Nurturing is at the heart of healing

1. Nurturing is at the heart of healing “It would be better if everyone would work together as a system, with the aim for everybody to win.” W. Edwards Deming Mary Hickey, MBA, Six Sigma Master Black Belt

2. “Push” Forces: challenging the Status Quo Health care reform Patient Safety Consumer Movement / Patient rights Transparency demands Croke Park Agreement / Cost effectiveness Licensing “Pull” Forces: Making the Future Attractive Organising the healthcare system around the patient and family works for everyone Optimizing the patient experience correlates with other outcomes, including clinical, financial and staff satisfaction Patient activation and self management is enhanced, achieving better chronic disease outcomes Caregivers are seeking a better patient experience for those they serve and for their own families Forces Impacting Patient and Family Centered Care Mary Hickey, AMNCH

3. DOHC Reports on Lifestyle Habits of the Irish Population Mary Hickey, AMNCH

4. Social cultural milieu of Ireland is changing…. • Increasing numbers of different ethnic groups from around the world are migrating to Ireland • According to 2006 census figures, 10.2% of people living in Ireland belong to minority ethnic groups • Highest number from EU – 40% Polish, others mainly from Asian countries China, India, Pakistan and Africa countries mainly Nigeria • Diets differ significantly to the diet of the Native Irish population in that it may contain a large amount of carbohydrate foods, pulses, legumes, vegetables and fruit. Higher intake of complex carbohydrates and lower fat intake • Diet greatly influenced by culture, religion and beliefs • Another study was published by HSE West on behalf of The Community Nutrition and Dietetic Services, Jan 2010 entitled “Minority Ethnic Groups: A Nutrition Resource for Dieticians and Health professionals”. Mary Hickey, AMNCH

5. HSE Quality Programme Mary Hickey, AMNCH

6. Governance framework for Patient Safety and Quality Knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes. Report of the Commission on Patient Safety & Quality Assurance DOHC, 2008 Mary Hickey, AMNCH

7. Food and Nutritional Care in Hospitals –Guidelines for Preventing Under – Nutrition in Acute Hospitals • “Caterers play an important role in helping patients to make healthy and nourishing food choices. Together with hospital dieticians, they can create a supportive environment for healthy nutrition. All food staff, by ensuring that patients eat well, help to improve both their physical and mental health, and thus speed up their recovery from illness.” • Mary Harney, TD • (former Minister for health & Children). Published by DOHC in 2008 Mary Hickey, AMNCH

8. Promoting good nutritional care in hospitals • The length of time a patient spends in hospital and the cost of that stay is linked to the patient’s nutritional status. Under nutrition in sick patients is associated with : • Impairment of every system in the body: muscle weakness, particularly in respiratory muscles, reduction of the ability of the immune system to function; and alterations in the structure and function of the gut • Delayed wound healing • Apathy and depression • Reduction of appetite and ability to eat • High rates of mortality • These change combine to increase both the length of time a patients spends in hospital and the cost of the stay. Apart from this the patients quality of life is severely affected, both while in hospital and after discharge. • A review of 22 surveys in 70 US hospitals showed that patients receiving early nutrition intervention had a shorter length of stay (average 2.1days) a direct saving of $697 per patient per day. Kings Fund UK, calculated the savings from treatment of under – nutrition would be in the region of 453m each year. Mary Hickey, AMNCH

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11. Nutritional Status of Hospitalised Patients can be compromised by a number of factors… • Failure to detect poor nutrition • Poor recording of information about patients’ nutritional status (such as weight loss) • Poor referral systems • Fragmented working practices • Inadequate educational or training programmes • Inadequate ward staffing • Confusion over who has the primary responsibility for patients’ nutrition • (Ref: Jan Savage, 2005, “Patients’ nutritional care in hospital: An ethnographic study of nurses’ role and patient s’ experience” RCN Institute London) Mary Hickey, AMNCH

