Adaptive Design The Path to Ideal Care

1. Adaptive DesignThe Path to Ideal Care Debra Shriver, MSN, RN Chief Nurse Executive Trinity Regional Medical Center, Fort Dodge April 2010

2. Objectives for the day • Review the IHS Vision • Provide overview for Adaptive Design • Share examples of Adaptive Design and the scientific methodology to solve problems (A3) • Outcome measures at various affiliates • Describe challenges, lessons learned, and integration of core processes into an EMR.

3. GOAL:Ideal care that achieves best outcome for every patient every time • Patient Centered • Based on best practice/evidenced based • Efficient/adds value/enhances the patient experience • Electronic medical record enables care • Professional practices nurtured/effective work teams

4. GOALS (not an all inclusive list) • 95% of patients willing to recommend • 0 codes on med/surg units • Less than 5% readmissions within 30 days • Achieve 90% or above in all quality measures (HF, MI, Pneumonia, Infection Preventions, etc.) • No patients fall • No skin breakdown • Increase caregiver time at the bedside to 60-70%

5. Adaptive Design is an improvement methodology developed by John Kenagy. It is an enabling technology that continually improves an organizations’ ability to deliver exactly what the patient needs while simultaneously lowering the cost of care. John Kenagy, 2009

6. Adaptive Design: • Toyota Production System • How people work and manage • How they think about their work • How they learn and work together to improve

7. What is Adaptive Design? • The foundation of the work is observation • Honors the work of the front line staff • Allows observer to ‘see’ the whole picture—eliminates assumptions • Detailed observations provide opportunities for problem solving • All the improvement work is based on the point of view of the patient • Creates a culture of improvement that uses the creativity, knowledge and problem solving ability of frontline staff to solve problems whenever care is not ideal.

8. Problem Solving • First order • Solving the problem for this patient and this clinician at this time (work around) • Second order • Get at root cause and solve the problem for future patients and clinicians

9. Adaptive Design sets Direction: Ideal Patient Care “My family and I get what we want and need, safely and without waste and without having to wait.”

10. Rules of Adaptive Design • Strive for Ideal Patient Care • Ideal Patient Care is a test to see if we are delivering the best outcome for every patient, every time. It can be answered with a yes or no. Did the patient get what he wanted, and needed safely without waste and/or having to wait?

11. Rules of Adaptive Design • There are 4 rules in Adaptive Design that are used to assist us with achieving ideal care • Rules 1-3 guide the work that is being done • Rule 4 guides us through problem-solving

12. Rule 1—How People Work-Activities • All work shall be highly specified as to content, sequence, timing, and outcome. • If work is highly specified, it does not allow variation in the way employees do their work. • Too much variation in a work process can lead to • Poorer quality • Lower productivity • Higher costs • Hinders learning and improvement in the organization because the variations hide the link between how the work is done and the results.

13. ACTIVITY

14. Rule 2- How People Connect-Connections • Every customer-supplier connection must be direct, and there must be an unambiguous yes-or-no way to send requests and receive responses. • The connection should not have any gray areas. • The connection should provide who, what, when, where, and how. • When a person needs assistance, there is no confusion over who will provide it, how the help will be triggered, and what services will be delivered. (Help chain) • This rule encourages employees to ask for help at once.

15. Rule 3-How the Production Line Is Constructed-Pathways • Every product or service flows along a simple, specified path • There should not be any deviation from the pathway • No forks or loops • Care and services do not flow to anyone, but to a specified person or equipment • The care we provide is a series of different pathways (services): • Admission • Medication Administration • Discharge • Each pathway has several different activities (Rule 1) and connections (Rule 2) • Those not connected to the pathway do not need to be there (Eliminate wastes and reduces repetition)

16. Rule 4-How to Improve-A3 Problem-solving • Any improvement to production activities, to connections between workers or machines, or to pathways must be made in accordance with the scientific method, under the guidance of a coach, and at the lowest possible organizational level. • Encourages management to mentor frontline staff and be facilitators • Develops staff members into a community of learners who participate in the problem solving • Problems, as signaled by staff, are solved using a scientific method • Tackles specific problems or failures rather than generalize or assume the issue. • The countermeasures are solutions developed based on the particular cause.

17. What is the Adaptive Design process? • Observations of the current state • Look for “signals” when patient care is not ideal • Problem-solve using a scientific method (A3s) • Implement and Test Countermeasures quickly • Continue with Countermeasure, until failure is signaled by frontline staff

18. Adaptive Design Transformation • Is a disciplined approach • Creates a culture change in how to solve problems • Every solution is a “test” and we expect it will fail---but we will learn more about the issue and come closer to the ideal • Every employee becomes a problem solver • Removal of barriers of ideal patient care • No “work-a-rounds” • No communication gaps • Eliminates repetition and redundancies • Increase quality • Increases nurse time on patient care • Increases patient satisfaction • Increases employee satisfaction

19. Allen Memorial Hospital • Tami Jones, RN, MSN • Clinical Director of Med/Surg and Nursing Innovation • Christa Lerch, RN, BSN • Staff Nurse on 4 Ortho

20. Frontline Design at Allen-Where we have been… • 4 Ortho • Elisia Heidt-Penrod, RN, BSN • 3 Medical • Andrea Johnson, RN, BSN • Pharmacy • Tim Schmidt R. Ph and Jeff Martin R. Ph • 3 Surgical • Rita Borrett, RN, BSN • 4 NET • Carmen Mundt, RN, BSN • Inpatient Therapy • Molly Ehrig, OTR/L • Distribution • Kari Beschorner

