Quality Improvement Changing a way of thinking and Unit Culture

June 2014

National Health Leadership Conference

Minette MacNeil & Michelle Morris

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About RVHS

Location

• Multi site organization

sites

• Two acute care

community hospital

campuses

• East Toronto and Ajax in

West Durham, Ontario

2013 stats

• Approx. 260 acute care beds

• Approx. 124,000 ED visits

• Approx. 15, 525 Surgical out-

patients

• Approx. 4600 Surgical in-

patients

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Objectives

• Background

• Goals

• Plan

• Current State

• Lessons Learned & Future State

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About Us-Inpatient Surgery

• 7 surgical services

• 39+ beds (flex to 57)

• 50 years- Average

age nursing staff

• 16 years- Average

years of service

• Recent change in

RN/RPN ratios

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Background: Why The Need for Change?

Patients Perspective

• Patient feedback

– Inadequate pain

management

– Not seeing the nurse for

long periods of time

– “your nurse is on break”

• Quality reviews

– Critical incidences

(fractures)

– Falls due to poor

toileting practices

Staff Perspective

• “It’s not my patient”

• Lack of/inadequate transfer

of accountability/shift report

• Inadequate updating of

bullet round boards and

Kardex’s

• Nurses leaving for break

without addressing patient’s

needs/issues

• Lack of team engagement

and morale

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6

Metrics-Initial Measure Initial

As of Nov 2013

Patient Satisfaction

(Overall care services)

89%

Call Bells- per day shifts 70

Falls 8.2 per month

Critical incidents (resulting from

falls)

3

NSAE – per 1000 patient

discharges

21.12

Staff Engagement 7% staff participating in unit

activities

Staff Survey-

Help & support to each other

Always 5.88 %

Most of time 64.71%

Occasionally 23.53%

Rarely 5.88%

Goals for the Change

• Enhance Communication

• Enhance quality of care and patient

outcomes

• Decrease Nursing Sensitive Adverse

Events

• Increase Patient Satisfaction

• Improve nurse/staff satisfaction

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The Plan

• Step 1: Leadership decision to adopt

structured rounding practices

• Step 2: Utilized a LEAN tool-Kaizen

Event

• Step 3: Shared results of the Kaizen

Event and implement changes on unit

(training).

• Step 4: Progress Reports-Tools/action

plans/metrics/sustainability

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• Corporate initiative to focus on Collaborative Care

Approach - Training Organizational wide

• Collaborative care team investigated the concept-

provided evidenced based research and experiences

from neighboring hospitals that had also adopted the

practice

• It tied into the philosophy of a multidisciplinary approach

in the care of the patient while potentially providing an

opportunity to address key issues in behaviours and

clinical practice on the unit

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Step 1: Plan to adopt rounding

• A Kaizen is

“a team activity dedicated to the

quick implementation of an

improvement in a specific area

that will make an overall

improvement to the

Value Stream”.

(RVHS, 2009)

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Step 2: KAIZEN Event

• Completed a VSA (Value Stream

Analysis) to map the

processes/steps in the daily routine

of the nurse’s journey to find areas

where waste can be eliminated

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Step 2: KAIZEN Event

Interruptions Call Bells Broken Processes

• Pharmacy calls

• Doctor’s

Rounds/calling

• Family Inquiries

• Admissions /

Discharges

• Unstable

patients

• Looking for

equipment

• No kitchen

stock

• Looking for

help during

break times

• Pain

• IV

• Positioning

• Bathroom

• Get up

• Standard work in

place but not

consistently followed

Initial State of a Typical Day: •Lots of Call Bells

•Lots of Interruptions •Gaps in processes

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Step 2: KAIZEN Event-Cont’d

Process changes: • Fewer call bells

• Fewer interruptions

• Standard work followed more consistently

• Better coverage during break times

• Improved coordination and organization

Kiazen- Planned Implementations

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1: Hourly rounding reduce call bells

