Intent of Slide:To explain what objective of the project was and provide context around same.Speakers Notes:.
Intent of Slide:To visually show participants the reason why we made changesSpeakers Notes: Cardiac surgeries compromise the largest number of surgical admissions to PICU; almost doubling the next highest post-operative population of neurosurgery We had tried to make improvements before and had failed as we created people, not process dependent systems But instead of talking about this further we felt it was best to heed the saying, “a picture is worth a thousand words”.
Intent of Slide:To further describe the reason for the change.Speakers Notes: What struck you about the handover process? Include the fact that the team members are siloed; no collective reporting; a lot of “doing” Historically cardiac patients were always the sickest. However, as our technology and care improved our perception didn’t change and we still expected the same level of instability. The points on the slide capture the chaotic nature of the handover process. It was not uncommon for the OR team to leave and the PICU staff to complain that the OR team didn’t tell them anything. Although we didn’t realize it at the time because our process was chaotic we missed information or heard misinformation. This lead to delays in care. As mentioned prior to our video, we had tried to improve the cardiac handover more than once but every time we experienced eventual failure due to:Ideas being person dependent not process dependentNothing in writing about process and when key players weren’t there no one knew what to do. This meant we had no standard work developed and/or support tools As one would expect, due to these contributing factors we returned to our old ways and attempts to regroup did not succeed due to competing improvement priorities; scheduling difficulties and quite frankly a logical improvement approach. Cardiac handover was identified as a gap in value stream we did with imPROVE. As a result, we began planning for our fourth rapid process improvement workshop with a focus on improving cardiac handovers. But first we had to figure out how we were going to do it and who should be involved.
Intent of Slide:To communicate defects identified during video recording observationsSpeakers Notes:We identified two team leads and began to observe the handover process. The handover was defined as “the exchange of patient information between the cardiac OR & the PICU team” and included the perfusionist’s visit. BCCH Handover Defects:6 Cases video recorded and analyzed for defects in process. Defects were identified as practices which hindered the team’s ability to deliver or hear report which could potentially or actually contribute to missed or misinformation or considered ineffective. These became our 7 defects. We calculated the defect rate per handover by taking the total number of times that defect occurred in all 6 handovers and divided them by 6 to come up with a way to compare pre-kaizen, RPIW week and post-kaizen measures.Role crossover – duplication of tasks, unclear who is responsible for what (e.g., OR RN reports on info already given, Anaesthesia Assist role unclear)Tangled equipment or lines – monitor cables tangles amongst chest tubes, foley, pacer wires & vent tubingsSupplies not where needed – needing to leave bedside or work space to retrieve needed equipmentIncreased unexplained staff - “lookiloos” who stand around and obstruct movement or add to chaos by “helping” without a request to do so Waiting for people – waiting for ICU physician(s) to begin handoverDeviations from “norm”- care or processes that did not follow adopted practice standards or were considered to be unsafe (e.g., connecting CT without looking at suction or drainage) “Presence” at handover – listening while busy performing tasks of admissions
Intent of Slide:To highlight the importance of selecting a good team.Speakers Notes: The team we chose had to include representatives from both silos (PICU & OR) in order to succeed. We knew in order to work we really needed to be positioned in the Gemba to facilitate idea generating and testing with staff. So we forgo a big wall display for cramped quarters and full access to the unit, OR and staff. Because the PICU and the OR are beside each other it made for easy access for both teams to participate and test in their areas. This broad team also was able to highlight the value of each role along with professional accountability. For example, one of the original ideas was to eliminate the OR nurse’s post-op report because PICU believed they didn’t say much that hadn’t already been said and everyone was too busy to listen. In actuality, they are required to do a report and this information helped us in dividing up who should be reporting on what information post-operatively. The physician and surgeons were utilized as idea generators and testers when available. This worked very well as we were in the unit and they could participate when able.
