IHI Expedition: Smart Use of Resources: Nurses’ Time

Session 1: Overview & Getting Started

Annette Bartley RN, MS, MPH

Mary Viney RN, MSN, CPHQ

Tracy Jacobs BSN, RN

These presenters have nothing to disclose

IHI Support Staff

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Tracy JacobsDirector

Kayla DeVincentisProject Coordinator

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What’s your favorite

spring activity?

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Join Passport to:

• Get unlimited access to Expeditions, two- to four-month, interactive, web-based programs designed to help front-line teams make rapid improvements.

• Train your middle managers to effectively lead quality improvement initiatives.

. . . and much, much more for $5,000 per year!

• Visit www.IHI.org/passport for details.

• To enroll, call 617-301-4800 or email improvementmap@ihi.org.

What is an Expedition?

ex•pe•di•tion (noun)

1. an excursion, journey, or voyage made for some specific purpose

2. the group of persons engaged in such an activity

3. promptness or speed in accomplishing something

Where are you joining from?

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How to Get the Most From This Expedition

• “All Teach, All Learn” philosophy

• Join and participate on all calls

• Use the 50-mile rule

• Test, test, test

• Share what you’ve learned (failures as well as successes)

• Participate in the listserv discussion

• Listserv address: NurseExpedition@ls.ihi.org

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What You Can Expect of Us?

• Interactive WebEx Sessions

• Prompt responses to your listserv questions (if needed)

• Email and phone contact info

• We’re learning from you and with you

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Faculty for the Expedition

• Annette Bartley RN, MS, MPH

IHI/Health Foundation Fellow

Quality Improvement Consultant

Lead -Transforming Care at the Bedside in Wales UK

• Mary Viney RN, MSN, CPHQ

Vice President Seton Healthcare Family

Austin Texas , member Ascension Health has been practicing & teaching principles of Transforming Care at Bedside since 2003.

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Overall Goal Of Expedition

AIM:

To provide participants with the content knowledge and skills to enable them to identify and eliminate waste in clinical processes and maximize the time nurses spend in direct patient care.

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Expedition Sessions

• Tuesday, April 24: Overview and Getting Started

• Thursday, May 10: Improve Work Environment Through Physical Space Design

• Thursday, May 24: Redesign Key Processes to Eliminate Waste - Admission Process

• Thursday, June 7: Redesign Key Processes to Eliminate Waste - Discharge Process

• Thursday, June 21: Redesign Key Processes to Eliminate Waste - Medication Administration

• Thursday, June 28: Optimized Staffing Models/Recap of High-Leverage Changes

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Objectives At the End of the Expedition, You Will Be Able to:

1. Recognize the seven categories of waste as they apply to hospital environment

2. Assess work unit for a project to improve nurses’ effectiveness and efficiency

3. Use diagnostic tools to study existing processes to identify workarounds and inefficiencies

4. Apply best practices to streamline key processes like admissions, discharge, and medication administration

5. Employ ideas about the use of physical space and placement of supplies and equipment to improve efficiency and reduce wasted movement and time

6. Design a test to increase nurses time spent in direct patient care

7. Describe the linkage between safety and nurses time in direct patient care

8. Theorize about alternative staffing models to more effectively use nursing time and expertise

Objectives for Session One

• Introduce the expedition team/faculty

• Provide some background and context for the work

• Describe how to undertake a diagnostic to uncover waste – using time sampling and observation

• How to assess their work unit for a project to improve the nurses effectiveness

• Provide an overview of the Model for Improvement

• Helps teams to design a test to increase nurses time spent in direct care

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It’s a Fact that …

“Without good and careful nursing many must suffer greatly, and probably perish, that might have been restored to health and comfort, and become useful to themselves, their families, and the public, for many years after.”

Benjamin Franklin (1751)

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The Reality in Practice

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Life Can Be Complicated

Which Direction? Get the picture

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Getting it Right:Co-ordinating Care

Setting the Context

• Nurses are the cornerstone of hospital care delivery and the hospital’s most costly and valuable resource; their efficiency and effectiveness are central to any effort to maximize patient safety and outcomes

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What Does the Literature Tell Us?