12. Nurses’ involvement in nutritional care has varied over time…… • By mid 20th century, matrons and senior nurses had relinquished direct managerial control over catering and other housekeeping functions in hospitals • Retained influence over standards of service provision (in the UK specifically after widespread “contracting out”) • Some blurring of roles and responsibilities of nurses and non – nurses in the preparation and serving of food • Initial nutritional assessment, care plan and monitoring (recording of food and fluid intake and weight) • Implementing the advice of dieticians and Speech & Language therapists • Checking patient menu card choices • Helping to feed patients who need help and providing appropriate implements for others Mary Hickey, AMNCH

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14. “If you always do what you’ve always doneYou’ll always get what you’ve always got" Mary Hickey, AMNCH

15. W. Edward Deming on Processes “Will be cross-functional, process-driven” “Eighty-five percent of the reasons for failure to meet customer expectations are related to deficiencies in systems and process… rather than the employee. The role of management is to change the process rather than badgering individuals to do better.” Mary Hickey, AMNCH

16. There is no secret formula to providing good food. “It’s a matter of care and attention, and making sure patients get what they like”. Lord Grossman Mary Hickey, AMNCH

17. NHS - Better Food Campaign • Launched in May 2001 • Some of the dishes were developed by a team of volunteer “leading chefs” including Anton Edelmann of the Savoy • Worked with NHS caterers to improve taste and Nutritional quality • At least 3 “chef’s recipes” must now appear each day on NHS menus in Acute Hospitals • Cost the government £40million over 4 years • Aim was to raise the food standard in all hospitals to the level of those of the best “The challenge is to embed the principle that good food is critical for the patients’ physical and psychological recovery. Even how food looks, the colour and smellcan buckyou up.” Lord Grossman Mary Hickey, AMNCH

18. Stanford University Hospital….. Stanford is often referred to as “the Farm” in keeping with its history and location on land donated by its founders, Jane and Leland Stanford. The more than 8,000-acre Palo Alto Stock Farm was given in the grant establishing the University, which opened in 1891. The food we serve is part of the commitment the hospital makes to help our patients heal as quickly as possible and to feel comfortable and cared for while they are in hospital. The hospital invited Chef Jess Cool, a nationally recognised chef, restaurateur and food writer to develop recipes with the hospitals catering staff. Mary Hickey, AMNCH

19. Other hospital initiatives • Kaiser Permanente, Northern California started hosting in hospital farmers markets back in 2003 and in 2006 began partnering with small local farmers to provide patients with organic fruit and vegetables • Healthcare without Harm, launched a programme in September 2009 to reduce meat offerings in patient meals and staff cafeterias by 20% in 12 months. The average portion of meat in the US is 8ozs while the recommended portion is 5/6ozs – over consumption of meat contributes to the overwhelming cost of US health system est. to be $147B as a result of obesity alone as well as climate change, water, air pollution. The food system accounts for 10% of overall energy use in the US. “Balanced menus is a climate change reduction strategy that also protects the effectiveness of antibiotics and promotes good nutrition.” Healthcare without Harm Mary Hickey, AMNCH

20. DMAIC - A Project Management Method “All improvement takes place project by project, and in no other way.” Dr. Joseph M. Juran Mary Hickey, AMNCH

21. Apply Rigour & Discipline Lean Six Sigma Key Concept The DMAIC (D-MAY-IK) Model Define Define the problem and project Measure Measure & gather current baseline data Analyse Analyse the data, identify root cause(s) Improve Improve by addressing root cause(s) Control Control to sustain gains Don’t jump to conclusions – arrive at the solution ! Mary Hickey, AMNCH

22. SIZE Six Sigma Lean • Central theme is the elimination ofwaste. Waste is any activity that does not add value for the customer. • The approach is typified by theToyotaProduction System. • Key measurement for Lean isvalue adding time. • Central theme is to create processes and products which are virtually defectand variationfree. • The approach is typified byMotorolaand GE • Key measurement for Six-Sigma isvariation. Lean Sigma fasterprojects lower costs higher quality Mary Hickey, AMNCH

23. Lord Kelvin, a Scottish mathematician and physicist who contributed to many branches of physics 1824 – 1907 “When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind.” Knowledge is in the Data As the level of analysis increases so does our success Mary Hickey, AMNCH