Intent of Slide: Describe team’s goals for weekSpeakers Notes: We set our targets based upon the prep work findings which included the observations and interviews with others who had tried this. For the first target we used past cardiac OR project work, Great Ormond’s Street handover protocol & participants ongoing input to define the characteristics and to develop standard work. We came up with two phases of care (pre-transfer and transfer). In the pre-transfer standard work the following was developed: PICU bed preparationPICU bedspot set-upPerfusionist’s report & confirmation of PICU admitting teamThe following was developed for the transfer standard work:Transfer process (moving patient from OR into PICU)Technology transfer process (moving to PICU equipment from OR portable monitor, hand ventilation, no chest tube suction and infusions)Handover process (handover of information, proposed plan of care, handover of care to PICU team)
Intent of Slide:To outline the activities for the week.Speakers Notes: We designed our work around the established RPIW process. This chart outlines the various activities we conducted to meet our targets over our 5 day period. [Barb you can pick out what you feel is important to highlight]
Intent of Slide: To show measured outcomesSpeakers Notes: In this graph we can see the results for the RPIW week as compared to the pre-kaizen week. The rate is average per handover. In the RPIW week there was one occurrence of the tangled equipment lines and three of supplies not where needed.
Intent of Slide:To show the actual changeSpeakers Notes: Measurement is important and enables us to show our changes over time but again... A picture says a thousand words, or in this case, a picture says as much or more than a graph.
Intent of Slide: To show measured outcomesSpeakers Notes: In the summer of 2011 we conducted a research evaluation of the handover process looking for sustainment of results. We reviewed 19 cardiac OR to PICU handovers.In this graph we can see the results comparison of pre, kaizen week and 2 years post-kaizen. The rate is average per handover. It is important to note that the presence at handover defect was really 2 nurses who went into the patient care area and started doing tasks prior to handover completed. These nurses are notorious for not being able to keep hands off. For 19 handovers this occurred 3 times. Perhaps one of our biggest test was when we hired a new cardiothoracic surgeon to BC Children’s. Without skipping a beat the PICU and Cardiac OR staff showed him how we do it here and why it worked. This surgeon, one of last years BCPSQC award winners, has dramatically improved the outcome for cardiac surgical patients and completely altered how we care for these children but our handover process was 100% adopted by him.
Intent of Slide: To describe spread approachSpeakers Notes: As with the previous attempts for establishing a cardiac OR to PICU handover there have been attempts to spread the successes of this initiative to other surgical teams. There have been two false starts on this project where other projects took priority or it was difficult to secure a designated leader. As of this winter there have been commitments from both the surgical services and PICU quality teams to make this a priority. The surgical council is reviewing the process and a working group has been established.
Intent of Slide: To highlight points of interest to avoid pitfallsSpeakers Notes:A pull for change is easier to make happen: This was a change people wanted. The PICU wants it standardized for all OR admissions.Right people on the team: In addition to having the key stakeholders represented you should include your silent leaders who have the ability to make or break a change through their influence in the workplace. We had those people on our team as both team members or as experts. In addition we insured that day and night shift in PICU and OR were involved in decisions.Value of senior leader on team: Having Barb on the team was valuable for so many reasons. She brought the exec closer to the bedside which was great for nursing, RT, NUC, MDs to spend time with her and get to know her. She asked tough questions and challenged us to think beyond the “just because that’s the way we do it” mentality. We learned together.Create a process dependent protocol; not person dependent: Previous attempts had failed. We were careful to create easily accessible and workable tools for guiding practice and explaining process.Don’t reinvent the wheel: We have wasted so much time trying to invent something new instead of just adapting the work other have done and have made available for us. As we have learned throughout our improvement education “Share generously and steal shamelessly”.Live quality improvement cycle; be responsive: We made a commitment to check in with staff and follow-up routinely. We had weekly then monthly then quarterly observations and formal check-ins. We also adapted our process when practices changed.
