Presentation on theme: "Adaptive Design The Path to Ideal Care"— Presentation transcript:
1 Adaptive Design The Path to Ideal Care Debra Shriver, MSN, RNChief Nurse ExecutiveTrinity Regional Medical Center, Fort DodgeApril 2010
2 Objectives for the day Review the IHS Vision Provide overview for Adaptive DesignShare examples of Adaptive Design and the scientific methodology to solve problems (A3)Outcome measures at various affiliatesDescribe challenges, lessons learned, and integration of core processes into an EMR.
3 GOAL: Ideal care that achieves best outcome for every patient every time Patient CenteredBased on best practice/evidenced basedEfficient/adds value/enhances the patient experienceElectronic medical record enables careProfessional practices nurtured/effective work teams
4 GOALS (not an all inclusive list) 95% of patients willing to recommend0 codes on med/surg unitsLess than 5% readmissions within 30 daysAchieve 90% or above in all quality measures (HF, MI, Pneumonia, Infection Preventions, etc.)No patients fallNo skin breakdownIncrease caregiver time at the bedside to 60-70%
5 Adaptive Design is an improvement methodology developed by John Kenagy 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
6 Adaptive Design: Toyota Production System How people work and manage How they think about their workHow they learn and work together to improve
7 What is Adaptive Design? The foundation of the work is observationHonors the work of the front line staffAllows observer to ‘see’ the whole picture—eliminates assumptionsDetailed observations provide opportunities for problem solvingAll the improvement work is based on the point of view of the patientCreates a culture of improvement that uses the creativity, knowledge and problem solving ability of frontline staff to solve problems whenever care is not ideal.
8 Problem Solving First order Second order Solving the problem for this patient and this clinician at this time (work around)Second orderGet at root cause and solve the problem for future patients and clinicians
9 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.”
10 Rules of Adaptive Design Strive for Ideal Patient CareIdeal 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?
11 Rules of Adaptive Design There are 4 rules in Adaptive Design that are used to assist us with achieving ideal careRules 1-3 guide the work that is being doneRule 4 guides us through problem-solving
12 Rule 1—How People Work-Activities All work shall be highly specified as to content, sequence, timing, and outcome.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 toPoorer qualityLower productivityHigher costsHinders learning and improvement in the organization because the variations hide the link between how the work is done and the results.
14 Rule 2- How People Connect-Connections Every customer-supplier connection must be direct, and there must be an unambiguous yes-or-no way to send requests and receive responses.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.
15 Rule 3-How the Production Line Is Constructed-Pathways Every product or service flows along a simple, specified pathThere should not be any deviation from the pathwayNo forks or loopsCare and services do not flow to anyone, but to a specified person or equipmentThe care we provide is a series of different pathways (services):AdmissionMedication AdministrationDischargeEach 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)
16 Rule 4-How to Improve- A3 Problem-solving 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.Encourages management to mentor frontline staff and be facilitatorsDevelops staff members into a community of learners who participate in the problem solvingProblems, as signaled by staff, are solved using a scientific methodTackles specific problems or failures rather than generalize or assume the issue.The countermeasures are solutions developed based on the particular cause.
17 What is the Adaptive Design process? Observations of the current stateLook for “signals” when patient care is not idealProblem-solve using a scientific method (A3s)Implement and Test Countermeasures quicklyContinue with Countermeasure, until failure is signaled by frontline staff
18 Adaptive Design Transformation Is a disciplined approachCreates a culture change in how to solve problemsEvery solution is a “test” and we expect it will fail---but we will learn more about the issue and come closer to the idealEvery employee becomes a problem solverRemoval of barriers of ideal patient careNo “work-a-rounds”No communication gapsEliminates repetition and redundanciesIncrease qualityIncreases nurse time on patient careIncreases patient satisfactionIncreases employee satisfaction
19 Allen Memorial Hospital Tami Jones, RN, MSNClinical Director of Med/Surg and Nursing InnovationChrista Lerch, RN, BSNStaff Nurse on 4 Ortho
20 Frontline Design at Allen-Where we have been… 4 OrthoElisia Heidt-Penrod, RN, BSN3 MedicalAndrea Johnson, RN, BSNPharmacyTim Schmidt R. Ph and Jeff Martin R. Ph3 SurgicalRita Borrett, RN, BSN4 NETCarmen Mundt, RN, BSNInpatient TherapyMolly Ehrig, OTR/LDistributionKari Beschorner