2: Hourly rounding with buddy prior to break times /

every two hours

increases knowledge of patients

do not need a separate break handover

helps with workplace injuries (assistance with

turning)

3: Verbal bedside shift report

best practice

reduce time chasing info

What Went Well • Followed through with staff

input

• Good results from trial on floor

• Staff were heard

• Openness and willingness of

improvement team

• Team dynamics

• Shift of thinking amongst the

team

• recognized importance of

teamwork, education and

communication

Lessons Learned

• Need to change

• Workload is high

• need to work together

• Better preparation for staff on

unit even for trialing during

event-met with resistance

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Kaizen Event: Reflections

Rounding: What is “4P”??

• PAIN

• POSITIONING

• PERSONAL NEEDS

• PROXIMITY

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Step 3- Training & Implementation

- Staff huddles-

sharing Kaizen

outcomes

- Standard work

- Competency

checklist

- Bedside training (4P

champions)

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Step 4-Progress Report

• Various lean tools

used for

transparency &

visual management

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Call bells

Month Average

# of call

bells/day shift

November 70

January 58

March 44

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Sustainability

• Welcome Card

placed on every side

table

• Random visits to

patients by

management to audit

frequency of

rounding and if

meeting needs.

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LEAN Tool- Kamishibai • Staff audit tool

• involves all of our team

members in process

improvement, with an

emphasis on supporting

daily improvement.

• The tool is designed to

expose process issues in

real time.

• Takes timely corrective

action

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CURRENT STATE

STAFF PERSPECTIVES

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Staff Perspective

“I think 4P rounds have helped the patients and also helped us with the workload by cutting down on the number of calls, making the patient more comfortable because we are asking the questions instead of walking away…It helps the patient get better and out of hospital as fast as possible feeling comfortable and well cared for.”

Carmelina Staff RN

Positive Impact:

• Nurse and patient satisfaction

• Improved quality of care

• Enhanced communication

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Staff Perspective

“4P rounding has honestly brought to my attention some other things that I would have considered less significant – the proximity of things to the patient for example and I guess it has decreased some of the call bell activity that was associated with expected things…it also reinforces to the patient that ‘you know what, I care about yah and I will be back in an hour’!”

Geoff Staff RN

Positive Impact:

• Nurse and patient satisfaction

• Improved quality of care

• Enhanced communication

• Decrease risk of Falls

• Awareness/Knowledge

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Staff Perspective

“As a physiotherapist, when I go to see patients often times the first thing they want to do is go to the bathroom and that really interferes with my treatment time. So if that’s all been taken care of before we even get there, we can actually focus on the physio and getting them mobile and progressing with our treatment times. I am still waiting for the changes or improvements in the toileting but the pain is being controlled before we even get there so that helps me to work a lot more easily with the patients.”

Ann PT Positive Impact:

• Improving patient outcomes

• Improved quality of care (pain management)

Challenges:

• Not following standard of work/addressing all areas

of the 4 Ps (toileting)

• Mismanagement of time

• Delay in patient care

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Staff Perspective

“4P addresses patient needs in a proactive manner that results in better outcomes and patient satisfaction. If nurses would focus on the 4P instead of how they feel- that it is a negative against their nursing care [because many feel they already do it], they would be more able to see the benefit in the process.”

Donna –Unit Coordinator

Challenges:

• Negative behaviours

• Resistance to change

• Failure to follow standard of work/adopt

practice

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Staff Perspective “It is good that when I’ve gone to break, the patient actually have a sense of security that someone is really answering that bell – instead of ‘ok I am going on break and there is someone covering’ and not knowing- at least they’ve got a name and a face and there is really someone there and they will be well taken care of. However, sometimes if you are busy in another room just at the time we need to do the break, it is difficult. If I am in a middle of a dressing, it is hard to try to do 4P with my partner. I know that it would be nice to go into each room but sometimes it is just not convenient.”