E8 Suzanne Fox - Lean in BC: Local Stories & Interactive Discussion with Physicians and Operational Leaders - Part 1
Quality Forum 2013BC Provincial Lean NetworkLean in BC: Local Stories &Interactive Discussion withPhysicians and OperationalLeaders
BC Provincial Lean Network: Background• Lean Network established in January 2010 • Provides expert advice to the Ministry on the Lean KRA and deliverables • Coordinates Lean activities • Champions the use of Lean in HAs • Partners with the MOH to ensure KRA deliverables are met
BC Provincial Lean Network Network Members• Rena van der Wal (VCH)• Jennifer MacKenzie (PHSA)• Erin McGarvey (IH)• Mélie De Champlain (VIHA)• Bonnie Urquhart (NH)• Eric Demaere (FH)• Emmy Beaton, Frances Bryan and Kevin Samra (MOH)
BC Provincial Lean Network Objectives• To promote the reduction of waste and increase value (efficiency and effectiveness) in the health care sector through the use of Lean methods.• To create ways to share best practices, tools and promote collaboration across health authorities.• To develop and share best practices in Lean education and training materials between the health authorities• To foster an environment receptive to innovation, change and ongoing improvement.• To document, quantify and monitor the gains of Lean initiatives.• To identify best practices (Lean initiatives) that should be implemented system wide.• To integrate Lean thinking into new capital projects and planning.
Provincial Lean Network Co-Chairs: Kevin Samra (MOH) & Rena van der Wal (VCH)BC Education BC Metrics BC Community of BC FacilitiesWorking Group Working Group Practice Working Working Group Group Rena van der Wal Chair: Marg Chair: Kate YangSeppelt (PHSA) (VCH) Eric Demaere (FH) (VCH)
BC Provincial Lean Network Session Today• Provide an opportunity to share our best practices and our learnings – What is working – what is an opportunity for improvement
BC Provincial Lean Network Session Today• Hear the presentations – it is not so much about the specific area of focus - listen for the themes – Successes – Challenges – Are they similar or different than yours• Be prepared to share your learning and ask questions• Let’s talk about what you can take back to your practice on Monday• What can the BC Provincial Networks do to support your work?
Lean in BC: Local Stories & InteractiveDiscussion with Physicians andOperational Leaders – Part 1:Improving Quality for Cardiac DeviceImplantation(Session E8)Minnie Downey, Program Director, Cardiac ProgramShahzad Karim, Medical Director, Cardiac Surgery
Objective• Cardiac and Surgical Services implemented a regional Implantable Cardiac Electrical Devices (ICED) program to: – improve patient access to services, – consolidate implant sites, – enhance efficiency of scheduling device implants and replacement, and – standardize and integrate pre and post procedure care in accordance with evidence informed practices.
Background• Patient dies waiting for a pacemaker,• Fasting for >3 days waiting for implant,• Implant cases cancelled/delayed due to inconsistent physician availability,• Patients inappropriately prepared,• ISSUE: – Capacity for 900 cases, actual 1400, – Budget for 1000 implants, actual 1400, – Inconsistent processes, and fragmentation, – Inconsistent physician availability.
Current State – pre change• Pacemakers implanted at RCH, ERH, BH and SMH, ICD/CRTs implanted at RCH,• SMH and BH worked independently,• All implants had an anethetist present for the procedure,• IP frequently waited 10 days for implants and were often added to OHS slate, or implanted during emergency OR time, and• Pre and post orders were site based and not coordinated across the region.
SolutionConsolidation from four site model (RCH, ERH, SMH, BH) to two regional sites (RCH, JPOCSC),Standardization of clinical practice tools, processes, inventory management, patient transfers, centralized intake,Integration of Intra-Procedure care implant team, including the use of an AA for preselected cases.
Results• Reduced duplications and redundancies,• Improved patient access – PPM wait list reduced from 110 to 40, ICDs from 30 to 3,• Pacemakers are performed 5 days a week, ICD CRTs weekly,• PPM IP implants within 72 hours and OPs 6 weeks – meeting or exceeding national stds,• No cancelled days due to resource availability,
Next Steps/Sustaining the Gains• Comprehensive evaluation in progress,• Moving from project to operations,• ICED Phase 2 planning in progress: – Post implant follow –up, – MUSE and PaceArt software integration, – Remote monitoring, – Integration of EOL care and ICD management,• Continuous Quality Improvement• Share learnings internally and externally,
Lessons Learned• Engagement with stakeholders early,• Cast the ‘net’ wide,• Develop the change in collaboration with team members,• Prepare for the unexpected,• It is a lot of work – but it is worth it,• Effective communication,• Plan, Plan, Plan.
