This document contains the results of a survey given to nursing staff about the current bedside shift reporting process. It shows that the current process takes too long, with the average being 55 minutes per nurse. It also contains redundant information between shifts. The document then outlines the new iNSPIRe bedside reporting process and shows data from testing it. With the new process, the average time per nurse decreased to 13 minutes. This results in over 6,800 hours being freed up for patient care annually between two departments. Patient and staff feedback on the new process has been positive.

1. Submitted
by:
Christian
Clark
Echegoyen

2. Define
and
Measure
2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10

11. 11
11
4
Q1.
What
is
good
about
our
current
process?
3
2
(n=25)
1
1
1
1
1
44.0%
60.0%
72.0%
80.0%
84.0%
88.0%
92.0%
96.0%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
25
20
15
10
5
0
read
report
and
also
do
verbal
(face-­‐
to-­‐face)
gives
clear
picture
of
the
patient/unit
from
previous
shift
none
works
good
in
general
easy
transition
very
informative
address
patient's
concerns
and
problems
does
not
disrupt
workflow
Nurse
carry
info
of
other
patients
aside
from
their
own
patients
#
of
respondents
Categories

12. 12
8
Q2.
What
is
not
working
in
our
current
process?
6
4
2
(n=25)
1
1
1
1
1
32.0%
56.0%
72.0%
80.0%
84.0%
88.0%
92.0%
96.0%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
25
20
15
10
5
0
#
of
respondents
Categories

13. 13
Q3.
What
is
so
time
consuming
with
our
current
process?
11
5
(n=25)
4
4
1
44.0%
64.0%
80.0%
96.0%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
25
20
15
10
5
0
none
distractions/too
much
talking
not
related
to
patient
(e.g.
personal
conversations)
no
comment
cumbersome/looking
up
for
info
redundant
process
(shift-­‐
shift
notes)
#
of
respondents
Categories
Very
interesting
feedback.
Upon
deep-­‐dive
analysis
of
this
data,
it
was
then
associated
with
real-­‐time
push
back
from
some
individuals
who
doesn’t
want
change.

14. 14
17
Q4.
What
creates
redundancy
in
our
current
process?
4
(n=25)
2
1
1
68.0%
84.0%
92.0%
96.0%
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
25
20
15
10
5
0
shift
to
shift
notes
(write/
read/verbal)
of
same
issues
no
comment
none
unnecessary
info
repetition
of
info
#
of
respondents
Categories

15. 15

16. 14
12
10
8
6
4
2
0
Histogram-­‐Current
State
Mean
54.77
Median
55.00
Mode
55,
58
38.4
41.7
45
48.3
51.6
54.9
58.2
61.5
64.8
68.1
71.4
Number
Values
n
31
Skewness
-­‐0.01
Stdev
5.09
Min
45.00
Max
65.00
16

17. I-­‐MR
X
Chart-­‐Current
State
(May-­‐June
2014
Time
Study)
UCL
71.2
CL
54.8
LCL
38.4
82.9
72.9
62.9
52.9
42.9
32.9
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Minutes
Observa.on
R
Chart
UCL
20.1
CL
6.2
25.0
20.0
15.0
10.0
5.0
0.0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Range
Observa.on
17

18. 18

19. 19

20. 20

21. 21

22. iNSPIRe
Hoopla
22

23. THE
BEDSIDE
REPORTING
PROCESS
IN
ACTION
23
iNSPIRe
(Nursing
Staff
Patient
Interactive
Report)

24. 1.
End
of
shift
patient
rounding
(offgoing
nurse)
One
hour
before
end
of
shift:
Sweep
patient
for
the
4P’s
(pain,
potty,
position,
place
items
within
reach),
let
patient
know
shift
change
is
coming,
check
IV
bag/site
and
have
2
hour
supply.
iNSPIRe
24
**Not
an
actual
patient

25. 2.
Get
assignment
Oncoming
staff
obtain
assignment
list
from
the
UR
desk
and
oncoming
RN
creates
mini
census.
iNSPIRe
25

26. 3.
Nursing
assistant
obtain
census
and
vital
signs
NA’s
obtain
short
census
and
start
getting
patient’s
vital
signs
and
entering
it
into
SCM
(computer)
while
in
the
room.
iNSPIRe
26

27. 4.
Before
entering
the
room,
Discuss
significant
events
or
issues
When
appropriate,
discussing
significant
events
or
psychosocial
issues
outside
patient
room
can
better
prepare
the
oncoming
RN
on
what
to
expect
when
entering
the
patient’s
room.
iNSPIRe
27

28. 5.
Sanitize
hand
Sanitizing
hands
before
and
after
touching
a
patient
promotes
a
clean
and
germ-­‐free
environment.
Doing
this
in-­‐front
of
the
patient
also
assures
them
that
we
are
serious
about
their
safety
and
protection
from
infection.
iNSPIRe
28

29. 6.
Greet
and
introduce
Greeting
the
patient
and
introducing
oncoming
RN
promotes
patient’s
confidence
in
care
continuity.
iNSPIRe
29
**Not
an
actual
patient