21. Frontline Design at Allen—Where we are… • Emergency Department • Mike Tiedt, RN, BSN • OR • Jenni Friedley RN, BSN, • Missy Michaelson, RN, BSN • PACU • Dana Clasen, RN, BSN • Ambulatory • Vonice Hoffman, RN • Sterile Processing • Janine Reuter, RN • Ambulatory Surgery Center • Kim Prinsen RN, BSN • Jenni Goos, RN • Joe Randall, RN

22. Frontline Design at Allen Where we are going… Everywhere!!!!

23. Frontline Design at Allen • Teachers • Tami Jones, RN, MSN • Shari King, MPT • Jessica Lovrien, RN, MSN • Lynne Blythe, MBA • Denise Schult • Chris Clayton, PharmD, MBA • Marty Colwell, MA

24. Allen A3: Detox on 4T

25. Root Cause

26. Target Condition

27. Countermeasures

28. Allen Outcome Measure • We are solving problems throughout the organization. • 376 A3’s in test as of April 1st!

29. Allen—What has this work meant to me as a staff RN? • Identifying 1st order problem solving and using 2nd order to solve the problems so I can spend time with patients • Decreased frustration with other department • We get to learn about and honor their work • Gratifying to get to the root cause and really solve problems

30. Blueprint Unit Trinity Regional Medical Center Fort Dodge

31. 2 North • 37 Bed Medical / Telemetry Unit • Blueprint Team • Staci Olson, RN Nurse Manager • Sue Niemeyer, RN Clinical Educator • Sara Ladlie, RN Staff Nurse (days) • Lori Hoover, RN Charge Nurse • Jenna Matton, RN Staff Nurse (nights) • Kim Bennett, RN Staff Nurse (days) • Carol Archer, PCT (nights)

33. Time Savings Example If one RN spends 5 minutes looking for an isolation gown while the patient is waiting to go to the bathroom and this happens to six nurses in 24 hours that would equal 184 hours of wait time for the patient and wasted time for the RN What could you do for your patients with 184 hours in a year?

34. Cost Savings Example If we have 100 A3s that save 30 minutes (gown example) in 24 hours for the RN = 184 hours 184 (hours) x 100 (A3s) = 18,400 hours / year = 8.8 FTEs or 9.7 FT (72 hr) = $20.00 x 9.7 = $194.00/hour x 72 hrs / pay period = $13,968 x 26 = $363,168 / year

35. Outcome Measures

36. Outcome Measures

37. What this work has meant Improvement in our work Saving time Making things run more smoothly Less running around Problems don’t occur again Reduction in waste Changed the focus from the nurse to the patient—hear more “what’s best for the patient” All about the patient; patient centered care Staff work together as a team

38. What impact has this had? Changes in our interactions with other departments Staff involvement with solving the problems that are signaled Increase quality time with the patient Cost savings, reducing waste

39. The Finley Hospital Adaptive Design Information for Leadership Symposium • Chris Wilson, RN MSN- Director of 4 Med/Surg and Inpatient Acute Rehab Unit • Sarah Bader, RN BSN, Staff nurse 5 Med/Surg and Clinical Adjunct Instructor for Clarke College Nursing School

40. Our two 20 bed med/surg units plus the 21 bed 5 North Med/Surg/Peds. units are engaged in adaptive design process. Blue Print team members include: • Diana Batchelor, RN MSN, CNO Finley • Teresa Neal, RN MS – Six Sigma Black Belt/ Blue Print lead facilitator • Pat Lehmkuhl, RN MSN- PI Coordinator and Blue Print team facilitator • Chris Wilson, RN MSN, Director 4 M/S • Cheryl Haggerty, RN, MSN, Director 5 M/S and 5 North • Londie Brauer, RN BSN, Educator 5 M/S and Rehab • Dee Maahs, RN, BSN, Educator 4 M/S • Sarah Bader, RN BSN, Staff RN 5 M/S • Melissa Shannon, RN, BSN Staff RN 5 M/S • Julie Beyer, RN, Charge RN 4 M/S

41. A3’s

43. Outcome Measures that we are proud of: • ● Redesigned the supply process on both floors to • apply LEAN concepts and to ensure that supplies • are readily available for the nurse so that the patient • does not wait for care. Since redesign we have • seen a significant drop in the number of calls to • Purchasing for missing items.

44. Outcome Measures that we are proud of: • ● We identified a significant issue with IV push for large doses of Lasix. Blue Print team worked with pharmacy to develop process to piggy back medication so that the nurse is free to monitor the infusion and attend to other needs instead of having to remain in the patient room for a long period of time pushing the medication. • ● Since beginning Blue Print in October 2009 we have completed 55 A3’s for 2009 and 44 A3’s are in process or completed as of April 2010.

45. Staff Nurse Perspective: What has this work meant to you and/or your unit? What impact has it had? • ● Working with Blue print has been exciting because it has given us the opportunity to really look at ideal care and what that means to the patient. I have enjoyed developing the definition of ideal care and working with the staff and the patients to identify and work signals. We have learned to think differently about problems and the process has opened our eyes to recognizing “work arounds” as problems that we can fix.

46. Iowa Health Des Moines N3 Blueprint Unit

47. IH-DM N3 Blueprint Unit • 24 bed Cardiovascular Unit 6.7 Admits per day 5.8 Discharges per day 32% Patient Turnover per day 58 Staff on Unit • Blueprint Team Members Jennifer Early (Director of Adult Behavioral Services) Pat Busick (Quality Improvement Coordinator) Sharon Henry, RN, BSN Toby Riddle, RN, BSN, Unit Based Educator Kathy Quick, Nurse Manager

48. IH-DM Ideal Care The patient and family will say, “I receive the care I need and want safely, on time, with respect and compassion”.

49. Senior Leader/Executive Director Experience • Purpose: • - To learn and honor the work of the • staff in a 2 hour experience • - Assist leaders to identify with us the • barriers in providing ideal care