Lean in BC: Local Stories & InteractiveDiscussion with Physicians andOperational Leaders – Part 1:The Patient’s Journey Within theContinuum of Care: The New NanaimoEmergency Department(Session E8) Drew Digney, Executive Medical Direct, Site Chief, Nanaimo Regional Hospital Suzanne Fox, Director, Emergency Services & Trauma Care, Nanaimo Regional Hospital
Objective• Opening New Emergency Department• Electronic Health Record• New geography
Background• 54,000 pts in small space 3x the size• Vision development• Visionary Team• Engagement of team• LEAN – value stream mapping
Current State• Integration Change in staffing models Developed new patient flow (PES) Electronic methods Communication requirements Changed materials management
Solution• Employee engagement/champions• Vision• Team approach established despite the new ED• Implementation is key to success• Barriers were identified when the focus was not on the patient/clinician interaction
Results• A Place Where People Want to Work• MHAS – right patient, right place, right clinician• Better tracking, documentation and communication• Legible clinical documentation to community GPs• Improved communication• Eliminated need for clinicians to deal with stocking
Next Steps/Sustaining the Gains• Visioning session• Continued focus on patient/clinician interaction• Sustainability of current solutions prior to new initiatives• Revisit LEAN value stream maps
Lean in BC: Local Stories & InteractiveDiscussion with Physicians andOperational Leaders – Part 1:Improving Post-Renal Transplant services(Session E8) Clare Bannon, Clinical Nurse Leader, Renal Transplant Gary Nussbaumer, Nephrologist Tom Tautorus, Director of Quality
Improving Patient SafetyRenal Transplant Clinic• What is the problem• What was the approach• What is the solution
The Problem• Exceptional Distribution Renal Transplants – Health Canada Regulations – Informed Consent • Patients at increased risk of infectious disease transmission – Inconsistent Communication • Organ Retrieval • Different Health Care providers involved • How is peri-transplant information communicated to post transplant team?
Current State• No clear or systemic process to ensure appropriate follow-up occurred.• Communication/Documentation – Donor procurement – in-patient chart – post transplant clinic – regional transplant center• Form was not 3-hole punched
Approach• LEAN process used to document current state, identify problems, propose and implement solutions
Solution• Standard Operating Procedure was developed and a process implemented• Stakeholders involved – Pre-transplant Clinical Nurse Leader, BC Transplant Organ Donation and Hospital Development (CDHD) Coordinator, BC Transplant Quality Assurance specialist, in-patient clinical leaders, post transplant care team, Infectious Disease leaders at BC Centre for Disease Control and SPH renal medical director
Solution• Created a process that supports transfer of all pertinent information – Pre, peri, and post transplant areas (including regional clinics)
Exceptional Kidney Distribution Process Additional Current Process Need to determine Information Exceptional Kidney Distribution Process Patient dischargedKidney Donation Donor Evaluation Risk identified and Organ offered to Recipient Recipient arrives Kidney in cooler Transplant Recipient goes to day #4 and chart Non-standardized Organ accepted Identified (MHSQ) documented nephrologist identified at hospital with forms to OR occurs ward to Medical follow-up Records Transplant QA reviews ED Risks identified Recipient informed ABO and virology If risk, QA faxes surgeon/physician form for disease during retrieval of ED results sent to 6B follow-up form signs part B transmission Pink and - ODHD/BCTS send preliminary culture RPR not available Could require goldenrod forms reports and final faxed cover sheet with STAT more tests go with cooler to recipient name and donor ID OR - ODHD always pages nephrologist on call if positive results ED form part A (white) goes to Pink form surgeon Where do faxes donor chart. signs part B and go? Yellow copy to QA returns to BCT - recipient chart (BCT) - doctor’s file Goldenrod goes to chart
