? Code compliance? 4

5 Code compliance? Current State Current State Wastes People- Underutilizing FTEs available at the unit-level People- Over-utilizing Accreditation FTEs to audit and follow-up on continued non-compliance Inventory- over ordering of supplies due to expiration Impact: Under sink storage- infection prevention Expired supplies- patient safety/financial impact High dusting- infection prevention/hcahps performance with cleanliness question Clean vs. dirty separation- infection prevention/patient safety Linen supply carts infection prevention Wall mounted sharps containers- employee safety/osha Multi-dose vials- patient safety 5

6 Opportunities Lack of identified environment of care champions outside of the Unit Services Supervisors role. Site-based EOC Committee lacks authority and scope to ensure continual environment of care compliance Lack of standardized environment of care expectations Lack of subject matter environment of care experts Opportunities cont. Lack of best practice spread throughout the organization Lack of hard-wired processes to facilitate continuous compliance Lack of sustainability and accountability at the local level when opportunities are identified Develop an audit process that ensures the collection of statistically relevant data needed to validate improvement Next Steps Finalize the list of EOC Champions Finalize the EOC Champions Manual Initiate System EOC Committee Implement VSURVEY Audit Process Deploy EOC Boot Camp Deploy Kamishibai Pilot Develop and Deploy Best Practices Library Implement EOC Annual Education Update Process 6

7 Targeted Champions Boot Camp Our Goal is to promote a safe, functional, and supportive environment within the hospital so that quality and safety are preserved. The Boot Camp will help educate individuals to identify the risks within their environment, including those associated with safety and security, fire, hazardous materials and waste, medical equipment and utility systems. Benefits Benefits Heightened awareness and support for hardwired continual regulatory readiness with the environment of care standards Trained over 220 champions through standardized education. Improved champion understanding by 90% 7

8 Environment of Care Champions Manual Prepared by Russ Harbaugh, CHEP EOC/Life Safety Officer Please send all feedback for future revisions to Russ Harbaugh at or Current Revision: 1/6/2012 SINGLE POINT LESSON TOPIC/SUBJECT AREA/DEPT PREPARED BY APPROVED BY Eye Wash Stations Environment of Care Russ Harbaugh EOC Committee 1. Where are eye wash stations located? Eye wash stations are installed in work areas where hazardous substances (i.e. chemicals, disinfectants) are used and/or there is potential of blood or body fluid exposure. Eye Wash signs identify the locations. Eye wash stations are located where they can be reached from the hazardous substance location within 10 seconds. Note: Contact Safety Officer to determine proper location for an eye wash station. 2. Who should know how to operate an eye wash station? All employees who might be exposed to a chemical splash will be trained in the use of the eye wash. 3. How often are eye wash stations tested? Eye wash stations are tested weekly. Weekly eye wash apparatus testing will be documented on a log sheet and kept in the vicinity of the eye wash. The department director or manager will select a person(s) to be responsible for the weekly testing requirement. All eye wash stations shall be inspected annually by a building services plumber to ensure they meet ANSI Z358.1 requirements. Assure that that water stream is crossing at the peak. Regulatory Standards: 29 CFR OSHA/ANSI Eye Wash Station Requirements The American National Standards Institute (ANSI) developed the ANSI standard Z OSHA (c) NFPA St. Luke s Policy: Eye Wash Safety (EC037) Infection Prevention, Facility-wide (IP054 TV) Blood borne Pathogens Exposure Control Plan (IP055 TV) 23 SINGLE POINT LESSON TOPIC/SUBJECT AREA/DEPT PREPARED BY APPROVED BY Construction Areas Environment of Care Russ Harbaugh EOC Committee 1. Who can visit construction sites within the hospital? Only trained, qualified, competent tradespeople are permitted to be within construction sites during construction and shall be trained in the hazards that might exist. All others wishing to visit the construction site will require approval and an escort. 2. What is the process for approved tours of construction sites? When construction or remodel work is in progress and a walk-through or tour is desired, either during or after normal work hours, by St. Luke s employees, tenants, physicians, donors, board members, or any other non-construction personnel, the following steps must be followed: A walk-through or tour will be managed in a safe, organized manner that meets all Construction Department and OSHA standards for safety and compliance. The tour will be conducted by qualified construction personnel only. Proper clothing and personal protective equipment (e.g., hard hats) are required. The Construction Department reserves the right to refuse visits and tours for nonconstruction personnel due to feasibility or safety concerns. 3. How can departments ensure construction/ remodel areas are safe and secure? Departments must review and assess the need to implement additional safety measures to ensure compliance with the following: Barriers to prevent accessibility by unauthorized persons, staff, and the public. Special attention should be given to controlling areas that children might access. Signage to alert and direct people away from the construction/ renovation area. Appropriate storage of equipment not in use. Appropriate closure of construction/renovation sites at the end of the work day to prevent accessibility by unauthorized individuals. Regulatory Standards: LS The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction St. Luke s Policy: Non-Construction Personnel Visitation to Construction Sites (EC076 TV) Interim Life Safety Measures (ILSM) (EC024 BMW) 24 8