30. 7.
Bedside
report
Warm
handoff
(with
patient
engagement)
includes
quick
head-­‐to-­‐toe
assessment,
patient’s
identifier,
patient
and
room
safety
sweep,
double-­‐check
epidurals,
work
list
check,
and
going
over
the
4Ps
(pain,
potty,
position,
and
proximity).
iNSPIRe
30
**Not
an
actual
patient

31. 31
Utilizing
the
clinical
summary
in
the
patient’s
room
to
review
pertinent
information
with
oncoming
RN
allows
for
real-­‐
time
and
updated
picture
of
patient’s
orders,
work
lists,
and
daily
plan
of
care.
iNSPIRe

32. 8.
Update
Patient
Care
Board
Update
the
communication
board
with
the
daily
patient’s
goals
and
plan
of
care
using
patient-­‐friendly
language.
iNSPIRe
32

33. 33
**Not
an
actual
patient
Thank
the
patient
and
ask
if
they
have
any
questions,
concerns,
or
issues
with
their
care.
This
will
enable
the
staff
to
address
them
right
away.
iNSPIRe

34. 34
Sanitize
hand
upon
exiting
patient’s
room
to
eliminate
the
risk
of
spreading
potential
infection
to
other
patients
and
staff.
This
is
for
YOU
and
your
PATIENT’s
safety.
iNSPIRe

35. 9.
Charge
nurse
calls
the
huddle
Huddle
includes
the
nursing
assistants
(NA’s),
UR,
charge
RN,
and
primary
RNs
in
the
oncoming
shift.
This
will
encourage
a
more
effective
and
reliable
team
by
having
everyone
aware
of
pertinent
or
“hot
topic”
information
involving
the
patients
in
the
unit.
iNSPIRe
35

36. 9a.
Vocera
hand-­‐
off
36
Off-­‐going
staff
hand
over
the
vocera
to
oncoming
staff
to
ensure
efficient
and
continuous
mode
of
communication
in
the
department.
iNSPIRe

37. 10.
Primary
RN
(incoming)
report
to
NA
Primary
RN
&
NA
report
out
to
each
other
to
ensure
appropriate
sharing
of
patient’s
plan
of
care
and
vital
information.
iNSPIRe
37

38. 38

39. UCL
19.6
CL
13.0
LCL
6.4
75
65
55
45
35
25
15
5
X
Chart-­‐
Test
of
change
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
Minutes
Period
TEST
OF
CHANGE
39

40. 10
9
8
7
6
5
4
3
2
1
0
Histogram-­‐Test
of
Change
Mean
13
Median
13
Mode
13
n
30
5
7
9
11
13
14
16
18
20
Number
Values
Skewness
0.48
Stdev
2
Min
9
Max
18
40

41. Main East & Terrace East Soft Benefit
Calculation:
Average minutes per RN per shift divided by 60
minutes equals to hours per shift as observed in
both units.
Without PI (Average minutes per outgoing RN to do
the routine task of handing-off all patients to the
incoming RN in one shift before seeing 1st patient):
v 55min/RN
per
shift
÷
60min
=
0.92
hr/shift
With PI (Average minutes per outgoing RN to do the
new improved bedside report hand-off on all patients
to the incoming RN in one shift and all patients have
been seen):
v 13min/RN
per
shift
÷
60
min/hr
=
0.22
hr/shift
Benefit:
55
min/RN
per
shift
(without
PI)
–
13
min/RN
per
shift
(with
PI)
=
42
min/RN
per
shift
x
4.5
(ave
#
RNs/shift)
=
189
min/
shift
allotted
back
to
patient
care.
12-month Key Assumptions
Impact
42 min/RN per shift x
30 day/mo = 1,260
min/mo x 12 mo/yr =
15,120 min/RN per
shift soft annual
time benefit
Data were collected
from real-time
observation in the
unit during the test-of-
change.
Annual
Benefit:
15,120
min/RN
per
shift
annual
x
4.5
(average
#
RNs
per
shift)
68,040
min/shift
annual
x
3
shifts
3,402
hours
X
2
Departments
(ME
&
TE)
equals
to
6,804
hours
=
204,120
min
or
ANNUAL
SOFT
BENEFIT
41
6,804
hours
Re-­‐ALLOCATED
BACK
TO
PATIENT
CARE!!!

