Leaning Toward Better Patient Care

When nurses in the medical-surgical unit at St. Joseph’s Hospital in Lexington, Kentucky, needed supplies from their kitchenette, they often faced a mini-marathon. The 57-year-old hospital’s architecture had the hub for food, coffee, and ice water, for both patients and staff, at one end of a 38-bed corridor. “The staff took a lot of long walks every day,” says LaJava Chenault, RN, director of the unit. In fact, she says, the 28 nurses and 10 nursing assistants clocked an average of 716 miles a month going to and from the kitchenette.
How did Chenault know exactly how much legwork the inefficient floor plan was costing her staff? “Last year we measured it utilizing a concept called ‘Lean IQ’ with the help of Rapid Modeling Inc., a consultant for the Institute for Healthcare Improvement (IHI),” she says. Then, armed with the facts, Chenault renovated an existing site to create a second kitchenette and installed an ice machine at the other end of the corridor. “We saved ourselves 288 miles of walking per month. We measured that, too.” The result, she says: quicker responses to patient needs and happier nurses.
Chenault’s war on wasted motion is part of the 445-bed St. Joseph’s move to implement Lean Management, an industrial philosophy long embraced by manufacturing innovators such as Toyota but relatively new to health care. Unlike its perceived evil-twin, “mean management,” which was highly criticized in the 1990s for advocating quick fix, cost-saving layoffs, and paying next to no attention to improving quality, Lean takes a more thoughtful approach to slimming down. Rather than targeting jobs, it targets the very things that prevent people from doing their jobs. By sorting through the individual steps in a process that go into delivering a product or a service, the Lean methodology identifies the steps that add value and eliminates the rest — so waste gets the boot, not people.
Increasing the value of care and care processes is one of the four pillars of Transforming Medical-Surgical Care Learning and Innovation Community that includes St. Joseph’s and 48 other hospitals.
Revamping the hospital workplace to function more efficiently and thereby more effectively is also central to IHI’s Transforming Care at the Bedside (TCAB) Collaborative launched in 2003. “Waste-free processes, including simple things such as storing supplies at the bedside, promote continuous flow in patient care. That improves outcomes and increases satisfaction among patients and staff,” says Patricia Rutherford, RN, MS, IHI vice president, who directs the TCAB project. Increased job satisfaction helps keep good nurses on the job, a vital factor in quality of care, says Rutherford, “Nurses are a scarce resource these days. Patients need them and we need to keep them from leaving the field.”
As part of TCAB, hospitals interested in applying Lean Management techniques to improving nurses’ job conditions are encouraged to begin with a “deep dive” into staff knowledge and experience. During a four-to-five day session, teams are prompted to vent their job frustrations by answering open-ended questions such as, “What would be the best possible way to perform your work and what gets in the way of doing that now?”
Once a team identifies a specific process that needs perfecting, it’s broken down step-by-step as it actually occurs — not as it’s supposed to occur — and visually mapped on a board. Next the group is asked how the process would operate in an ideal state and, finally, how the current steps could be reconfigured to eliminate waste and move closer to the ideal. The team then conducts a small-scale test of the proposed changes, measuring and comparing the results before and after to determine whether the reconfigured process is as efficient as possible or needs further paring down.
At St. Joseph’s, “We looked for small changes that could produce big results right away,” says LaJava Chenault. In addition to rethinking the location of the original kitchenette, unit staff also placed a clock face with moveable hands at the spot where pharmacy runners make regular deliveries. After each delivery, the runner resets the hands so nurses know when the next delivery is due and don’t waste time looking for medications ahead of schedule. A two-flag “notification of patient discharge” system notifies floor staff when a patient room has been vacated and when it has been cleaned. “This allows us the ability not to assign patients to vacant rooms that aren’t ready for them yet,” says Chenault. Further, she says, by distinguishing between impending discharges and completed ones, the system promotes collaboration between environmental services and floor staff, improves patient flow, and raises everyone’s level of satisfaction, including the patients’. The hospital plans to extend these ideas to all units, including the two other locations in its network.
The University of Pittsburgh Medical Center’s (UPMC) 450-bed Shadyside campus has been experimenting with Lean principles since 2000, says Susan Christie Martin, MSN, a director at UPMC’s Center for Quality Improvement and Innovation. One early test challenged the assumption that tight control of narcotics precluded nurses from carrying their own keys to pain relief pumps. “When a surgical patient needed a higher pump setting or bolus of pain medicine, nurses had to go looking for the one set of keys on the unit,” says Martin. Now, each surgical unit nurse carries a set of keys, which is returned and reallocated at the end of each shift. “We do a recount each time and there’s never been a problem.” The policy saves an average of 49 minutes per nurse per shift but, just as important, says Martin, “It treats nurses like the professionals they are.”
Another test at UPMC aimed to simplify communication between nurses and physicians. “Nurses used to page the doctors, who would call back the nurses’ station a few minutes later, by which time the nurse was gone so the receptionist had to leave the station to find her while the doctor waited. It wasted everyone’s time,” says Martin. The solution: “pocket phones” — portable units connected to the hospital’s internal phone system — which allow doctors and nurses to call one another directly. Though the phones are expensive — $1,000 each — the initial 2003 trial of six phones on one 12-bed unit was so successful that the Shadyside campus has more than 400 in use hospital-wide, saving each of the hospital’s 70 nurses an average of 28 minutes per shift.  
Virginia Mason Medical Center (VMMC), a 336-bed hospital in Seattle, Washington, began making Lean improvements in 2002 and has been closely tracking the work of TCAB. Last fall, the hospital decided to test Lean ideas on its cardiac telemetry unit. Rather than assign the unit’s five nurses and four nurse assistants anywhere among 27 beds, staff were organized into “cells” with responsibility for a group of patients in adjacent rooms. “We used to be careful about distributing the patients with especially high needs but we wanted to test whether their care would be just as good, if not better, by promoting natural partnerships among caregivers through proximity,” says Charleen Tachibana, RN, VMMC’s Chief Nursing Officer. One immediate effect of the cells was that “they fostered stronger human alliances that made communication and back-up much easier.”
At the same time, the staff took a close look at the unit’s first shift — between 7 AM and 11 AM — to see how long it took nurses and nurses’ assistants to do their work. “We standardized all our processes and choreographed them in a way that optimized staff time and still allowed for flexibility,” says Tachibana. For example, documentation and staff-to-staff reports on patient care were conducted inside patient rooms, rather than outside. “It’s called parallel processing,” says Tachibana, “While records and reports are completed, patients and families have ‘touch time’ with caregivers to get updated, ask questions, and offer information.”
Results have been impressive. Within 90 days, staff were completing their work during the morning cycle in two hours rather than four. “That gave them so much extra time that it didn’t matter how many high-need patients any one cell happened to get,” says Tachibana, and the percentage of patients activating call lights during that shift dropped from 5.5 percent to none. These and other Lean improvements have increased the percentage of time nursing teams spend in direct patient care from 38 percent to 90 percent, much to the liking of the staff.
Tachibana plans to conduct a job satisfaction survey among the nursing staff, but thanks to the increase in direct care she says she already knows how it’s going to come out. How does she know? “We no longer have any trouble keeping all our nursing positions filled.”
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