• Recent studies (Aiken et al, 2002; Needleman et al, 2002; Seago, 2001 and Kovner, 2002) show that lower nurse-to-patient staffing ratios are associated with higher rates of adverse events

• National RN Turnover Rates ranged from 13.9% to 16.8% in 2004 and from 12.1% to 13.5% in 2005; generally nursing turnover is the highest on medical and surgical units (AHA)

• Total time all health care workers (not just nurses) spent in direct patient care on a med/surg unit is a median of 1.7 hours in a 12-hour period (IOM, Keeping Patients Safe, 2004)

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What Does the Literature Tell Us?Nursing and Patient Outcomes

• Strong links between nurse staffing and the quality of the nurse work environment to the efficiency of nursing care and patient outcomes (Clarke & Aiken, 2006).

• 7% increase in mortality (and a 7% increase in the odds of failure to rescue) for every additional patient per staff nurse (Aiken et al., 2002).

• This work is supported by findings from other studies in North America, Europe, Russia, and New Zealand also demonstrating a link between nurse staffing, the quality of the nurse working environment, and quality of patient care (Clarke & Aiken, 2006).

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Figure 1: Reported nurse time by location

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Care Coordination and Documentation Subcategories by Location.Analysis of nursing practice subcategories by location found that care coordination was performed primarily at the nurse station (69.2%) and

documentation was also performed primarily at the nurse station (80.6%).

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767 nurses participated from 36 hospital units within 17 healthcare systems across 15 states!

• Documentation (35.3%; 147.5 minutes)

• Medication administration (17.2%; 72 minutes)

• Care coordination (20.6%; 86 minutes)

• Patient care activities accounted for 19.3% (81 minutes) of nursing practice time

• Only 7.2% (31 minutes) of nursing practice time was considered to be used for patient assessment and reading of vital signs

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• The study identified three main targets for improving the efficiency of nursing care:

1. documentation

2. medication administration

3. care coordination

• Changes in technology, work processes, and unit organization and design may allow for substantial improvements in the use of nurses’ time and the safe delivery of care

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Interruptions and Hassles in Nursing

• Disruptions in the supply of materials or information, also called work-system failures, contribute to nursing workload and stress.

• Tucker and Spear reported that nurses experience an average of 8.4 work system failures per 8-hour shift (Tucker & Spear, 2006).

• The five most common work system failures reported by nurses involved

1. disruptions in the supply of medications

2. orders

3. supplies

4. staffing

5. equipment

• Nurses were interrupted mid-task an average of 8 times per shift.

• Spent a large percentage of their time hunting and gathering!

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Burnout!

• An English study, reported that surgical patients in hospitals in the lowest quartile of patient-to-nurse ratio had consistently better outcomes (Rafferty et al., 2007).

• Hospitals with the highest patient-to-nurse ratios had 26% higher mortality, and nurses in these hospitals were approximately twice as likely to be dissatisfied with their jobs, show high burnout levels, and report low or deteriorating quality of care.

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The Case for Change

• Innovations in hospital design and work processes offer the potential to:

• Enhance the recruitment and retention of staff

• Increase the efficiency of care delivery and impact on cost

• Improve the quality of clinical care and patient

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TCAB Wales

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Expedition

• Transforming Care at the Bedside (TCAB)

• IHI/RWJF

• Share our experience and learn together

• Share tools and methods

• This expedition is designed to be participative and interactive

• We depend on your active participation

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It’s Time…

• A little less conversation a little more

action

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Diagnostics to Uncover Waste

• Time Sampling and Observation

• Direct Observation

• WHAT IS IT?

• Shadowing a person in real time to understand work

• Record timing, location, activity, and interaction information

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Why Observe?

Allows you to gather more accurate information than other

data collection methods

Allows you to see the process and all of the associated details(timing, interruptions, barriers, etc.)

• Repeated calls to pharmacy to get a med

• Number of trips to supply room

• Volume of interruptions during med preparation

• Hunting and searching for a chart

• GAIN RESPECT… “now you have seen what we face each day” Validation of challenges

During the Observation

• Record events as they occur

• Note timing and location

• Write down statements made & others involved

• Note particulars related to your purpose

• Avoid interrupting staff while they work

• Exception: patient safety issues

• Jot down your questions, ask them later

• Make honest comments that ‘connect’ you to staff

• Member’s world (“It took over an hour…….”)

• Know that you may need to observe a typical work sampling multiple times

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Analysis of the Observation

• Tally number of minutes spent on each activity

• LEVEL 1: Assign activities into TYPE of work grouping:

─ A. VALUE ADDED: transforming goods or services to

meet a patient need; what a patient would pay for

─ B. NECESSARY: preparatory steps required to provide

value added care; what a patient may not recognize

as important

─ C. NON VALUE ADDED: anything that does not add

value to the final product or service; what a patient

would clearly recognize as not important

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Options for Observation

• Assign an observer to follow a nurse and record nursing activity at a designated rate, such as every five minutes.