24. The Productive Ward: Releasing time to care • The Productive Series is a set of programmes developed by the NHS Institute of Innovation and Improvement to help NHS teams redesign and streamline the way that they work. • The three main components are: • Knowing how we are doing (recording, displaying and using key measures) • The well organised Ward – workplace organisation • Patient status at a glance – improving the patients status using display boards • Videoing of Mealtimes is a core component of this programme to identify areas for improvement Mary Hickey, AMNCH

25. Productive Ward cont. • “The major key to the success of the Productive Series is the empowerment of staff to enable them to drive forward improvements, overcome difficult practice challenges and make positive changes to the way they work. The process encourages a continuous improvement culture to ensure that results are solid and lasting”. Airedale NHS Foundation Trust • “Completing the module has enabled the staff to spend more time with patients monitoring their dietary intake at meal times, this is in addition to the good work we have already achieved with the Royal College of Nursing on the Nutrition Now campaign”. County Durham and Darlington NHS • Savings of £100,000 per year have been made by Hull and East Yorkshire Hospitals NHS Trust by working on the ‘Productive Mealtime’ module within the Productive Ward programme Mary Hickey, AMNCH

26. Why Lean Healthcare? • 20,000 incorrect drug prescriptions per year U.S. • 500 incorrect surgical operations per week • 50 new born babies dropped at birth per day • Enormous defect rate (estimated at nearly 45% by the New England Journal of Medicine, June 26, 2003) • Cost escalation (e.g., General Motor Corporation reported in 2005 that healthcare expenditures equate to $1,525 per car) “For every dollar spent on healthcare over 75% is spent on non-patient care activities of communicating, scheduling, coordinating, supervising, and documenting care.” HealthMEDX, 2005 Mary Hickey, AMNCH

27. How do you do it? • Stabilize processes • Standardize processes • Simplify processes Mary Hickey, AMNCH

28. Level 1 Level 2 Process levels Focuses on the REAL root cause(s) of problems Patient Admission Core Business Greet patient Identify Patient Log Patient Queue patient BusinessProcesses Map / SIPOC Take patient details Confirm patient’s GP Confirm Condition / injury Advise patient of next steps Level 3 Mary Hickey, AMNCH Detailed Sub-process Map

29. Current State Future State Mary Hickey, AMNCH

30. Stabilize – Understanding Waste Waste: anything that adds cost or time without adding value Mary Hickey, AMNCH

31. Understanding Waste • Unnecessary Services or Overproduction –producing work prior to it being required is waste and is the greatest of all the wastes • Unnecessary Motion - any movement of people, paper, and/or electronic exchanges that does not add value is waste • Excess Transport – the extra or unneeded time element associated with the delivery of work or a patient to a process • Over-processing - putting more work or effort into the work required by internal or external customers is waste Mary Hickey, AMNCH

32. Understanding Waste cont. • Inventory (Time) - work piles, excessive supplies, and excessive signature requirements are waste • Defects or Mistakes - refers to all processing required creating a defect or mistake and the additional work required to correct it • Underutilization of People - is a result of not placing people where they can (and will) use their knowledge, skills, and abilities to the fullest (considered an 8th Waste) Mary Hickey, AMNCH

33. Suggestions for Improvement • A Nutritional Committee in place in all hospitals to include caterers, dieticians, speech & language, food service staff, nurses and a clinician to help develop closer collaboration • Develop a hospital policy on nutrition • Protected mealtimes and hospital policy on managing conflicting priorities • Nutritional screening tool (MUST) to be used in the initial assessment of patients to identify those at risk and thereafter becomes part of nursing notes • Regular Patient Satisfaction Surveys – results published • A system to manage complaints about food and there resolution • A streamlined system for special diets with a description of the diet on the menu card • Nutritional training for medical and nursing staff as part of their formal education and a refresher course for all staff involved in the preparation and service of food – should also be a standard element of induction • Tray waste audits – develop and validate a system for food recording • Develop patient information leaflets which could be provided to patients in their pre – admission pack for elective patients • Introduce Food Moulds for specific diets Mary Hickey, AMNCH

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