1 E P 7: Describe and demonstrate the structure(s) and process(es) used to engage internal experts and external consultants to improve care in the practice setting. When Riverside nurses from any level identify a need for new equipment, technological applications, or process improvement initiatives, they use several structures and processes to engage internal experts and external consultants. Structures Internal structures include the 60-member Patient Care Council (PCC), Patient Care Forum, Nursing Leadership Council, and Senior Management Meeting. Additional structures upon which engagement is based are the Vigilance Professional Nursing Practice Model and Care Delivery Model, nursing foundations at Riverside. Components of each model, which apply to engagement of internal experts and external consultants, include the following: Vigilance Professional Nursing Practice Model Components Organizational Vigilance: The continual observation, detection, interpretation, and communication of the changing needs and expectations of external and internal sources that result in creating purposeful change. Partnerships- Cooperation with other care providers that is guided by open communication, trust, and shared decision-making. Shared Governance - Organizational structures and processes that demonstrate a commitment to empower professional nursing staff s and managers active engagement in policy- and decision-making. Nurses engaged in shared decisionmaking influence their professional practice environment and define, promote, and evaluate consistent nursing practice. Care Environment and Management Vigilance: The ongoing, continual oversight of the unit s changing needs and responses which result in modification of fiscal, material, and human resources and expectations that impact patient care, nursing practice, and outcomes on the unit Resource Availability The possession of tools, technology, people, and materials that are readily available to meet the needs of the patients and the workforce. Team Competence - The supportive nature of the interrelationships between the individual and other caregivers. Culture of Inquiry The promotion of expectations of calculated risk-taking, innovation, and reflection that generates new knowledge and practices.
2 (Nursing Care) Vigilance: The primary abilities the nurse needs to have for vigilant nursing care within the work environment. The nurse s watchful, continual oversight of the patient s changing needs and responses resulting in effective clinical judgments, nursing actions, and intended outcomes. Collaboration - The ability to partner with others to achieve intended outcomes. Vigilance Care Delivery Model Components Consultation - Consistently and appropriately identifies and uses available resources to define and implement the plan of care. Collegiality - Consistently and appropriately contributes to the professional development of peers and colleagues through effective interaction and mentoring in the planning and delivery of nursing services to achieve optimal outcomes. Transformational Leadership and Shared Decision-Making- Consistently and appropriately effects change through engagement, involvement, and participation of peers and colleagues, leading others where they need to be rather than where they want to go. Processes When internal experts are needed to begin a project, committees or task forces might be formed. Determination of committee membership is based on the type of project; available human resources; competency, skills, and knowledge base; and experience in clinical or management settings or previous or current committee memberships. When internal employees do not meet these criteria, any nurse can request to engage external consultants. Internal and external requests are made to executive nursing staff (CNO, Vice Presidents) or oversight committees. Once an executive staff member approves the request, the committee or task force develops a charter. Our charter template is shown below. **************************************************************************************************** Committee Charter Operations Committee, Quality Improvement Committee or a Vice President must approve all Committees Committee Name: Committee Champion: (list name of Committee) (list VP in charge of Committee)
3 Committee Goals: (list Goals of the Committee) 1. 2. 3. Committee Membership: Title (list by Title and Name each member of the committee) Name Committee Structure: Meeting Chairperson: Meeting Time: (list who will chair the Committee) (list frequency of meetings, weekly, monthly, etc) ***************************************************************************** Next, the chairperson develops an agenda and convenes the group. In many cases, the goals are established before the committee begins meeting. Generally, at the first meeting, goals are approved, meeting times and frequencies are established, and often ground rules are determined. For external consultants, contractual agreements and financial remuneration arrangements are made and the external consultant usually meets first with the chairperson. Throughout this process, nurses at all levels are engaged in decisionmaking. The quality improvement structure and process of Plan-Do-Check-Act (PDCA) also may be used when the project is related to quality improvement. The PDCA structure and process has been described throughout these sources of evidence. Our Evidence Based Practice model (Iowa model) is used often as a process for determining the