• Observations may be customized for each unit. Three examples of how to accomplish this are as follows:

─ Observe a nurse for an hour per day, recording observations every five minutes. Rotate the hour each successive day until all 24 hours are observed over a month.

─ Observe a nurse for four hours, collecting data every five minutes, and repeat six times a month until 24 hours are covered.

─ Observe an entire shift.

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Value Added Care

• Training eyes to see the waste

• Waste in time

• Waste in process steps

• Understanding that each step adds value

• Learning to observe & record observations of work

• Find and remove hassle factors

• Interviewing to ask WHY 5 times

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GroupedCategory Group Comparison

Admin

11%

Direct Care

36%

In-Direct

Care

28%

Personal

4%

Waste

21%

Group Location Category

Category

Count

Location

Count

Group

Count

Admin 6

Ancillary Department Dropping Off Patient Supp 1 1

Nursing Station Calling Ancilllary Depart 3 3

Patient Room Admission / Discharge 2 2

Direct Care 19

Ancillary Department Escorting Monitor Patient 1 1

Patient Room 18

ADL 3

Communicat. with patient 2

Documentation 2

Incontinence 1

IV Monitoring 3

Meds 6

Observation 1

In-Direct Care 15

Nursing Station 12

Comm. with CareTeam memb. 4

Comm. with Family 1

Documentation Paper Chart 3

Elect. Entry Patient Data 1

Nursing or Patient report 3

On the Unit Care Conferen 3 3

Personal On the Unit Personal Time 2 2 2

Waste 11

Ancillary Department Waiting Delay 1 1

On the Unit 10

Looking for Equipment 3

Looking for person 1

Looking for Supplies 2

Waiting Delay 1

Walking Station, oth.Room 3

Total 5339

Types of Waste

1. Defective products2. Overproduction3. Waiting4. Transportation5. Inventory6. Motion7. Excess Processing

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What is 5S?

Spring cleaning on steroids!Goal - Organize your work place so that your material and flow sustainably fit your needs

Sort – Seiri (organization) Set in Order – Seiton (orderliness) Shine – Seiso (cleanliness) Standardize – Seikutsu (standardized cleanup) Sustain – Shitsuke (discipline)

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WASTE:Color Coded Supply System

• Supplies placed in easy access wall bins

• Color coded by categories

─ IV supplies are coded red

─ Hygiene supplies coded green

─ Sharps are coded blue

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Spaghetti Diagram

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Learning from Other Industries

5S and eliminating the

waste of movement…

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Example: Tracking Over Time

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Model for Improvement

1 - Storytelling

2 - Snorkeling

3 - Prioritizing

4 - Building a hypothesis - Prediction

5 - Small tests of change

6 - Evaluate based on hypothesis

7 - Adopt, Adapt or Abandon

8 - Rapid cycle testing

9 - Spread48

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Degree of Belief in Changes

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Think Small

• N of 1

• One patient

• One Nurse

• One admitting clerk

• One shift

• One day

• 52 Tuesdays

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hunches,

theories &

ideas

changes that result

in improvement

Testing and Implementing Changes

Plan

Study

Act

Do

Cycle 6

Cycle 8

Cycle 1

Cycle 2

Cycle 3

Cycle 4

Cycle 5

Cycle 7

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hunches,

theories &

ideas

changes that result

in improvement

Testing and Implementing Changes

Plan

Study

Act

Do

“Staff involvement in designing rapid tests of change generatedenergy, enthusiasm and empowerment quickly.”

“Building improvementcapability at all levelsof the organizationis a critical leadership responsibility.”

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Questions from You

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Teamwork for Action Period

• Undertake a time sampling diagnostic to help you uncover where waste is in your processes

• Three volunteers to report out on the next call

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Volunteers?Volunteers?Volunteers?Volunteers?

Summary

• What we have discussed

• What is the work during action period

─Post questions and share experiences using the listserv: NurseExpedition@ls.ihi.org

• Next call: Thursday, May 10th

─Time: 1:00 – 2:00 PM EST

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Expedition Communications

• If you would like additional people to receive session notifications please send their email addresses to improvementmap@ihi.org.

• To use the listserv, address an email to NurseExpedition@ls.ihi.org.

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