1. Adaptive Design The Path to Ideal Care Mary Ann Osborn RN, MSN VP/CNO St. Luke’s Hospital, Cedar Rapids Panel Members from Quad Cities, Cedar Rapids & Sioux City IHS Symposium April 2010

2. Objectives for the day Review the IHS Vision Provide overview for Adaptive Design Share examples of Adaptive Design and the scientific methodology to solve problems (A3) Outcome measures at various affiliates Describe the borrow forward process challenges, lessons learned

3. GOAL: Ideal care that achieves best outcome for every patient every time Patient Centered Based on best practice/evidenced based Efficient/adds value/enhances the patient experience Electronic medical record enables care Professional practices nurtured/effective work teams

4. GOALS (not an all inclusive list) 95% of patients willing to recommend 0 codes on med/surg units Less than 5% readmissions within 30 days Achieve 90% or above in all quality measures (HF, MI, Pneumonia, Infection Preventions, etc.) No patients fall No skin breakdown Increase caregiver time at the bedside to 60-70%

5. Adaptive Design is an improvement methodology developed by John Kenagy. It is an enabling technology that continually improves an organizations’s ability to deliver exactly what the patient needs while simultaneously lowering the cost of care. John Kenagy, 2009

6. Adaptive Design: Blend of 2 innovative concepts Disruptive Innovation Encourages leaders to look for effective, simpler, less costly ways to provide better service Gives permission to look at other industries for ideas or answers Toyota Production System How people work and manage How they think about their work How they learn and work together to improve

7. What is Adaptive Design? The foundation of the work is observation Honors the work of the front line staff Allows observer to ‘see’ the whole picture—eliminates assumptions Detailed observations provide opportunities for problem solving All the improvement work is based on the point of view of the patient Creates 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 Solving the problem for this patient and this clinician at this time (work around) Second order Get 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 Care Ideal 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 care Rules 1-3 guide the work that is being done Rule 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 to Poorer quality Lower productivity Higher costs Hinders learning and improvement in the organization because the variations hide the link between how the work is done and the results.

13. ACTIVITY

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 path There should not be any deviation from the pathway No forks or loops Care and services do not flow to anyone, but to a specified person or equipment The care we provide is a series of different pathways (services): Admission Medication Administration Discharge Each 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 facilitators Develops staff members into a community of learners who participate in the problem solving Problems, as signaled by staff, are solved using a scientific method Tackles 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 state Look for “signals” when patient care is not ideal Problem-solve using a scientific method (A3s) Implement and Test Countermeasures quickly Continue with Countermeasure, until failure is signaled by frontline staff

18. Adaptive Design Transformation Is a disciplined approach Creates a culture change in how to solve problems Every solution is a “test” and we expect it will fail---but we will learn more about the issue and come closer to the ideal Every employee becomes a problem solver Removal of barriers of ideal patient care No “work-a-rounds” No communication gaps Eliminates repetition and redundancies Increase quality Increases nurse time on patient care Increases patient satisfaction Increases employee satisfaction

19. Trinity Quad Cities 6 North Unit – Surgical/Ortho Background: Post-op surgical inpatient population. 30 - bed unit with 25 private rooms. 9 Ortho Certified RNs Core Blueprint Team: Kathy Yadon RN, MS, CMSRN – Manager 6North Kim Chant RN, ONC – CAP III Staff Nurse Megan Neal RNC, BSN – Clinical Nurse Educator Lauren Monks BA, CPHQ – PI Champion Jewels Stark MBA, MS, BSN, RN – Director, Acute Care Services

20. Current State of Blueprint Blueprint fully implemented. Staff “get it”. Blueprint has become a living entity. We’ve gained momentum We’re working on sustainability

21. Call light A3

22. Call Light A3 – Root Cause

23. Call Light A3 – Counter Measures

24. Our Proudest Outcome: Unit-Based Shared Decision Making

25. Staff Perspective Staff no longer feel threatened by change; they feel empowered to look for things that need changing! It’s no longer “They vs. Us”, now it’s “We” It’s a “can-do” environment Staff have begun to challenge their own status quo

26. St. Luke’s Hospital-Cedar Rapids 5 East-Medical Blueprint Unit 25 beds Diane Pfeiler, RN-Adaptive Design Coach – Manager, 5 East-Medical Connie Bulman, RN-Adaptive Design Coach – Lead RN, 5 East-Medical

27. Areas involved with Adaptive Design at St. Luke’s-CR 5 East-Medical – Diane Pfeiler, RN, Manager Emergency Department – Sandi McIntosh, MSN, Director Admission Process Committee – Carmen Kinrade, MSN, Chair Medication Reconciliation Committee – Carmen Kinrade, MSN, Co-Chair – Pat Thies, RPh, MS, FACHE, Co-Chair

28. St. Luke’s-Cedar Rapids DNR orders A3

29. DNR orders A3 Background

30. DNR orders A3 Current State

31. DNR orders A3 Root Cause

32. DNR orders A3 Target Condition

33. DNR orders A3 Countermeasures

34. DNR order A3 Test Question

35. St. Luke’s-Cedar Rapids 5 East Medical Outcomes Total Number of A3s completed179 Total Number of A3s related to Pt. Safety29 Total Number of Departments Involved31 Total Number of Frontline Staff Completing A3s 16 % Staff OvertimePre AD = 2.36% Post AD = 0.82%

36. Improving Patient Safety 12 A3s related specifically to patient falls since October 2009

37. St. Luke’s-CR: What has this work meant to me as a Manager? Problems/Issues are dealt with right away Able to spend more time with frontline staff Staff give their input related to signals to me A3 are useful learning tools for my staff and hospital Builds staff members’ experiences and knowledge bases It’s not extra work, it’s how I do my work

38. St Luke's-CR How has this impacted my work as a Lead RN? Adaptive Design is now my work Incorporated with frontline staffing duties Utilizing Adaptive Design in committee work Increased connection with other departments Constant interaction with frontline staff

39. St. Luke’s-CR: How has this work impacted the frontline staff? They come to us with things that get in the way of Ideal Care They are involved in developing countermeasures They think differently about the problem solving process “Working through the A3 helped me to evaluate what the real problem was. It helped me see that there are other solutions that would be safer for the patient.”—Angela, RN, 5 East

40. St. Luke’s Blueprint Work Began Jan 5,2010 4A Surgical/Oncology Unit Team members include: Lisa Pishek Vikki Bridgford Wendy Hamblen Laurie McCurry

41. Blueprint Team

42. Impact on our work “It shortens the time spent going and running to get things.” Megan Fick (RN <1yr)

43. 4A’s Favorite A3 (so far)

44. Departments working together

45. Conclusion We are excited because: The patient is the focal point of our work. Frontline staff are driving the process. Managers are coaching and mentoring. We’re back at the bedside and finding joy in our work.