IHI Expedition:

Smart Use of Resources:

Nurses' Time

Session 5 – June 21, 2012

Content: Redesign Key Processes to Eliminate Waste:

Medication processes

IHI Support Staff

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Tracy Jacobs

Director

Kayla DeVincentis

Project Coordinator

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Faculty for the Expedition

• Annette Bartley RN, MS, MPH

IHI/Health Foundation Fellow

Quality Improvement Consultant

Lead -Transforming Care at the Bedside in Wales UK

• Mary Viney RN, MSN, CPHQ

Vice President Seton Healthcare Family

Austin Texas , member Ascension Health

Transforming Care at Bedside since 2003.

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Overall Goal Of Expedition

AIM:

To provide participants with the content knowledge and skills to enable them to identify and eliminate waste in clinical processes and maximize the time nurses spend in direct patient care.

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Overall Objectives of the Expedition At the end of the expedition will be able to:

1. Recognize the seven categories of waste as they apply to hospital environment

2. Assess work unit for a project to improve the nurses effectiveness and efficiency

3. Use diagnostic tools to study existing processes to identify workarounds and inefficiencies

4. Apply best practices to streamline key processes like admissions, discharge, and medication administration

5. Employ ideas about the use of physical space and placement of supplies and equipment to improve efficiency and reduce wasted movement and time

6. Design a test to increase nurses time spent in direct patient care

7. Describe the linkage between safety and nurses time in direct patient care

8. Theorize about alternative staffing models to more

effectively use nursing time and expertise7

Session Five Objectives

At the end of this session each participant will be

able to:

• Explore your medication systems

─ From the patient experience

─ Handovers of care

�Within hospitals

�To and from community

• Flow chart from time medications are ordered

until patient receives

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Today’s Agenda

• Feedback from action period

• Eliminating waste in the medication administration process – Debra Halkett Providence Health Vancouver

• Key process – Medications

• Any questions from previous four sessions?

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Volunteers

• Debbie Lowe, Improvement Advisor, Novant Health, Winston-Salem, North Carolina

• Brenda Sturm, VP Nursing, Davies Community Hospital, Washington, Indiana

• Loraine Frank-Lightfoot, CNO, Wooster Community Hospital, Wooster, Ohio

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Work for Action Period

• Study your discharge process

─From patient perspective

─Documents required, caregivers interacting

• Review your Medication Administration process

─What will make the transition smooth to the

next location?

─What are the keys to successfully keeping the

patient home?

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Debra Halkett

Providence Health Vancouver

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Key Processes in Hospital Units

• Admissions

• Transfers In/Out of unit– within the hospital

• Discharges or transitions outside hospital

• Documentation

• Medication Management

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Medications/Pharmacy

• Ordering

• Reconciling

• Storage/Security

• Delivery

• Administration

• Evaluate Outcomes

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Involve Patients & Families

• Whenever possible ask patient to participate

• Teach Back methods

• Develop questioning attitude

• Prepare yourself and the team to be questioned for safety

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Involve Patients & Families

• Whenever possible ask patient to participate

• Teach Back methods

• Develop questioning attitude

• Prepare yourself and the team to be questioned for safety

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Shadow the Patient’s Journey

1. Establish what you are trying to achieve and how shadowing will

help you achieve it

2. Clarify why this process is appropriate and what aspect of the

patient pathway you want to focus on (e.g. tracking the

medication administration process)

3. Develop a template to capture key timings e.g. the time patient

arrived, time first seen by clinician, time referred for test.

4. Ensure the shadower fully understands and is comfortable with

their role

5. Ensure the patient fully understands and is comfortable with

their role; get their informed consent to participate

6. Write an information sheet about the aims, what is involved and

the expected outcomes of the study that can be given to the

patient

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Shadow the Patient’s Journey (cont)

7. Make it clear that the presence of the shadower will not influence

the care the patient receives

8. Observe how the patient is treated by members of staff

9. Observe how easy / difficult the process is for the patient

10. What goes smoothly for the patient? What doesn’t?

11. Are any tasks duplicated?

12. Observe the environment

13. Provide support for the patient and shadower; acknowledge

their time and effort

14. Feed back to the patient and the shadower about how their work

has helped with service improvement.

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Our Shadowing Experience

• Medication round

• Felt hurried

• More focus required

• Frequent interruptions

• Lack of understanding of medications

• Lack of explanation

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Red Apron Scheme:

Patient’s view• In my husband's NH the nurses wear the red tabard

when giving out medication. I have no objection as thank

God for they are concentrating on an important job at

that time.

• I find that if there is an emergency they still respond

quickly so there is no question that patients do not take

priority. In fact the opposite, the care of patients is a

priority and so is their medication.

• The people who are complain about this may have more

justification if their loved one is given the wrong

medication - especially if the nurse in question has been

disturbed with a trivial request.

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Pharmacy Role on Admissions

• Reconciliation of Home Medications

─All points of entry

�Surgery

�Emergency

�Direct admissions

─Who provides this service?

�Consider LVN/LPN roles

�Pharmacy technicians

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First Dose Medications

• Partnering with pharmacy at all entry points

─To achieve pharmacy review

─Work to agree on timing , availability of first

dose medications

─Use of automatic dispensing machines to

stock

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Routine & PRN Doses

• Locating routine medication either in or near patients’ rooms to reduce the amount of walking and time involved in delivering routine meds to patients

• Agreements about which medications can be close to patients

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Identify High Risk Medications

• Create the list

• Engage pharmacist, nursing, physicians

─Limit access : Store only in pharmacy if

possible

─Separate look-alike, sound- alike

─Read back – not repeat back

─Standardize protocols

─Abbreviations; eliminate

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Prevention Interventions

1. Reduce or eliminate possibility of error

─Reduce stock ( different concentrations)

─Reduce availability (KCL)

─Remove high – alert drugs from clinical areas

�(Magnesium Sulfate)

2. Make errors visible

─Two persons independently check infusion

settings

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Stocking & Par Levels

• Working with pharmacy to adjust the stocking process so that meds are consistently available (reduce waiting, time spent calling pharmacy for missing meds)

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Delivery of Meds

• Working with pharmacy to create signals or visual signs to let nurses know when medications are available (reduce repeated “checking” to see if meds are there)

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Thanks to Our Guest Presenter!

• Deb Halket, Providence Health Vancouver

• Any other questions from today or from any of the previous sessions?

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Work for Action Period

• Review your Medication Administration process

─What will make the transition smooth to the

next location

─What are the keys to successfully keeping the

patient home

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Volunteers?Volunteers?Volunteers?Volunteers?

Summary

• Review processes associated with medications systems. What can be done to make can more reliable, safer and reduce waste

• Final Session Next Week:

Redesigning Care Delivery Teams:

New Roles and Redesigned Roles

• Date: Thursday, June 28 1:00 – 2:00 PM ET

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