Paulette Staff RN Positive Impact:

• Enhanced Communication

• Improved quality of care

Challenges:

• Inconvenient/lack of time

• Unable to always follow standard work

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Staff Perspective

4P rounding has helped a lot because it has reduced the number of calls for pain medication, bathroom calls and requests for ice water. However, we still have family members coming to the desk to complain that their family has not been washed and/or assisted to the washroom. Some patients or families also complain that they have been waiting a very long time for a nurse to come after the call bell is answered or that they have not seen them for a couple of hours. Even though this is still occurring there has definitely been a decrease in the number of complaints.

Donna- Unit Clerk

Challenges:

• Family/patient dissatisfaction-complaints

• Failure to follow standard of work/adopt 4P

practice

Positive Impact:

• Reduction in call

bells

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Staff Perspective

“When 4P rounding has been done the patients and families seem to feel they know their nurses-they know where their nurses are-whether they’re here, or on break and they feel like they know who they can go to- who they can ask for their needs to be met. They seem less anxious. They seem to be more informed as to what’s going on and what’s in store for the rest of the day.”

Christine- SW

Positive Impact:

• Communication/information sharing

• Patient satisfaction-sense of security

Staff Training

Education Length of training Percentage of staff

trained

4P rounding training 1:1 training on unit All

Start with HEART

training

2 hours 100% (PT & FT)

Respond with HEART

training

2 hours 83%

Collaborative Care

training

3 day training session 83%

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Patient Feedback

“On the Surgical Floor(5W) the nursing care was excellent. Again the cheerful and caring attitudes was much appreciated and were much appreciated and went a long way in creating a positive atmosphere for encouraging

recovery” (April 24, 2014)

“Thank you for joining the nursing workforce. You are outstanding. Your dedication and professionalism brought us such comfort knowing our boy was in good hands.” (April 6, 2014)

Patient Satisfaction

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Questions October January March

Overall how would

you rate you care? (very good & excellent)

89% 89%

92%

Would you

recommend RVHS?

88% 100% 100%

Improvement Metrics

Measure Initial

As of Nov 2013

Current Desired

Patient Satisfaction

(Overall care

services)

89% 97% 100%

Call Bells- day shift 70 56 50%

Reduction

Falls 8.2 per month 4 per

month

50 %

Reduction

Critical incidents

(resulting from falls)

3 0 0

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Improvement Metrics-Continued

Measure Initial

As of Nov 2013

Current Desired

NSAE – per 1000

patient discharges

21.12 16.02 13.53

Staff engagement -

participating in unit

activities

7% 70% 80%

Staff Survey-

Help & support to

each other

Always 5.88 %

Most of time 64.71%

Occasionally 23.53%

Rarely 5.88%

In-

progress

Increase

Always to

65% of

the time

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Lessons Learned

• Identify ALL the stakeholders

• Flexibility

• Time

• Resistance

• Effort

• Customize tools to work for us

• Compliance issues

• Don’t take your eye off past improvements

• Continuous communication & reminders

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Future State- Next steps Current State Barriers

Communication • Transfer of Accountability • Lateness

• Timing

• Resistance

Communication • New Kardex/Care Plan • New format

• Colour

NSAE • New Pneumonia Protocol

• Product availability

• Continuous effort

required

Team

Engagement

• Unit Council

• Formulating unit

champion groups

(Pressure ulcers, falls,

infection control, health

workplace, H&S,

Medication safety, staffing

• Building of leadership

skills for sustainability

• High Sick time

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Thank You

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References

Orchard, C., King, G., Khalili, H., Bezzia, M. (2012). Assessment of Interprofessional Team

Collaboration Scale (AITCS): Development and Testing of the Instrument. Journal of Continuing

Education in the Health Professions, 32(1): 58-67. DOI: 10.1002/chp.21123

Sheppard, L. (2103). Stop going in circles! Break the barriers to hourly rounding. Nursing

Management. www.nursingmanagmeent.com DOI: 10.1097/01.NUMA.0000426147.98903.ae

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