maximizing nurse recruitment and retention strategies with lean six sigma
TRANSCRIPT
Maximizing Nurse Recruitment and Retention Strategies with
Lean Six Sigma
Patricia J. Atkins, RN, MSDirector, Six Sigma
Jason Broad, MBASix Sigma Black Belt
Sharp HealthCare
• 4 acute care hospitals; 3 specialty hospitals
• 80,000 annual discharges• 1,842 licensed beds• 2,600+ affiliated physicians• 13,000+ employees• $1.6 billion in annual revenues
Lean Six Sigma Timeline at Sharp HealthCare
• 2003: Initial training through UCSD School of Engineering
• 2004: ‘Demonstration’ Projects• 2005: Wave 1 Projects with GE• 2006: Wave 2 Projects with GE
Enterprise-wide Strategy
Lean Six Sigma is One of Many Toolsin the ‘Sharp Experience’ Sharp Experience’
Performance Improvement Tool BoxPerformance Improvement Tool Box
Lean Six SigmaLean Six SigmaCAPCAPWork-OutWork-Out™™
TeamTeamResourceResourceManagementManagement
BaldrigeBaldrigeProcessProcess
Knowledge Knowledge ManagementManagement
Customer Customer Service ToolsService Tools
Evidence-Evidence-based practicebased practice
Sharp HealthCare’s Top Ten Strategic Challenges
• Limited capital depth and margins
• Legislative mandates*
• Capacity issues/access*
• Workforce shortages*
• Increase in the uninsured
• Physician alignment• Ability to create culture
of service excellence*• Ability to infuse a
collaborative system-focused culture*
• Aging infrastructure• Implementation of
evidenced-based medicine
*Affected by the nurse shortage
Nursing Shortage
Healthcare
State of the California (and USA)Nursing Shortage Crisis*
2006 2010 2015
Shortage of FTE
RNs
% of demand
Shortage of FTE
RNs
% of demand
Shortage of FTE
RNs
% of demand
CA -23,162 -12% -42,174 -21% -78,057 -34%
USA 168,356 -8% 275,215 -12% 507,063 -20%
*Projected Supply, Demand, and Shortage of Registgered Nurses: 2000 – 2020; U.S. Department of Health and Human Services, July 2002
WorkforceStability
Business Objective
Customers
Nurses
Key Driver
Nurse Recruitment
NurseRetention
Business Process Mapping for Translating Business Objectives to Metrics and Strategies
NurseProduction
Business Objective Metrics - The Big ‘Ys’
Business Objective Metric ‘Y’Workforce Stability Tenure, turnover, vacancy
Registry and traveler RN use
Nurse Retention Turnover, exit interview trends
Nurse Satisfaction
Employee Opinion Survey
NDNQI - Natl Dbase RN Qual Indicators
RN mgr effectiveness score
Workload satisfaction
Nurse Recruitment # Hires, vacancy
Conversion rate of qualified applicants
Conversion rate of externs
Nurse Production # RNs produced per year in San Diego
# Qualified applicants turned away
Open faculty positions in local RN schools
Methods of Collecting Nurse Voice of the Customer
InterviewsLeadership RoundsExit InterviewsTeam Activities
Voice of theVoice of theNurseNurse
Focus GroupsLeadersStaffUnion Leaders
Direct ObservationWorkflow studiesTime-motion studiesSpaghetti mapping
LiteratureResearch studiesAdvisory BoardMagnet Criteria
Survey ToolsNDNQIEmployee Opinion Survey
Insert CTQ tree from Med admin?
