3. Leadership. Building staff capabilities for the future requires uncovering leaders in three major ways:

• Team Building. Collaborating at the unit level allows staff to develop processes together so that changes stick and outside experts are not needed to monitor whether change is happening.

• Professional Development. Developing leadership, presentation, and quantitative skills is a critical way to build a culture of leadership and meet the Magnet standards.

• Personal Development. Reconnecting to mission brings urgency and meaning back to the work place.

4. Executive Support means guiding and supporting staff to build capability throughout the organization. Frequently this means relinquishing some control to the frontline.

REAWAKEN YOUR NURSING MISSIONLean 3.0: Putting the People Back Into Lean for Lasting TransformationLizzie Cunningham, Barbara Kohnen Adriance CareOregon, Portland, OR

ProblemHospitals pay large sums of money to private consultants to implement LEAN because …

• Cost of care is going up and administrators think Lean will solve their problems

• Patient outcomes and satisfaction are not getting better

• Workforce doesn’t have the skills to improve on a continuous basis

…But often these programs don’t work. Typically they are:

• Top down, driven by leadership, often in an inflexible way

• Tool driven

• Alienating, by using language that distances caregivers from Lean experts

• Disconnected from real human behavior and motivation

Aim• To adapt Lean methodologies to different unit and specialty cultures within several hospital organizations

— Starting with the current processes, language, attitudes and values of the people working there

• To systematically build a culture combining the old and the new in a lasting and sustainable way

Key Measures• Outcomes

• Satisfaction/HCAHPS scores

• Morale

• Leadership

Methods• Pilot two adaptive Lean-based methodologies that frontline workers understand, in two acute care settings:

Releasing Time to Care™ (RT2C) and The Productive Operating Theater ™ (TPOT).

Strategy for Change1. Participation. Guided by the principle of democratic participation, team leads gather input and let groups vote on the changes they want, thereby guaranteeing that everyone’s voice is heard.

2. Accountability and local decision making. Using the principle that those closest to the work should control the work and take responsibility for it, front line staff develop the vision for the team, the measures for improvement, tests, evaluations, and new changes.

By working on all major nursing processes, front line staff interact with other stakeholders in the healthcare organization, building shared goals and eventually system wide transformation.

Reduce Nurse Interruptions at Mealtimes Legacy Good Samaritan Hospital, Portland, Oregon.

• Unit hostesses interrupt nurses to clarify dietary status before passing food tray to patient

• Interruption times average 13.5 minutes per meal (cost $10.80 per meal in nursing time)

• Working through RT2C process staff implemented a Tray Pass sign. Interruption times per meal are now 0 to 1.5 minutes, a savings of $11,800 in nursing time per year.

Measurement of ImprovementReducing incidence of Harm Events — Patient Falls

Providence Portland Medical CenterPatient falls rate exceeded acceptable levels (Benchmark: NDNQI 50th percentile.) Initial RT2C work focused on measures to reduce falls. Since Q3 2010 this unit has sustained a 30% reduction in its falls rate.

Nurse Response to Answering Patient Call Lights Providence Portland Medical Center

Unit ranked at 20% for response to patient call lights according to HCAHPS data. Targeted improvement efforts using RT2C have led to a significant improvement above the 90% mark.

“Our Chief Nurse Executive sees RT2C as an opportunity to give nurses the tools to implement sustainable change. The manager of the showcase unit saw this as an opportunity to develop informal leaders at the bedside. Through mentorship, staff nurses have progressed into trainers, facilitators, and leaders on the unit. We are even seeing previously overlooked nurse leaders emerge and shine within this program, thereby developing and creating ownership and sustainability of RT2C.”

Staff Nurse, Providence Portland Medical Center

“RT2C is making sure everyone has a voice by giving them a vote. Having a vote is leading to more ownership.”

Director, Tuality Healthcare

Well Organized WorkplaceStaff made changes to unit envionment to ensure it supported rather than hindered their work, enabling staff to refocus time on patient centered activities.

Samples of Supplies Savings — Providence Portland Medical Center Using the well organized work place module, the team reorganized their supply storage to inprove their workflow.

OHSU – Example of Savings Using 5S Process In Supplies Room

Time Savings On One Unit For Four Well Organized Workplace Improvements

Translating Corporate Goals into Action – Hourly Rounding — Tuatilty Healthcare

• Previous management led project to implement best practice initiative of hourly rounding only sustained for a few weeks

• New initiative to implement hourly rounding using the RT2C approach has been sustained

• Team measured reasons for call lights to understand if new process was working and where they may need to focus their efforts to make further improvements.

The Productive Operating Theater — Operating Room Turnovers Legacy Good Samaritan

Team set a goal for the OR team to take 30 minutes or less to turn over the OR between cases. Team implemented color zoning for OR preparation between cases. Also provided clarity on the duties associated with roles and zones in the OR.

