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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 wide-ranging 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.

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Environment of CareSome 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

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Environment of Care

BackgroundThe 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

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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?

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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

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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

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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.

BenefitsBenefits

Heightened awareness and support for hard‐wired continual regulatory readiness with the environment of care standards

Trained over 220 champions through 

standardized education.

Improved champion understanding 

by 90%

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Environment of Care Champions Manual

Prepared byRuss Harbaugh, CHEPEOC/Life Safety Officer

Current Revision: 1/6/2012

Please send all feedback for future revisions to Russ Harbaugh at 381-2257 or harbaugr@slhs.org

SINGLE POINT LESSON

TOPIC/SUBJECT Eye Wash Stations

AREA/DEPT Environment of Care

PREPARED BY Russ Harbaugh

APPROVED BY EOC Committee

Regulatory Standards:29 CFR 1910.151 OSHA/ANSI Eye Wash Station RequirementsThe American National Standards Institute (ANSI) developed the ANSI standard Z358.1-1990OSHA 1910.151(c) NFPA 99 10.6St. Luke’s Policy:Eye Wash Safety (EC037) Infection Prevention, Facility-wide (IP054 TV)Blood borne Pathogens Exposure Control Plan (IP055 TV)

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.

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SINGLE POINT LESSON

TOPIC/SUBJECT Construction Areas

AREA/DEPT Environment of Care

PREPARED BY Russ Harbaugh

APPROVED BY EOC Committee

Regulatory Standards:LS.01.02.01 The hospital protects occupants during periods when the Life Safety Code is not met or during periods of constructionSt. Luke’s Policy:Non-Construction Personnel Visitation to Construction Sites (EC076 TV)Interim Life Safety Measures (ILSM) (EC024 BMW)

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 non-

construction 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.

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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

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Kamishibai

TransformHealthcare

Continuous Improvement

Justin

Time

Builtin

Quality

Standardization

Staff Focused

5SWorkplace Organization

Visual Management

Culture of Accountability

Patient Centered

Problem Solving

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.

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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

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Board Key Requirements

Board layout must contain:

– Planning Rack

– Audit Rack

– Single Point Lesson

– Action Item List

– Cards

Board Example

Planning Rack

Action Item List

Single Point Lesson

Completed Audit

Kamishibai Board

Board Example

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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

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AuditCentral RxSup

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.

Area Security: No doors held open by people/equipment.

During Shift

End of Shift#1

Red Tape Zones: All Alarm pull boxes and fire extinguishers are tapped off and clear of any items

AuditCentral RxSup

Daily: Environment of Care

Carts in Proper Location

Container Rack in Proper Location

Damaged manifolds noted properly

During Shift

End of Shift #2

Decon rounds board up to date

Area free of slip hazards and water on the floor

Area Organized & Clean

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.

AuditCentral Rx Sup

Daily: Environment of Care

During Shift

End of Shift#1

AuditCSPD Sup

Daily: Environment of Care

During Shift

End of Shift#2

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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

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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 on-going basis

•Shared educational tools with system partners through the newly established System Environment of Care Committee

• Created KamishibaiEnvironment of Care templates

•Developed a deployment plan for Kamishibai Card Implementation across the continuum of care

• Implemented KamishibaiCards on 14 inpatient nursing units and 1 clinic

•Implemented process to gather data on key project goals with reporting

transparency

.

•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 on-going basis

•Shared educational tools with system partners through the newly established System Environment of Care Committee

• Created KamishibaiEnvironment of Care templates

•Developed a deployment plan for Kamishibai Card Implementation across the continuum of care

• Implemented KamishibaiCards on 14 inpatient nursing units and 1 clinic

•Implemented process to gather data on key project goals with reporting

transparency

.

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

FY10 Compliance Rate FY11 Compliance Rate

Sharps Containers: Are sharps containers unobstructed and less than 2/3 full?

89.9% 92%

Wall-Mounted Sharps Containers: Are wall mounted sharps containers 52" to 56" high?

95.8% 96%

Identification Badges: Are staff wearing their identification badges? 98.6% 90%

Facility Security: Are critical areas of the department appropriately secured and accessed only by those authorized?

97.0% 97%

Medication/Syringe Security: Are syringes and pharmaceuticals locked, within line of sight, or within a secure unit (surgical services,

critical care, etc.)?

88.4% 90%

Warming Cabinets: Are warming cabinets set below 105 degrees for liquids and 130 degrees (+/-) for blankets?

81.1% 99%

Crash Carts: Are crash cart logs complete with no missing dates? 77.1% 95%

Hazardous Chemicals: Are hazardous/flammable materials properly stored and labeled?

99.1% 98%

Housekeeping Closets: Are housekeeping closets and other chemical storage areas locked if not within a secure unit?

97.3% 99%

Eyewash Stations: Are eyewash stations available and tested at least weekly?

84.4% 96%

Ceiling Tiles: Are ceiling tiles present and free from stains, scuffing, visible dirt, cracks, and breaks?

63.4% 81%

Kitchen Cleanliness: Are kitchen appliances (refrigerators, microwaves, etc.), including those used by patients, clean?

94.7% 91%

Under Sink Storage: Are only non-porous items (cleaning supplies and flower vases) stored under sinks?

83.1% 88%

Expired Items: Are patient care supplies and medications (PYXIS, refrigerator, and floor stock items) in date?

33.6% 67%

Refrigerators: Do refrigerators only contain appropriate items? 94.7% 97%

Temperature Logs: Are refrigerator temperature logs maintained and actions taken if out of compliance?

85.1% 93%

Clean vs. Dirty: Is there appropriate separation of clean and dirty supplies?

97.2% 92%

Linen/Clean Supply Carts: Are linen/clean supply carts covered and do the carts have a solid bottom?

97.6% 95%

High Dusting: Is high dusting completed regularly? 79.7% 76%

Egress: Are exit signs available and illuminated? 97.7% 100%

Corridors: Are corridors free of equipment and clutter (food carts, beds, etc.)?

94.6% 98%

Hallways: Do hallways have 4-6 feet of clearance with equipment 97 0% 99%

Slips, Trips, Falls

The Slip/Trip/Fall incident rate has

dropped below the One Standard

Deviation Improvement level as of

March 31st (1/2 through the fiscal year).

We are currently at 1.16 events

per 100 FTE and the 1 StndDev

goal is 1.26. (Note: Hours worked

were based on Jan 2012 hours-worked

until the injury scorecard is released…

it might lower the rate even more).

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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!