RN Knowledge / Competency
MAR is accurate
Safe Medication
Administration by RN
Right Drug / Dose is
Available
Packaging is clear and distinct
Route is available (IV,
FT)
Prescription is clear and complete
Clear P&Ps / Standard Operating Procedures
(eg 5Rs) and provided to RN
Two Patient Identifiers present
Med Prep and Supplies
RN knows when and how
to double check
Reconciliation process is
well outlined
RN follows 5Rs - according to P&P
Only standard abbreviations
used
Route prescribed is available and
appropriate for level of care
Transfer orders are up-
to-date
OrdersTranscribed accurately
Meds reconciled to pharmacy
system
Generic and trade names
are both listed
No duplicate orders
All DCd orders are
DCd
Handwriting is legible
RN aware of Pyxis /
Micromedex resources
Pharmacist readily
available if needed
RN has resource to look up drug when busy
Med prep info available (eg
crushing)
Indication for patient is clear
All given meds are
documented
Toggle markers
effectively prompt RN
Communication from MD is clear (no 'transfer with
same orders')
All verbal orders read back (or repeated
back in emergencies)
Unit stock is accurate
Med available in dose
prescribed
Nonstock drugs
delivered in timely manner
Stored so it is hard to grab
the wrong the drug
Override is available if appropriate
Adequate space and
logical geographic
flow
Area is clean and sorted to
supply all med preps
Area is a respected quiet zone
without interruptions
Supplies are well stocked
All bins, drawers,
shelves are well labeled
Workload distribution is
sufficient
Staffing is adequate and
appropriate
Armband accurate and
present
Allergies are documented on MAR / Pyxis &
accurate
Appropriate monitoring
available and applied
Essential info available (labs,
H&P, prn parameters)
Patient is compliant
Patient is well informed
Drug interactions (drug-food & drug-drug)
known
Location of drug is clear
(Pyxis, fridge, etc)
Pt's meds are not kept in
patient's room
IV pumps available and functioning when needed
Communication expectations
(checkbacks) defined
Prescription is written
whenever possible
Medication Administration P&P is known
Drug info is
automatically available
(speedbump)
Med prep area organized,
supplied, and free of distractions
RN communication (checkbacks)
performed
Orientation and training
sufficient and assessed
Patient Education
Tools updated and available RN Manager Pharmacy Physician Ward Clerk
Who Controls the process?
DefineRN Customer Requirements
Prioritize Customer Requirements
“Disgusters” “Must Haves”
“Annoyances” “Frills”
Negative Positive
Important
Less Important
KeyFocus
Some of the Identified ‘Disgusters’
– Lack of Respect• Non-collaborative environment
– Inefficient Systems• Missing meds• Delayed lab and radiology results• Duplication and rework
– Lack of adequate supplies and equipment• Hunting for equipment
Business Process Map Template
BusinessObjective Customer
KeyDriver
Value CreationStrategy
KeyProgram& Process
ProjectMetrics/Targets
Business Process Map – Dynamic Document
Data-driven project selection
NurseRetention
Key Driver Value Creation Strategies
Voice of the Customer Determines Value Creation Strategies
Competitive Compensation / Benefits
Meaningful Reward and Recognition
Efficient Work Environment
Attractive Career Development
Professional Practice
Adequate Resource Availability
Desirable Staffing and Scheduling
Efficient WorkEnvironment
Key Programs & ProcessesValue CreationStrategies
Voice of the Customer Determines Key Programs and Processes
Safe and Desirable Facilities
Supplies & Equipment
Access to Information
Efficient Workflow
Teamwork and Collaboration
Technology
Ancillary Dept Cycle Time
Efficient Work EnvironmentKey Programs & Processes
Projects (partial list)
Metrics(partial list)
Safe Facilities Ergonomic Evaluation Initiative
Workers Comp Events
Available Supplies & Equipment
5 S Nursing Station, Med Rooms
Employee Survey
Value added minutes
Efficient Workflow Med Admin Process # Interruptions during Med Pass
Teamwork Team Resource Management
Team skills rating
Safety culture survey
Technology FMEA Computer Interface Employee survey
Med errors, QVRs
Ancillary Cycle Time Radiology, Lab, Pharmacy Turn-around time
Information Access Documentation study Employee survey
% time spent documenting
Project PrioritizationBased on Numerical Rating
Impact x
8Improvement permanently removes cause(s); 100% mistake-proof; no work-arounds 8 8
7Will permanently monitor condition; partially removes cause; 90% mistake-proof; no work-arounds 7 7
6Will partially monitor condition; partially removes cause; 80% mistake-proof; 1-2 work-arounds 6 6
5Will partially monitor condition; partially removes cause; 70% mistake-proof; 2-3 work-arounds 5 5
4Will partially monitor condition; partially removes cause; 60% mistake-proof; 3-4 work-arounds 4 4
3Will partially monitor condition; 60% mistake-proof; 3-4 work-arounds 3 3
2Will permantently heighten awareness of condition; not mistake-proofed; several work-arounds 2 2
1Will temporarily heighten awareness of condition; not mistake-proofed; several work-arounds 1 1