Solution• Safety Checks Established – BC Transplant faxes ED form to Post-Transplant as a cross-check to ensure no cases are missed. – If patient transfers to another clinic, the ED status is now included on the transfer form – Yearly audit done for all patients to ensure screening bloodwork has been completed
Results/ Expected ResultsExpected results are that 100% of patients will have appropriate follow up in the post transplant period at 4, & 8 weeks, 6 months and 1 year
Acknowledgements Clare Bannon Jennifer Chow Amable Cruz Camille Rozon Tom Tautorus Michele Trask• With the support of the Entire Kidney Transplant Team
Lean in BC: Local Stories & InteractiveDiscussion with Physicians andOperational Leaders – Part 1:Leading the Transfer of Care for CardiacPatients from Cardiac OR to Pediatric IntensiveCare Unit(Session E9)Tracie Northway, Strategic Project Manager, BC Children’s & Sunny Hill Health CentreBarb Fitzsimmons, Senior VP Patient Care Services, BC Children’s Hospital & Sunny Hill Health Centre
Objective• The aim of this initiative was to streamline & standardize a safe admission and handover process of cardiac patients from the Operating Room to the Paediatric Intensive Care Unit.
Background• Historically, post-op cardiac surgery patients unstable• Identified need• Largest post-op group• Cluster/flock care• Chaos• No clear communication• Missed critical information• Delays in care http://img69.imageshack.us/img69/4634/chaosfieldhp0.jpg• Previous improvement attempts had failed
Current State Cardiac OR to PICU Handover of Care: Pre-Kaizen Average Defects per Handover (6 Handovers) 4.5 4.2 4.0 3.5 Average Defects/Handover 3.0 2.8 2.5 2.0 1.5 1.5 1.5 1.3 1.2 1.0 0.7 0.5 0.0 Role crossover Tangled Supplies not where Increased Waiting for people Deviations from "Presence" at equipment/lines needed unexplained staff "norm" handover Defect Category (n=# of occurences over 6 handovers)
SolutionSet and met 4 targets: 1. Determine characteristics of a safe patient handover from OR4 to PICU 2. Define standard work (process, roles and responsibilities) for a safe patient handover 3. Develop tools to guide & support standard work 4. Test standard work tools
Solution Activity Day 1 Day 2 Day 3 Day 4 Day 5Orientation to Lean principles Team goal setting for the week Define “standard work” for Cardiac OR to PICU safe handover of care Development of Handover Tool Bed Set-up (crib) defined, prototyped & tested on admission Protocol for handover drafted Education for OR #4 Team and PICU staff admitting CVS Patient Digital recording of admission Debriefing with OR & PICU staff about admission Review of debriefing notes Areas for improvement discussed Strategies brainstormed Handover Tool (Checklist) revised & tested Protocol for handover revised & tested Admission recording reviewed, standard work documented & defects counted Daily “report out” to Sensei Iwata “Stamping” of project work by Sensei Iwata Practice for “Final Report Out” Team “Final Report Out” to Sensei Iwata, other teams, sponsors and administration Creation of sustainment plan Ongoing
Results of Kaizen Cardiac OR to PICU Handover of Care: Comparison of Pre-Kaizen to RPIW Average Defects per Handover 4.5 4.2 4.0 3.5Average Defects/Handover 3.0 2.8 Pre Kaizen (6 Handovers) 2.5 Kaizen Wk (3 2.0 Handovers) 1.5 1.5 1.5 1.3 1.2 1.0 1.0 0.7 0.5 0.3 0.0 0.0 0.0 0.0 0.0 0.0
Results of Kaizen (2 Years Post) Cardiac OR to PICU Handover of Care: Comparison of Pre-Kaizen to RPIW to 2 Years Post Kaizen 4.5 4.2 4.0Average Defects per Handover 3.5 3.0 2.8 2.5 2.0 1.5 1.5 1.5 1.3 1.2 1.0 1.0 0.7 0.5 0.3 0.1 0.2 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Role crossover Tangled Supplies not Increased Waiting for Deviations from "Presence" at equipment/lines where needed unexplained staff people "norm" handover Defect Category Pre Kaizen (6 Handovers) Kaizen Wk (3 Handovers) 2 yrs Post-Kaizen (19 Handovers)
Next Steps/Sustaining the Gains• Adopted for spinal surgery handover• Plans for spread to 100% of surgical teams for 2013-2014 • Agreement from Surgical Council • Improvement planning group meeting
