1. Spotlight on Clinical Problem-solving When Small Changes Have Big Impact

2. Objectives Describe Ideal Patient Care Discuss what a barrier to Ideal Care is Explain the impact of workarounds in everyday patient care Describe how making small changes one at a time impacts bigger processes

3. Adaptive Design Emergency Services Daphne Willwerth, RN, BSN, CEN Manager, Emergency Services Trinity Regional Medical Center Fort Dodge, Iowa

4. Training Began training core Adaptive Design Group in June of 2010 Core Group consisted of ED Charge RNs and EMS Supervisors Began training 8 hours per week and then decreased to 4 hours scheduled training time per week

5. Ideal Patient Care The patient and family’s physical and emotional needs are met with compassion in a safe and timely manner.

6. 4 Rules of Adaptive Design 1.All work shall be highly specified as to content, sequence, timing, and outcome 2.Every customer-supplier connection must be direct, and there must be an unambiguous yes or not way to send request and receive responses

7. 4 Rules of Adaptive Design 3.The pathway for every product and service must be simple and direct 4.Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization

8. Observations Activities Connections Pathways Work of an individual Communication between individuals Processes (activities + connections)

9. Observations 1 Hour patient pathway observations completed by core group 1 Hour patient pathway observations completed by all ED and Ambulance staff with assistance of a coach Began work with A3s

10. Adaptive Design Process in the ED

11. Signal Log Completed by staff when patient does not receive Ideal Care Coach uses to start A3

13. Communication A3 One of our first problems was how do we communicate all of our counter measures

14. Pre-Shift Huddles Used every shift to communicate problems and counter measures Charge nurse to all staff

15. Monthly Newsletter

16. Spreading Adaptive Design Improvements in Signal Form Pulling more staff into our scheduled Thursday training days Working A3s with staff involved in the signal Posting A3s in break room and discussing counter measures with each huddle Coming in on night shifts to train night staff

17. A3s to Solve Problems All Peminics All core measures that fall out for pneumonia and STEMI All signaled problems Performance measures not met on Stroke and Trauma patients Staffing issues if they impact our ability to give ideal patient care NDNQI survey results that were lower than comparative data

18. Increase Staff Involvement Coaches assigned to specific staff 1 hour classes on Thursday morning during shift changes Work department A3s during ED and EMS Unit meetings (e.g. ED Noise levels)

19. Impact on the ED

20. Vitality Survey

22. Mean TrendsEmergency Department - Acute Trinity Regional Hospital Displayed by Discharged Date Overall AcuteEmergency Department Overall

23. Mean TrendsEmergency Department - Acute Trinity Regional Hospital Displayed by Discharged Date Question - Likelihood of recommending Acute

24. Mean TrendsEmergency Department - Acute Trinity Regional Hospital Displayed by Discharged Date Question - Staff cared about you as person Acute

25. Mean TrendsEmergency Department - Acute Trinity Regional Hospital Displayed by Discharged Date Question - Overall rating ER care Acute

27. Lessons Learned One patient, one problem at a time Focus on Ideal Patient Care Observe for opportunities to solve problems with the A3

28. Using Adaptive Design to Improve Admission Core Process Work Jim Abel, RN, BSN Cathy Hunt, RN, BSN St. Luke’s Cedar Rapids

29. Admission Core Process Set Direction Observations Document Current State Identify workarounds and barriers to Ideal Patient Admission (signals) A3 problem-solving

30. Ideal Admission Process “The admission process accommodates the wants and needs of my family and me safely and without waste and it provides my caregivers with the information necessary to care for me.”

31. Admission Core Process Observations –Direct and ED Admissions –Adult and Pediatrics –Patient –ED pod RN, ED charge RN –Physicians (ED, admitting) –Bed Placement –Admission Center RN –Inpatient charge RN, bedside RN, secretary Documented current state Identified barriers to ideal care and workarounds (signals) –Patient Family Advisory Council –Frontline staff

32. A3 problem-solving Signal: I was not an appropriate patient for the room I was assigned –Root cause: ED charge nurse who provides the information to bed placement does not have a full picture of the patient and is a loop in the connection between the customer who has the full picture (ED pod RN) and the supplier (bed placement) –Countermeasure: Remove ED charge nurse from process and have direct connection between ED pod RN and bed placement

33. Adult transfers-1 st 24 hours

34. A3 problem-solving Signal: My home medication list wasn’t ready for my admitting physicians when he/she wrote my admission orders which resulted in many workarounds –Root cause: There was no specified process for getting a complete and accurate home medication list prior to physician writing orders –Countermeasures: Admission nurses now work out of the ED Prioritize completion of the home medication

35. Home Med Documentation

36. Change Process to Team Ownership Leaders Communicate to Organization Teams Understand Teams Adopt Teams Own Leaders Set Direction Most difficult part of process

37. Countermeasures Train med/surg managers and supervisors in Adaptive Design using four week “cohorts”: Twelve 5 hour days of learning Develop Standard Work Process Guides Encourage real-time coaching of new work processes

38. The real key to stabilizing and sustaining work is…… Patience and Perseverance

39. My Patient Story Cultural Diversity & Fall Aimee Derby Assistant Nurse Manager- 5A St. Luke’s Hospital- Sioux City

40. Story Dialogue Utilized by Adaptive Design Methodology  Elderly Hispanic gentleman hospitalized on Surgical/Oncology floor.  Married with adult children- wife and son visiting, present in patient room.  Patient and wife spoke Spanish only, adult children bilingual.  Patient and family had been previously instructed to call for help with ambulation.  Current State: Patient attempted to ambulate without help and fell while wife and son sat in room and watched.