Initial cost is moderate; some recurring expense; no capital investment
Initial cost is significant; no recurring expense; no capital investment
Initial cost is significant; large recurring expense; large capital investment
Initial cost is significant; some recurring expense; no capital investment
Initial cost is moderate; some recurring expense; small capital investment
Initial cost is significant; moderate recurring expense; moderate capital investment
Initial cost is negligible; no recurring expense; no capital investment
Initial cost is moderate; no recurring expense; no capital investment
New technology. Implementation time 6-9 mos; many timing/political/ cultural constraints
New technology. Implementation time >9 months; many timing/political/ cultural constraints
No new technology. Implementation time 3-4 months; few timing/political/ cultural constraints
No new technology. Implementation time <3 mos; moderate timing/political/ cultural constraints
No new technology. Implementation time >3mos; moderate timing/political/ cultural constraints
New technology. Implementation time 3-6 mos; moderate timing/political/ cultural constraints
No new technology. Implementation time <1 month; few timing/political/ cultural constraints
No new technology. Implementation time 1-3 months; few timing/political/ cultural constraints
Impact Score Criteria Effort Score Criteria Cost Score Criteria
Effort x CostRisk Priority Index (RPI)
D I F F I C U L T Y
I MPACT
1 2 3 4 5 6 7 8
Prioritization –Impact/Difficulty Matrix
8
7
6
5
4
3
2
1
Efficient Work Environment:Ancillary Department Cycle Time
Pharmacy
– Strategies•Implemented Fax Server
•Staffing Adjustments
– Results•Reduced ‘Fax’ to ‘Verification’ time from 82 to 40 mins
Fax to Verification Time
Frequency
8006004002000-200
120
90
60
30
0
8006004002000-200
120
90
60
30
0
aBefore After
Well After zLast
aBefore
39.66StDev 50.53N 129
Well AfterMean 81.66StDev 185.1
Mean
N 80
zLastMean 22.60StDev 31.57N 187
81.57StDev 132.4N 155
AfterMean
Histogram (with Normal Curve) of Fax to Verification Time by Series
Panel variable: Series
Before Remeasure 1
Remeasure 2 – Post-IT initiative Control
Efficient Work Environment:Ancillary Department Cycle Time
Laboratory
– Strategies• Phase 1 - Kaizen event in lab
• Phase 2 - One-piece specimen flow
Active project
– Results (expected)• Reduce lab results turn-around time
Lab Turn-around ProjectPhase 1: Kaizen Event in Lab
Results: Decreased cart stocking time by 50%
Provided additional 3 hours daily for customer service – lab assistants interacting with nurses
Efficient Work Environment:Available Supplies & Equipment,
Efficient Work EnvironmentTelemetry
– Strategies• 5S event medication room• Standardized medication administration
process
– Results• Reduced average number of interruptions
(from 3.8 to 0.7 per medication pass)• Reduced harmful events related to medication
(from 4 to 1 in 9 month period)
MedAdministrationIdeal Process
Map
RN Prompted to give med
RN interprets MAR (5Rs)
RN explains med to pt
RN washes hands
RN identifies patient
RN procures med/IV & supplies
(5Rs)
RN preps med
RN performs pre-administration assessment /
checks allergiesRN prepares to admin med
(final 5Rs)
RN gives med
RN documents
med
RN evals effects of med
RN washes hands
1. Waited in line to get meds @ 9:00
2. One med grayed at – not here, one gray ed at – in refrigerator
3. Search refrigerator
4. Went to P #1, found 1 med – MVI still missing, tapped drawer to get cubie to open
5. Two meds left to find – may be in room. Crushed meds in paper cups
6. Piston syringe in room – No date – went to supply room to get another
7. Found MVI but NO med cups - ? Refrigerator MVI
8. Searched room for fiber or med cup – on bedside table – no way to administer
9. Back to med room
10.Back to room
11.Mixed meds in cup in admin – DONE 0920
Total Time – 13 minutes
CR
28 1&2 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 1&2
LinenDocRm
MD
Doc
30 MDP #1
31
LeadOffice
32 1&2Supplies P #2 Kitchen Mg
33 1&2 34 35 36 37 38 3 4 5 6 7 8 9 10 11 1&2
29 1&2
Nur
se S
tatio
n #2
Kitc
hen
Util
ity H
all
Med Admin Real
Process Map
RN Prompted to give med
RN interprets MAR (5Rs)
RN explains med to pt
RN washes hands
RN identifies patient
RN procures med/IV & supplies
(5Rs)
RN preps med
RN performs pre-administration assessment /
checks allergiesRN prepares to admin med
(final 5Rs)
RN gives med
Phone call
Need to clarify
Call MD;Wait;Get
clarification
Order is questionable
Unexpected nsg task
Can’t find med; look in 4
places; call pharm then
find it
Wait in line
Phone call
Unexpected nsg task
Locate Missing supply
Phone call
RN documents
med
RN evals
effects of med
RN washes hands
Grossmont - Delivered Doses by Time of DayJune 2004
0100020003000400050006000700080009000
100001100012000130001400015000160001700018000190002000021000220002300024000
Time Dose Delivered
# D
os
es
De
liv
ere
d
N=114,755 doses* Only units on Clinicomp represented in data* Excludes PRN and IV meds
When are the majority of meds given?
