Adaptive DesignThe Path to Ideal Care

Debra Shriver, MSN, RNChief Nurse Executive

Trinity Regional Medical Center, Fort Dodge

April 2010

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.

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

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%

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

Adaptive Design:

Toyota Production System How people work and manage How they think about their work How they learn and work together to improve

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.

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

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.”

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?

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

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.

ACTIVITY

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.

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)

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.

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

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

Allen Memorial Hospital

Tami Jones, RN, MSN Clinical Director of Med/Surg and Nursing

Innovation

Christa Lerch, RN, BSN Staff Nurse on 4 Ortho

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

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

Frontline Design at Allen Where we are going…

Everywhere!!!!

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

Allen A3: Detox on 4T

Root Cause

Target Condition

Countermeasures

Allen Outcome Measure

We are solving problems throughout the organization.

376 A3’s in test as of April 1st!

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

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)

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?

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

RN Time at Bedside

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Outcome Measures

Cost / Patient

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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

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

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

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

A3’s

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.

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.

● 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.

Staff Nurse Perspective: What has this work meant to you and/or your unit? What impact has it had?

Iowa Health Des Moines

N3 Blueprint Unit

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

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”.

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

Reflections

● Senior Leaders - Quotes

● Blueprint Team - Culture Change

Last but not least:

● Adaptive design guides work in identifying steps in core processes. 1. Admit (Jan.) 2. Discharge (Feb.) 3. Medication administration/reconciliation (Mar.) 4. Care of the Patient (April) 5. Orders (pending)● In terms of content-sequence-timing i.e, admit hx present illness Patient profile (ht, wt, allergies) Med Rec Physical Assessment Screenings Advanced Directive Documentation of immediate – non immediate care

Last but not least:

● Timing 1. Direct admit: 60 minutes or less 2. ED admit → nursing unit – 30 minutes uninterrupted● IT Enabled: A few examples: 1. Order sets automatically generated from data entered 2. CPOE 3. Work list for physicians/eliminate “sticky” notes 4. Template data from previous admission, ED, clinics, pharmacies 5. Work list of incomplete handoffs. 6. Single sign on.