Lessons Learned• A pull for change is easier to make happen• Right people on the team• Value of senior leader on team• Create a process dependent protocol; not person dependent• Don’t reinvent the wheel• Live quality improvement cycle; be responsive
Lean in BC: Local Stories & InteractiveDiscussion with Physicians andOperational Leaders – Part 1:Improving Mental HealthPatient Flow in Emergency(Session E8)Andrew Janiec, Patient Care Coordinator, Vancouver General Hospital Psychiatric Assessment UnitPatti Maisonet, Psychiatric Triage Nurse, Vancouver General Hospital Psychiatric Assessment Unit
Objective• To provide timely and quality care to mental health and addictions clients who arrive in ED and require hospitalization.• To enhance our ability to pull patients into our care from the ED as soon as safely possible while meeting P4P target timelines
Background• Problem Statement: Currently some patients are not admitted within 10 hours of arriving in the ED - even when we have beds.
Issues Identified• Patients are asked to repeat their story to multiple clinicians• Redundant information gathering on forms• Code white or agitated patient in the quiet rooms can delay admissions• Admission delays due to not having empty beds available – no capacity• Staff are being taken away from the unit to escort patients for diagnostic testing• Timing of meals can delay patient transfers to inpatient units• Staff time spent searching for charts, patient belongings, keys, forms etc.• Patients/Families do not consistently have the information they need about the unit
SolutionImprovement Trial BenefitRevised nursing assessment forms decrease redundancies and simply the forms with check boxesCreated nursing care plan template reduce repetitive handwriting•Created laminated chart finding cards, Decrease searching time•Ordered keys for all staff,•Established process for PTNs to collect old charts & indicate if patient haspersonal belongingsDeveloped guidelines for when staff accompanying patients for diagnostics Decrease time staff spend away from the unittestingEstablish process to expedite after hours bed cleaning through Patient Access Decrease admission delayInpatient unit to call PAU when bed available or discharge planned Inpatient “pulling” patients & increase PAU bed capacityUnit clerk to enter all orders & MAR requests & prep patient charts in AM Improved skill task alignment
SolutionImprovement Still Under Development BenefitConduct a 5S of PAU to make space for patients to be •PAU Open Side staff can admit patientsadmitted beside the Quiet Rooms not through them •Decreases admission delaysRevise/ update PAU welcome booklet and provide to all •Provides patients/family informationpatients / families they need •Decreases time clinicians spend answer the same question, multiple timesWork with food services to align PAU & Inpatient unit • Decreases transfer delaysmealtimes and for bag lunches to be on the unit in case • Increases PAU bed capacitypatient still needs to be transferred during mealtimes.
Next Steps/Sustaining the Gains• Continue implementing improvements eg. 5S• Continue PDSA & sustain gains using Lean Management tools – Improvement huddles – Continuous improvement board – Gemba – Break through lanes
Lessons Learned - Challenges• Communicating outcomes of RPIW to all staff and ensuring they are engaged through entire journey• Accepting there are some quick wins but will be a journey to achieve the results we want – Rome was not built overnight!• Finding a patient to participate in the RPIW• Gaining buy-in from external stakeholders and support services to support improvement ideas (eg: change of meal times)
Lessons Learned - Benefits• Staff have better understanding how their efforts impacts how long patients have to wait to get into the right bed• Staff can see progress and impact of their actions (improvement board)• Patients are getting to the right care sooner
Lean in BC: Local Stories & InteractiveDiscussion with Physicians andOperational Leaders(Session F8)