Patient Preparation For Surgery – improvements using RT2C Methodology

• Completion of pre-assessment 72 hours pre surgery. Team now consistently performing between 84% and 96% - previously 65% to 85%

• Patient ready 30 minutes prior to surgery. Team now consistently performing between 80% and 97% - previously between 40% to 80%

SummaryLean-based methodologies with culturally specific engagement strategies create the environment for hospitals to develop sustainable improvements that benefit the entire organization or system.

For information contact: cunninghaml@careoregon.org

Unit RT2C project Time saved in hours

Time saved in distance Money saved

7N Reorganization of telemetry equipment

2.2 6.5 $6,000 in supplies $2,720 in time

5GUse of snap gowns versus tie gowns in patients admitted from the ED

197 $6,600 in supplies Approximately $9,000 in time

CICU Reorganization of telemetry equipment

128 385 $7,800 in time $12,000 in equipment

Time New water bottle location

New location for bladder

scanner

All RNs on shift issued with PCA

key

Vitals machines located in each

patient room Totals

Day 4.3 minutes 4.5 minutes 30.4 minutes 50 minutes 89.2 minutes

Week 30.1 minutes 31.5 minutes 212.8 minutes 350 minutes 624.4 minutes

Month 2 hours 2.2 hours 14.2 hours 23.3 hours 41.7 hours

Year 24 hours 26 hours 170 hours 280 hours 500 hours

John D. Dingell VA Medical Center, Detroit MI

“I see other staff have ideas that are just as good as mine. I’m more open to getting everyone’s suggestions.”

Lead Nurse, Tuality Healthcare

“RT2C opens up staff engagement & pushes decisions down to the bedside, having the experts make decisions about how their work changes and how we spend more time with patients.”

Pam Steinke, Chief Nurse Executive, St. Charles Health System

“I wanted to get involved with Releasing Time to Care™ because I knew we needed some help. Despite having an incredible team of smart, dedicated people with high standards, we were struggling to demonstrate outcomes. As we’ve moved forward with Releasing time to care™, I can see how it has helped us all think differently. We’ve become intolerant to wasted steps and inefficient processes that don’t add value for our patients. It’s exciting to see the support that direct care staff are getting to implement ideas that make sense to their workflow and eliminate some of the ones that don’t...”

Staff Nurse, Providence Portland Medical Center

Candice Hoag, Staff Nurse, Providence Portland Medical Center

“Since my involvement with RT2C began I have really noticed a change in my personal work flow at the bedside with my patients. I have noticed that I am able to analyze what is wrong with my work flow and my work processes and environment, and really identify the work arounds and waste that we have in our current system.”

“How many of you have ever heard your nurse peers complain about another department? RT2C gives us all the need and the ability to work directly with other departments that are involved in the changes we decide to make on the unit. We initiate and own the process of creating the change that needs to occur by contacting the other departments ourselves, setting up meetings on the unit and working together to make the changes happen. The Manager’s role is supportive rather than operational. This results in all of us now knowing the people in other departments on a first name basis and learning how the other departments work. The other departments then feel excited and empowered to work with the direct care staff because they know they’re actually making a difference for the patients. We all become one team. Along with other departments we also have other groups trying to initiate change in the hospital and have been able to help inform and breathe new life into their work using RT2C tools...”

Staff Nurse, Providence Portland Medical Center

“We have a chance to care the proper way, the right way, for someone who is somebody’s loved one – it gives us a voice with management enabling us to do what we need to do.”

Selena Smith, Staff Nurse, St. Charles Health System

Sacred HeartMedical CenterPeaceHealth

Releasing Time to Care-ProductiveWard returned this amount worth of unused Pyxis suplies back into theOHSU sustem !!

WOW !!!

$11,634.63Where we are now-WOW Module

Bathroom Pain Positioning IV/Alarms Misc Total

Number of Call Lights Pre and Post Hourly Rounding

60

50

40

30

20

10

0

Num

ber o

f Cal

l Lig

hts

May 2013 Pre Shift total

Oct 2013 Post Shift total

May June July August September

Turnovers May - September 2013 60

40

20

0

Min

utes

Wheels Out to Mop OutMop Out to OR ReadyOR Ready to Wheels InGoal = 30 Minutes or Less

5R Response to Call Light National Ranking100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12

28%

65%

76% 76%

92% 98%

2%

20%

Goal = 90+ percentile

4%

RT2C

Initi

tate

d

5G Quarterly Fall Rate6

5

4

3

2

1

0

RT2C

Initi

tate

d

Perc

ent F

alls

/100

0 Pa

tient

Day

s

Goal = </= 50% percentile of NDNQI on like units

Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012Quarter and Year

4.6

5.2

4.4

2.7

3.4

3.9

0

3.23.3

1.9