4 scope of a project, which may include the need for internal experts and external consultants. Engaging Lean Consultants Another example of structure and process used to engage experts and external consultants is our ongoing Lean initiatives. The Lean initiative came to Riverside Medical Center in 2006 as an effort within the laboratory and has carried on to the pharmacy, and several inpatient nursing units. A brief history of Lean at Riverside will be described to first understand the impact Lean has had on the culture and processes at Riverside; and how the Lean initiative has become a model of structure and process for nursing practice, decision-making, empowerment, and a culture change initiative, (much like Magnet principles!). In the 1950s, Toyota developed the Toyota Production System (TPS) as not only an industrial process to manufacture cars, but also as a management philosophy. In the 1980s, other manufacturing companies started to copy the Toyota Way in efforts to streamline production, eliminate waste, and to develop company cultures focused on quality. Massachusetts Institute of Technology (MIT) created the word Lean to describe these processes in 1990. Hospitals began to adopt Lean methodology in the 2000 s for the same reasons as the manufacturing industry: to increase quality, decrease waste, streamline processes, and developing a culture to sustain these efforts. Although Lean was developed for the manufacturing industry, industries outside of manufacturing are applying Lean philosophy to a number of initiatives. Lean philosophy supports consolidation of all aspects of a project to improve structures, processes, and outcomes. By freeing human potential, Lean adds value to patient care and improves quality. Key terms for Lean used in obtaining critical preliminary observation results are: value added, required waste, and pure waste. Value added is something a customer is willing to pay for, or something that changes the form, fit, or function of a product or service. Direct patient care is considered value added. Required waste is non-value added, meaning it must be performed but does not change the form fit or function of a product. For example, walking to put away medications is not necessarily a task a customer is willing to pay for, but it is required. Pure waste simply means an operator is idle or nonproductive. Waiting on hold on the phone is a good example of pure waste. Leaning the Lab Lean at Riverside began as a consolidated effort to improve turn-around times in the Lab. Stephanie Mitchell, RN, MBA, the Director of Riverside s Laboratory, identified a need to improve their processes. The Lab Department had been experiencing increased turn around times for tests, lack of space and staff resources, poor standardization of processes, and poor staff morale. In searching for a solution, Stephanie attended a conference where Lean was explained. She determined the Valuemetrix Company approach, which incorporates Lean, was appropriate for the Riverside Lab. After
5 meeting the Valuemetrix team, Stephanie adopted Lean methodology as part of her management philosophy and contracted with the Valuemetrix company to help her. Senior leaders approved the Lean project and the Valuemetrix consulting services because the issues in the lab were becoming critical for patient care. An interdisciplinary Lean team comprised of internal staff and external Lean experts from Valuemetrix was formed and a 12-week process took place to restructure the lab. The successes from the project were significant: Turn-around times for labs were significantly reduced; Standardization of all tests and measures were developed and carried out; Fewer errors were occurring; The lab s physical space was rearranged to improve work flow while reducing time wasted on walking; The need for more space was eliminated; Staff had the tools and resources to do their job at their work sites; and Dashboard and quality reporting measures were developed. Now instead of spending time fielding complaint phone calls from the ED and other areas, the Lab was receiving complimentary phone calls regarding their quick turnaround times and their commitment to quality outcomes. Included are the outcome measures before and after implementation of Lean structures and processes. Metric Before After Potassium IP Turn- Around Time 74 min (June 06 avg) 48 min (Nov 06 avg) (35.1% reduction) Troponin ER Turn Around Time 54 min (June 06 avg) 34 min (Nov 06 avg) (37.0% reduction) % of Results on Chart before 62% (10/10) 85% (Nov 06 avg) 7 AM Specimen Travel Distance 146 feet 67 feet (54% reduction) Chemistry Hem. Tech Walking Distance per Hour 1620 to 2028 feet/hour 500 to 800 feet/hour (estimated based on std work) Square Footage 228 sq ft freed up (behind manual area, to side of special chemistry) These successes directly impact patient care and the nurses who provide that care. Faster turn around times for the lab means quicker diagnosing for physicians and decreased length of stay for patients. Also, prior to Lean there were plans to move the lab due to lack of space. With Lean there was no need to move the lab.