41.  Nurse arrives in room and assists patient back to chair.  Patient had no apparent injuries.  Nurse spoke to adult son who explained in his culture, children are expected to be obedient and respectful toward parents; therefore, he is not comfortable telling his father not to get up alone.  Traditionally, father is head of household and holds ultimate decision-making authority.

42. Action Plan  Applied personal alarm to patient when up  Created a sign in Spanish that stated “Call Don’t Fall” to hang in the room as a visual reminder  Reinforced with staff in daily huddle the cultural implications of Hispanic family dynamics and safety  Reinstructed patient and family to call and wait for staff assistance before attempting to get up

43. A3

44. Hospital Admit vs Population Diversity 01/01/2010 - 12/31/2010 Hospital Admits 9,748100% Number of Med Recs Percent of Total Sioux City Population RACE 1351.4%2.6% AASIAN 2662.7%2.2% BBLACK 7,69278.9%78.5% CCAUCASIAN 1,10711.4%10.0% HHISPANIC/LATINO 5095.2%1.8% IAMERICAN INDIAN/ALASKA NATIVE 340.3%4.9% MMULTIRACIAL/UNKNOWN/DECLINED/OTHER 50.1%0.0% PPACIFIC ISLANDER/HAWAIIAN NATIVE

46. Decrease in Fall Rates  First Quarter (Jan-Feb 2010)- 7.41 falls per 1000 patient days  First Quarter (Jan-Feb 2011)- 3.21 falls per 1000 patient days

47. Why the Decrease?  Reliable Rounders Program (initiated in March 2011)  Communication (shift huddles, bedside report, white boards, fall signage)  Safety Devices (personal alarms, bed alarms, low beds, fall mats)  Patient-Family Centered Care (engaging the family)

48. Bedside Shift Report Sarah L. Scott, B.S.N., R.N. Allen Hospital

49. To begin… A problem was signaled involving shift report The patient was not being kept informed The nurse wasn’t receiving the information needed to care for his/her patients Thus, observations were made and an A-3 was completed

50. Observations Observations were completed by nurse managers and staff nurses It was observed that shift report was not consistent The current state was: shift report was occurring at the nurse’s station, hallway, outside of the patient room, and at the bedside A consistent tool was not being utilized across the medical-surgical units

51. What we learned 51 Nurse managers and staff nurses met to discuss common themes throughout their observations As a group, we identified what we learned We discovered that shift report was variable Varied from nurse to nurse-unit to unit Not always at the bedside Needs some degree of variability Patient not always engaged

52. Principles Basic Principles for Shift Report Shift report should: »Tell the patient story »Keep the patient engaged »Patient focused »Consistent »Needs to be specified »Utilization of the white board »Accountability from giver to receiver »Any “I don’t know” should have an answer before the off going nurse leaves and the answer should be relayed

53. Content/Sequence As a group, we developed what the content and sequence to shift report should consist of: Introductions Reason for admission Medical History Precautions/Safety Course of hospital stay Plan of Care Closure

54. CareCast Report A report was being utilized by some of the units, but not all Required the nurse to hand-write the patient’s diet, activity, IV, intake and output, vital signs, labs, and assessment

55. Old Shift Report Tool

56. Shift Report Tool A new shift report tool was developed from the Trinity Quad Cities Patient Care Tech report The new RN report was developed by IT with feedback from staff

57. New Shift Report Tool

58. Shift Report Tool The new shift report tool was implemented on medical-surgical units A poster was created to remind staff of items to include in report and was placed at the head of the patient’s bed Report was to occur at the patient’s bedside

59. Shift Report Poster

60. Another Signal A patient signaled that report was not occurring at the bedside Another A-3 was created As a result, the content was re-specified It was found that nurses were reading off of the report tool which was redundant

61. Re-specified Content The needs of shift reporting at the bedside Introductions Course of hospital stay (high-lights) Plan of care Closure

62. Work in Progress A new poster was created for the patient’s room with the re-specified content, placed above the head-of-the-bed to remind nurses of what report should consist of Report tool was standardized across all medical-surgical units at Allen Hospital This is a continual work in progress to ensure that nurses are practicing report at the patient’s bedside

63. New Poster with Re-specified content

64. Questions? Thank you for your attention