28 Allen Outcome MeasureWe are solving problems throughout the organization.376 A3’s in test as of April 1st!
29 Allen—What has this work meant to me as a staff RN? Identifying 1st order problem solving and using 2nd order to solve the problems so I can spend time with patientsDecreased frustration with other departmentWe get to learn about and honor their workGratifying to get to the root cause and really solve problems
30 Trinity Regional Medical Center Fort Dodge Blueprint UnitTrinity RegionalMedical CenterFort Dodge
31 2 North 37 Bed Medical / Telemetry Unit Blueprint Team Staci Olson, RN Nurse ManagerSue Niemeyer, RN Clinical EducatorSara Ladlie, RN Staff Nurse (days)Lori Hoover, RN Charge NurseJenna Matton, RN Staff Nurse (nights)Kim Bennett, RN Staff Nurse (days)Carol Archer, PCT (nights)
33 Time Savings ExampleIf 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?
34 Cost Savings ExampleIf 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
37 What this work has meant Improvement in our workSaving timeMaking things run more smoothlyLess running aroundProblems don’t occur againReduction in wasteChanged the focus from the nurse to the patient—hear more “what’s best for the patient”All about the patient; patient centered careStaff work together as a team
38 What impact has this had? Changes in our interactions with other departmentsStaff involvement with solving the problems that are signaledIncrease quality time with the patientCost savings, reducing waste
39 The Finley Hospital Adaptive Design Information for Leadership Symposium Chris Wilson, RN MSN- Director of 4 Med/Surg and Inpatient Acute Rehab UnitSarah Bader, RN BSN, Staff nurse 5 Med/Surg and Clinical Adjunct Instructor for Clarke College Nursing School
40 Our two 20 bed med/surg units plus the 21 bed 5 North Med/Surg/Peds 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:Diana Batchelor, RN MSN, CNO FinleyTeresa Neal, RN MS – Six Sigma Black Belt/ Blue Print lead facilitatorPat Lehmkuhl, RN MSN- PI Coordinator and Blue Print team facilitatorChris Wilson, RN MSN, Director 4 M/SCheryl Haggerty, RN, MSN, Director 5 M/S and 5 NorthLondie Brauer, RN BSN, Educator 5 M/S and RehabDee Maahs, RN, BSN, Educator 4 M/SSarah Bader, RN BSN, Staff RN 5 M/SMelissa Shannon, RN, BSN Staff RN 5 M/SJulie Beyer, RN, Charge RN 4 M/S
43 Outcome Measures that we are proud of: ● Redesigned the supply process on both floors toapply LEAN concepts and to ensure that suppliesare readily available for the nurse so that the patientdoes not wait for care. Since redesign we haveseen a significant drop in the number of calls toPurchasing for missing items.
44 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.
45 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.
47 IH-DM N3 Blueprint Unit 24 bed Cardiovascular Unit 6.7 Admits per day 5.8 Discharges per day32% Patient Turnover per day58 Staff on UnitBlueprint Team MembersJennifer Early (Director of Adult Behavioral Services)Pat Busick (Quality Improvement Coordinator)Sharon Henry, RN, BSNToby Riddle, RN, BSN, Unit Based EducatorKathy Quick, Nurse Manager
48 IH-DM Ideal CareThe patient and family will say, “I receive the care I need and want safely, on time, with respect and compassion”.
49 Senior Leader/Executive Director Experience Purpose:- To learn and honor the work of thestaff in a 2 hour experience- Assist leaders to identify with us thebarriers in providing ideal care
54 Last but not least: Adaptive design guides work in identifying steps in core processes.1. Admit (Jan.)2. Discharge (Feb.)3. Medication administration/reconciliation (Mar.)4. Care of the Patient (April)5. 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
55 Last but not least: Timing IT Enabled: A few examples: 1. Direct admit: 60 minutes or less2. ED admit → nursing unit – 30 minutesuninterruptedIT Enabled: A few examples:1. Order sets automatically generated from dataentered2. CPOE3. Work list for physicians/eliminate “sticky” notes4. Template data from previous admission, ED,clinics, pharmacies5. Work list of incomplete handoffs.6. Single sign on.