9 Accomplishments Identified EOC Champions and alignment with key stakeholder groups Development and implementation of EOC Champions manual Held sessions of EOC Boot Camp Scheduled Quarterly EOC Boot Camps Shared educational tools with system partners through the newly established System Environment of Care Committee Created Kamishibai Environment of Care templates Developed a deployment plan for Kamishibai Card implementation across the continuum of care Implemented Kamishibai Cards on 14 inpatient nursing units and 1 clinic Implemented process to gather data on key project goals with reporting transparency Kamishibai Have you experienced: Improvements that do not sustain the gain Missed quality audits Work overload Difficulty balancing your work activity Too many activities happening to remember where you have been Kamishibai Kamishibai is a systematic approach to organize and balance repeatable tasks using time frequencies to trigger the event Kamishibai is a Tool used to sustain the process improvements from foundational tools of Lean House 9

10 Kamishibai Transform Healthcare Continuous Improvement Staff Focused Just in Time Built in Quality Patient Centered 5S Workplace Organization Problem Solving Culture of Accountability Standardization Visual Management Kamishibai Origin - Japanese card play (traditional children's story card game) Cards deliver a pictorial message, which in turn prompts an action to explain the picture and tell a story - similar to charades Link to Lean - elimination of unevenness (Mura), overburden (Muri) and waste (Muda) that has been identified in the development of the process improvement systems Too much to remember Repeated unnecessary tasks Differing workloads, hour by hour, day by day Differing workloads person by person Applications Overview Kamishibai is a system that can be used to audit on a random, a time based or count based interval. The interval used is determined by needs of the application being audited. This tool can be applied to ensure Safety, Quality, Productivity, Cost, etc. 10

11 Safety The Kamishibai system is used to audit safety in a random fashion, although there will be sets of cards to complete. A process review from management can be performed on a regular basis to be proactive for accident prevention. Quality Quality is audited by the team with the cards ensuring all check intervals are properly maintained. Supervisors can audit the cards that are being performed by the assigned staff. In addition, they can randomly audit the services by performing the check themselves; noting compliance. Standardized Work Sheets can be audited to confirm that each staff member is following the proper sequence of events Tools and Concepts of Kamishibai Board - Depends on size or frequency of tasks Card - Listing tasks and frequencies Paperless - No check lists or ticks in boxes Visual Aid - Quick reference of tasks Periodical - To be utilized on a set frequency Standard Procedure- Follow standards 11

12 Board Key Requirements Board layout must contain: Planning Rack Audit Rack Single Point Lesson Action Item List Cards Board Example Kamishibai Board Single Point Lesson Action Item List Planning Rack Completed Audit Board Example 12

13 Kamishibai Requirement Guidelines When Daily, Weekly, Monthly activities Who Everybody at all levels Why Helps remember Day to Day audits Where Anywhere that you have regular tasks Standards Stable and standardized conditions Types of Kamishibai Cards Every card in the system is one of two types: Task - Performing duties to meet standards Audit - Verifying tasks Card Handling Standards As a standard, there are three places a card may be: 1. On the board it has been completed 2. In your hand you are completing it 3. In the zone post it is not yet completed 13

14 Sup Central Rx Audit Sup Central Rx Audit Daily: Environment of Care Daily: Environment of Care Trip Hazards: No trip or slip Hazards exist. Area Clutter: Storage area and other areas are clean, orderly, free of trash, and well lighted. Carts in Proper Location Container Rack in Proper Location Area Security: No doors held open by people/equipment. Damaged manifolds noted properly Red Tape Zones: All Alarm pull boxes and fire extinguishers are tapped off and clear of any items Decon rounds board up to date Area free of slip hazards and water on the floor Area Organized & Clean During Shift End of Shift #1 During Shift End of Shift #2 Two Sides Each card has two sides Red side ~ abnormality occurred Green side ~ standard is met Upon completion of an audit or task card, the side turned outward indicates the current condition. If the red side is left outward, an action item must be created to countermeasure the issue identified. Sup Central Rx Audit Sup CSPD Audit Daily: Environment of Care Daily: Environment of Care During Shift During Shift End of Shift #1 End of Shift #2 14