6 The Pharmacy Goes Lean The need to disseminate the successes of Lean quickly became evident. Senior leaders decided that Lean should be disseminated to other Riverside departments. The next department to be Leaned was our inpatient Pharmacy, because this department was experiencing some of the same problems as the Lab, and the results were similar: unhappy physicians and nurses and increased wait times for medications. The Pharmacy area was going to be remodeled and Lean methods were used to determine an optimal floor plan and layout of equipment to improve workflow. There also were many new medication distribution processes about to occur for the pharmacy (such as having a pharmacist on duty 24/7), so standardization was of high importance. During the Lab experience, our external consultants trained Riverside employees to be competent in applying Lean principles, and members of the Lab Lean Team became internal experts for the Pharmacy project. The methodology employed by the lab was applied in the Pharmacy. The goal was to reduce or eliminate waste. At the conclusion of the Pharmacy project, the outcomes of Lean in the Pharmacy included: A 73% reduction Pharmacy stock outs of medications in the Pyxis machine. This outcome was significant to nurses because medications needed on patient care units would be available in Pyxis when needed. Pharmacy was able to reduce their inventory by 14% The number of medications returned to the pharmacy decreased by 50%. Two new roles and assignments were reallocated to support inventory management and customer services. And on to Physicians Lean next moved to physician clinics, which were not part of the hospital. Lean began with the Center in Wilmington and was needed because of delays with patients phone calls and visits. Staff and physicians were spending time searching for different supplies and information, and were becoming increasingly frustrated. Through the Lean project, the Kanban ordering system was introduced, which dramatically decreased ordering time for the manager. The Kanban system is an inventory management system. All information about supplies and inventory needs are written on a card for ease of ordering. All staff can restock as the number supplies falls below a pre-established target number. Lean also affected the physicians. A podiatrist was observed making many trips from the exam room to the procedure room to get supplies and instruments for patient use. At times it was noted that this physician would walk approximated 670 ft during one patient visit to gather was needed. Through this observation a cart was made to house
7 all of the supplies that the doctor would need during his procedures. This cart was now placed between his exam rooms to reduce his walking. This cart is filled weekly to ensure that all of the supplies needed are available. This is the cart that the podiatrist now uses to better serve his patients This is an example of a spaghetti diagram showing where the podiatrist walked to get supplies. This one trip equaled 670 ft. Lean Comes to Nursing Nursing units were next to be Leaned. A nurse team leader from 2ICU, Korene Scharp, RN, BSN, had been on the Pharmacy Lean team and served as an internal expert to the nursing units. On the nursing units, the initial team consisted of nurses, certified nursing assistants, and a secretary, who were regular employees on the unit. They received indepth training from an external consultant from the Valuemetrix company. After the newest Lean team was trained, they were ready to begin nursing s journey with Lean. To gain baseline knowledge of the nursing unit staff s satisfaction, an initial survey was created and completed before the project began on 5 th Telemetry. The survey was used to evaluate needs for improvement. From the survey, it was determined that some preparatory work should be done to reduce employee stress before leaning began on the nursing units. Knowing that change is stressful, the Lean team and Janet Jensen, Director of Educational Services, gave employees the opportunity to attend a stress management class that allowed them to get reacquainted with HeartMath. HeartMath is a stress reduction technique offered to employees at Riverside. Riverside has several certified trainers: Janet Jensen and LeAnn McCormick, Onboarding Coordinator from Educational Services. HeartMath helps staff to deal with stressful situations as they
8 happen by using breathing techniques and visualization. Leaders believed this would help all nursing staff to cope more easily with the changes being introduced by Lean. Next, the team implemented a Lean tool called the Idea Board. This tool allows nursing staff to take control of the workplace by letting them solve their problems. Direct care nurses and staff are the knowledge experts for patient care practices on the nursing unit, and are caregivers who should be proposing the solutions. Below is an example of the 5 th Telemetry idea board, which is still used. Idea Board Direct care staff generate the ideas: they identify a problem and a possible solution. The idea is written down on a blank idea card, and then placed on the idea board. While the Lean team is in the unit, they are in charge of the ideas on the idea board. The unit manager checks the idea board twice weekly for new idea cards. He or she reviews the ideas and solutions, writes on the back of the form, and/or communicates back to the staff member who generated the idea. Blank Idea Card
9 The Lean methodology continues to permeate our inpatient nursing units. The original Lean Team Leader, Abby Pfeiffer, is now an Educational Specialist in our Educational Services department. Her experience on the Lean team has contributed to her professional growth and she uses the lessons learned from Lean in her role as a nurse educator. New teams are formed as Lean moves through the hospital nursing units. Stephanie Mitchell, RN, Lab Director, continues in her role as internal consultant. Summary Lean continues to support change, collaboration, and process improvements throughout the organization. Using the ongoing Lean process has stimulated nurses to explore their creativity, problem identification, and innovating thinking, and to develop resolutions that improve work flow. The outcome is improved employee and patient satisfaction through reduction of waste. Two improvements related to nursing practice and the use of internal experts and/or external consultants will be described and demonstrated in EP7EO.