42. Pain
Management
Communication
about
meds
HCAHPS
3rd
Quarter
data
will
be
available
late
this
year
or
early
2015
42

43. 1
4
3
9
7
3
5
2
11
18
12
15
19
12
17
11
7
7
6
6
11
8
2
Staff
is
accountable
for
compleIng
nursing
care
Before
I
assume
care
of
paIents,
my
quesIons
about
the
paIents
are
answered
Interpersonal
relaIonships
between
shiPs
are
good
PaIent
condiIon
matches
what
I
get
in
report
ShiP-­‐to-­‐shiP
report
report
gives
me
perInent
informaIon
related
to
paIent
condiIon
Report
Ime
is
adequate
Staff
is
accountable
for
compleIng
kardex
10.31.14
Post-­‐implementa.on
Survey
Licensed
Staff
(n=28)
Poor
Fair
Good
Excellent
43

44. 44
"This
was
the
best
experience
I've
had
at
CHOMP."
The
nurses
were
very
responsive
to
ques.ons.
"The
nurses
addressed
my
ques.ons
&
concerns,
without
me
having
to
ask."
"I
also
liked
that
they
shared
informa.on
with
me
included,
so
I
didn't
have
to
repeat
myself."
"A
good
idea
to
have
the
nurses
involve
the
pa.ent
in
report."
"I
didn't
feel
they
were
talking
over
me."
“I
love
the
communica.on
boards,
especially
like
that
the
boards
are
kept
up
to
date.

45. Control
45

46. 46
Change Concept PDSAs Adopt, Adapt, Abandon?
Improve
Workflow/ Change
the work
environment
Created a reporting workflow that will bring the
change of shift handoff to the patient’s bedside.
ADOPT
Customer
interface
Patient engagement during handoff to discuss
about their plan of care with both off-going and
oncoming nurse.
ADOPT
Focus on service/
Producer
interface
Nurses are required to check the clinical
summary (computer) in each patient’s room to
review medical updates on the patient, and to
go over nursing work list.
ADOPT
Improve
Workflow/ Change
the work
environment
Charge nurses workflow integrated with the
process, including the huddle with nursing
assistants and primary nurses.
ADAPT
Leadership
Engagement
Do the Gemba walk with executive sponsor as
well as the department’s director to observe
and coach the process.
ADAPT

47. Information about the
bedside reporting
during shift change
should be included in
the admission packet
so patients are aware
Utilize Kaizen Board
for staff engagement
in continuous
improvement.
→ Staff Education /
Process
Patient inclusion in
the discussion of
plan of care.
Education Fair
program preview to
promote awareness.
→ Enhance
Facility Employee
Awareness
Encourage teach-back
technique to staff about
the new process.
Oncoming nurse
introduced to the
patient during handoff.
Huddles during shift
change to talk about
pertinent issues on
the floor.
Increase interface with
patient during shift
→ Enhance Patient
Awareness
Storyboard posted in
the nurse’s lounge
area to enhance
program awareness.
Spot-audit using
competency tools with
real-time coaching.
We Can Do It!
Act Plan
Study Do
Provide tools such as
videos and cheat sheet
about the new process.
Plan-­‐Do-­‐Study-­‐Act
(PDSA)
Coaching and
mentoring by the
unit’s RN educator
and PI champions.
47

48. 48

49. 49

50. 50

51. ¡ Key
to
Success
§ Continuous
monitoring
and
engagement
with
ME
&
TE
staff
utilizing
the
“Kaizen”
board
to
incessantly
improve
the
process.
§ Executive
leadership
support
with
the
initiative.
§ Leadership
doing
a
“Gemba
walk”
at
least
once
a
month
in
the
nursing
unit.
§ Encourage
“catch-­‐ball”
method
of
problem
resolution
with
the
process.
Note:
The
“catch-­‐ball”
concept
is
basically,
ideas
being
thrown
back
and
forth
between
employees
and
managers.
¡ Barriers
§ Since
this
is
a
“culture-­‐change,”
we
anticipate
some
push-­‐backs
initially.
§ Compliance
and
competency
issues
due
to
deviation
from
the
original
process.
§ Front-­‐line
staff
afraid
to
speak
up
to
management.
§ Lack
of
staff
and
manager’s
commitment
to
the
program.
¡ Lessons
learned
§ Engagement
with
employees
is
a
must,
employees
need
to
know
that
leadership
are
supportive
and
confident
with
the
new
improved
process.
§ Leaders
willing
to
listen
and
accept
feedback
from
staff,
and
must
learn
how
to
manage
conflicts.
§ Promote
a
safe
environment
where
staff
are
able
to
voice-­‐out
their
opinions.
§ Leaders
and
champions
must
have
at
a
minimum
the
basic
knowledge
of
continuous
improvement
or
Lean
&
Six
Sigma.
¡ Next
steps
§ A
sustainability
plan
will
be
developed
by
the
process
owners
and
director,
and
subsequently
signed
by
all
parties
including
executive
sponsor
to
enhance
ownership
and
accountability
to
ensure
high-­‐reliability
of
the
new
process.
§ Continue
“spot-­‐audit”
with
real-­‐time
coaching
(not
punitive),
when
appropriate,
to
staff
to
improve
their
competency
of
the
process.
§ Conduct
patient
survey
right
after
the
spot-­‐audit
to
validate
the
observation.
§ Include
and
make
the
improved
process
as
part
of
the
competency
requirement
for
all
staff.
§ Embed
in
the
policies
and
procedures,
where
appropriate.
§ Get
ready
for
Spread!
51

52. 52