15 Color Standards The Audit tasks interval color code. Daily Task Weekly Task Monthly Task Red side out ~ abnormality occurred and observed Green side out ~ standard is met How to Respond Any identified abnormality at any level requires response. Use of the action item list initiates and tracks countermeasure to completion. Also supported by a standardized problem solving methodology. Action Item List Operation An action item is created when an issue is raised. When the issue is completed, the person who completes it strikes a line through it. Should an issue carry to the next week, a red dot is placed at the end of its row. This indicates it has been outstanding and needs a higher level of focus, support or resources 15

16 FY10 Compliance Rate FY11 Compliance Rate 10/07/2012 Kamishibai Benefits Accountability adds responsibility Standardized process - disciplined, requires rules Promotes teamwork - all involved - collective responsibility Process driven Supports work balance Eliminates complacency Flexible - dynamic can add or take away Visual - easy to view and interpret status or adherence Environment of Care & Life Safety Identified EOC Champions and alignment with key stakeholder groups Development and implementation of EOC Champions manual Held sessions of EOC Boot Camp Quarterly EOC Boot Camp sessions scheduled on an ongoing basis Shared educational tools with system partners through the newly established System Environment of Care Committee Created Kamishibai Environment of Care templates Developed a deployment plan for Kamishibai Card Implementation across the continuum of care Implemented Kamishibai Cards on 14 inpatient nursing units and 1 clinic Implemented process to gather data on key project goals with reporting transparency. Sharps Containers: Are sharps containers unobstructed and less than 89.9% 92% 2/3 full? Wall-Mounted Sharps Containers: Are wall mounted sharps containers 95.8% 96% 52" to 56" high? Identification Badges: Are staff wearing their identification badges? 98.6% 90% Facility Security: Are critical areas of the department appropriately 97.0% 97% secured and accessed only by those authorized? Medication/Syringe Security: Are syringes and pharmaceuticals locked, within line of sight, or within a secure unit (surgical services, 88.4% 90% critical care, etc.)? Warming Cabinets: Are warming cabinets set below 105 degrees for 81.1% 99% liquids and 130 degrees (+/-) for blankets? Crash Carts: Are crash cart logs complete with no missing dates? 77.1% 95% Hazardous Chemicals: Are hazardous/flammable materials properly 99.1% 98% stored and labeled? Housekeeping Closets: Are housekeeping closets and other chemical 97.3% 99% storage areas locked if not within a secure unit? Eyewash Stations: Are eyewash stations available and tested at least 84.4% 96% weekly? Ceiling Tiles: Are ceiling tiles present and free from stains, scuffing, 63.4% 81% visible dirt, cracks, and breaks? Kitchen Cleanliness: Are kitchen appliances (refrigerators, 94.7% 91% microwaves, etc.), including those used by patients, clean? Under Sink Storage: Are only non-porous items (cleaning supplies and 83.1% 88% flower vases) stored under sinks? Expired Items: Are patient care supplies and medications (PYXIS, 33.6% 67% refrigerator, and floor stock items) in date? Refrigerators: Do refrigerators only contain appropriate items? 94.7% 97% Temperature Logs: Are refrigerator temperature logs maintained and 85.1% 93% actions taken if out of compliance? Clean vs. Dirty: Is there appropriate separation of clean and dirty 97.2% 92% supplies? Linen/Clean Supply Carts: Are linen/clean supply carts covered and do 97.6% 95% the carts have a solid bottom? High Dusting: Is high dusting completed regularly? 79.7% 76% FY 10 Compliance vs FY11 Out of 28 areas surveyed under the EOC inspection process there were: 17 areas improved 8 areas slipped back by a small percent 3 areas stayed neutral Egress: Are exit signs available and illuminated? 97.7% 100% Corridors: Are corridors free of equipment and clutter (food carts, beds, etc.)? Hallways: Do hallways have 4-6 feet of clearance with equipment 94.6% 98% 97 0% 99% Slips, Trips, Falls The Slip/Trip/Fall incident rate has dropped below the One Standard Deviation Improvement level as of March 31 st (1/2 through the fiscal year). We are currently at 1.16 events per 100 FTE and the 1 StndDev goal is (Note: Hours worked were based on Jan 2012 hours-worked until the injury scorecard is released it might lower the rate even more). 16

17 Slips, Trips, Falls Departments who have implemented the Kamishibai Audit cards for Identification of STF hazards have seen a 61% reduction in STF total events (based on projection of same rate for next 6 months). Summary Kamishibai originated from a card play game Kamishibai is a systematic approach to organize and balance repeatable standardized tasks using time frequencies to trigger the event Displays clearly (visually) status of completion real time Can be applied to any area and any level within an organization - fully flexible Like any system requires discipline to be effective! 17