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  • PROVIDING COST EFFECTIVE QUALITY CARE: A TOYOTA LEAN NURSE-DRIVEN QUALITY IMPROVEMENT PROGRAM

    by

    Vanessa Behrend

    BS in Business Administration, American University, 2007

    Submitted to the Graduate Faculty of

    Graduate School of Public Health in partial fulfillment

    of the requirements for the degree of

    Master of Public Health

    University of Pittsburgh

    2013

  • UNIVERSITY OF PITTSBURGH

    GRADUATESCHOOL OF PUBLIC HEALTH

    This thesis was presented

    by

    Vanessa Behrend

    It was defended on

    April 2, 2013

    and approved by

    Thesis Advisor: Beth Nolan, PhD

    Assistant Professor Behavioral and Community Health Sciences

    Graduate School of Public Health University of Pittsburgh

    Committee Member: Christopher Keane, ScD

    Assistant Professor Behavioral and Community Health Sciences

    Graduate School of Public Health University of Pittsburgh

    Committee Member: Nicholas Castle, PhD

    Professor Health Policy and Management

    Graduate School of Public Health University of Pittsburgh

    ii

  • Copyright by Vanessa Behrend

    2013

    iii

  • ABSTRACT

    Healthcare quality is a priority in this country. Interventions addressing this problem have been

    done frequently leading to entire hospital departments being dedicated to quality. Nurses

    comprise the largest sect in healthcare. They have direct access to patient safety. They also have

    firsthand knowledge of the processes that drive quality. Nurses have been underutilized as

    quality drivers in health care. One solution was a nurse-driven quality improvement program,

    called Providing Cost Effective Quality Care, that used Toyota Lean as its model for quality

    improvement. The purpose of this thesis was to determine if the programs successes and deficits

    could be identified comprehensively within the context of a theoretical implementation

    framework.

    The objectives of the program were to support ongoing quality improvement initiatives,

    while increasing nurses access to continuing education, all to improve the quality of patient

    care. Two cohorts of nurses attended the training and implemented quality improvement projects.

    Changes were made between cohorts to increase program effectiveness. Results of the program

    showed that nurses should be selected based on their knowledge of and dedication to the project

    at hand, that the training program was an effective way to introduce Lean concepts but should

    allow for team project time, that the use of a coach was an integral component for project

    effectiveness, and that a lack of administrative support stunted project uptake and

    implementation. The findings in this thesis demonstrate that the successes and deficits of the

    Beth Nolan, PhD

    PROVIDING COST EFFECTIVE QUALITY CARE: A TOYOTA LEAN NURSE-DRIVEN QUALITY IMPROVEMENT PROGRAM

    Vanessa Behrend, MPH

    University of Pittsburgh, 2013

    iv

  • Providing Cost Effective Quality Care program could be described within the implementation

    framework. Additional research is needed to use the theoretical implementation framework to

    drive the program planning and a long-term outcomes evaluation is needed to determine

    effectiveness in improving patient safety.

    This program has public health significance because it makes use of nurses, who are on

    the frontline of patient care. The nurses are in the position to support improving patient safety

    and quality of healthcare, thereby reducing unnecessary adverse health events. This, in turn,

    reduces the burden of preventable diseases.

    v

  • TABLE OF CONTENTS

    PREFACE .................................................................................................................................... XI

    1.0 INTRODUCTION ........................................................................................................ 1

    2.0 BACKGROUND .......................................................................................................... 3

    2.1 QUALITY IMPROVEMENT INITIATIVES IN HEALTHCARE ............... 3

    2.2 FIXSEN FRAMEWORK .................................................................................... 5

    2.3 NURSE-LED INITIATIVES .............................................................................. 7

    2.3.1 Transforming Care at the Bedside ................................................................. 8

    2.3.2 Integrated Nurse Leadership Program ....................................................... 10

    2.3.3 Clinical Scene Investigator Academy .......................................................... 11

    2.4 TOYOTA LEAN ................................................................................................ 13

    2.4.1 Define Value from a Customers Standpoint .............................................. 14

    2.4.2 Map the Value Stream .................................................................................. 15

    2.4.3 Create Flow .................................................................................................... 16

    2.4.4 Establish Pull.................................................................................................. 17

    2.4.5 Seek Perfection ............................................................................................... 17

    2.4.6 Lean Tools ...................................................................................................... 18

    3.0 METHODS ................................................................................................................. 19

    3.1 PARTICIPANTS ............................................................................................... 20

    vi

  • 3.1.1 Nurses ............................................................................................................. 20

    3.2 PROCEDURES .................................................................................................. 20

    3.2.1 Selection .......................................................................................................... 21

    3.2.1.1 Program ............................................................................................... 21

    3.2.1.2 Nurses ................................................................................................... 21

    3.2.2 Training .......................................................................................................... 21

    3.2.2.1 Nursing Perspective and Quality Improvement ............................... 22

    3.2.2.2 Toyota Lean ......................................................................................... 23

    3.2.2.3 Teamwork and Conflict Management .............................................. 24

    3.2.3 Coaching and Consultation........................................................................... 24

    3.2.4 Staff Evaluation ............................................................................................. 25

    3.2.5 Program Evaluation ...................................................................................... 25

    3.2.6 Facilitative Administrative Supports ........................................................... 25

    3.2.7 Systems Interventions.................................................................................... 26

    3.3 MEASURES ....................................................................................................... 26

    3.3.1 Training Evaluation Survey ......................................................................... 26

    3.3.2 Five-Month Follow-up Survey ...................................................................... 27

    3.3.3 Qualitative and Quantitative Assessments of Team Projects and

    Sustainability .............................................................................................................. 27

    3.4 ANALYSIS ......................................................................................................... 28

    4.0 RESULTS ................................................................................................................... 29

    4.1 SELECTION ...................................................................................................... 29

    4.2 TRAINING ......................................................................................................... 30

    vii

  • 4.2.1 Perspective of Nursing in Quality ................................................................ 31

    4.2.2 Toyota Lean.................................................................................................... 32

    4.2.3 Teamwork and Systems Management. ........................................................ 34

    4.3 COACHING AND CONSULTATION ............................................................ 35

    4.3.1 Case Study A: Green Mile ............................................................................ 36

    4.3.2 Case Study B: Handoff .................................................................................. 37

    4.4 STAFF EVALUATION..................................................................................... 39

    4.5 PROGRAM EVALUATION ............................................................................ 41

    4.5.1 Case Study A: Green Mile ............................................................................ 41

    4.5.2 Case Study B:

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