09 & 21What else is
happening at thosetimes?
Balance the Distribution of WorkAdministered Meds by Time of Day
24 06 09 12 17 21
Number of ‘Unnecessary’ Interruptions During Med Pass
p<0.000 Mann-Whitney test
*No statistical difference in number or route of meds given
Num
ber
of 'U
nnece
ssary
' In
terr
uptions
Re-MeasureBaseline
5
4
3
2
1
0
95% CI for the Mean
Would you interrupt these critical activities?
Sign Placed on Medication Room DoorShows Respect for RN
Frontline RNs empowered to improve Medication Room efficiency
Before After
Better visualization of supplies = less searching
Visual Chaos
Visual Management Control
Timely Hiring Process Project:Decrease applicant-to-hire cycle time
– Strategies (active project)• Same-day hire program
• Create pull in hiring process
– Results (expected)• Goal - Reduce cycle time from 22 to 12 days
• Goal - Increase conversion rate of qualified applicants (data collection in process)
Business Objective Metrics - The Big ‘Ys’
Business Objective Metric ‘Y’Workforce Stability Tenure, turnover, vacancy
Registry and traveler RN use
Nurse Retention Turnover, exit interview trends
Nurse Satisfaction
Employee Opinion Survey
NDNQI - Natl Dbase RN Qual Indicators
RN mgr effectiveness score
Workload satisfaction
Nurse Recruitment # Hires, vacancy
Conversion rate of qualified applicants
Conversion rate of externs
Nurse Production # RNs produced per year in San Diego
# Qualified applicants turned away
Open faculty positions in local RN schools
RN Turnover TrendsAnnual Turnover by Job Class
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Management /Supervisor
Technician /Specialist
Registered Nurse
Natural Class/Fiscal Year
Perc
en
t
FY 2000FY 2001FY 2002FY 2003FY2004 FY2005 YTD CHA Best in Class (25th Percentile)Benchmark: CHA Average
Good
Employee Satisfaction
Trends
Employee Satisfaction Rankings for Key Questions
0.00 1.00 2.00 3.00 4.00 5.00
Quality of care is a high priority ofSharp HealthCare
Sharp HealthCare is a leader inproviding high-quality services.
I believe my w ork contributes tothe success of Sharp HealthCare.
I am proud to be an employee ofSharp HealthCare.
Overall, I feel that Sharpmanagement sees employees as
a priority.
My department provides excellentcustomer service.
Overall, I am satisf ied w ith myemployment w ith Sharp.
Score (0-5)
2001200220032004
GoodOverall Satisfaction Benchmark - Hay GroupE-perceptyx Benchmark
Worker’s Compensation
System Report Card GoalWorker's Compensation Claims to Insurance
Carrier per 1,000 FTEs
-4080
120160200240280
Calendar Year
Cla
ims p
er
1,0
00
em
plo
yees
Claims reported to Insurance CarrierGoal Good
Workforce VacancyCalendar Year 2004 Workforce Vacancy
0%5%
10%15%20%25%30%35%40%45%50%
Specific Positions/SHC Overall
Perc
en
t
CHA BENCHMARK
Good
• Develop Business Process Map
• Understand the Nurse VOC
• Focus on High Impact Projects
Maximizing Nurse Recruitment and Retention Strategies with
Lean Six SigmaSummary