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

Mary Hickey, AMNCH

Forces Impacting Patient and Family Centered Care

“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

Mary Hickey, AMNCH

DOHC Reports on Lifestyle Habits of the Irish Population

Mary Hickey, AMNCH

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

HSE Quality Programme

Mary Hickey, AMNCH

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

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

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

Adult Inpatient Admissions [Excluding Psych] by Adm Type

0

200

400

600

800

1000

1200

Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09

No. o

f Adm

issio

ns

A/E Elective Other

Mary Hickey, AMNCH

% Adult Bed Occupancy [Exclude Psych, ITU, CCU & Emergency Bed Ward]

60%

70%

80%

90%

100%

110%

120%

130%

Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09

Surgical Medical Total

Mary Hickey, AMNCH

Nutritional Status of Hospitalised Patients can be compromised by a number of factors…

1. Failure to detect poor nutrition

2. Poor recording of information about patients’ nutritional status (such as weight loss)

3. Poor referral systems

4. Fragmented working practices

5. Inadequate educational or training programmes

6. Inadequate ward staffing

7. 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

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

Mary Hickey, AMNCH

“If you always do what you’ve always done

You’ll always get what you’ve always got"                 

Mary Hickey, AMNCH

“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.”

W. Edward Deming on Processes

“Will be cross-functional, process-driven”

Mary Hickey, AMNCH

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

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 smell can buck you up.” Lord Grossman

Mary Hickey, AMNCH

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

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

“All improvement takes place project by project, and in no other way.”

Dr. Joseph M. Juran

DMAIC - A Project Management Method

Mary Hickey, AMNCH

Define

Measure

Improve

Analyse

Control

Define the problem and project

Measure & gather current baseline data

Analyse the data, identify root cause(s)

Improve by addressing root cause(s)

Control to sustain gains

The DMAIC (D-MAY-IK) Model

Don’t jump to conclusions – arrive at the solution !

Lean Six Sigma Key ConceptApply Rigour &

Discipline

Mary Hickey, AMNCH

Central theme is the elimination of waste. Waste is any activity that does not add value for the customer.

The approach is typified by the Toyota Production System.

Key measurement for Lean is value adding time.

Central theme is to create processes and products which are virtually defect and variation free.

The approach is typified by Motorola and GE

Key measurement for Six-Sigma is variation.

lowercosts

fasterprojects

higherquality

Lean Six Sigma

LeanSigma

SIZE

Mary Hickey, AMNCH

Knowledge is in the Data

““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.”

Lord Kelvin, a Scottish

mathematician and physicist who

contributed to many branches of physics

1824 – 1907

Su

cc

ess

Su

cc

ess

Extent of Knowledge(Derived from observation and measurement)Extent of Knowledge(Derived from observation and measurement)

Su

cc

ess

Su

cc

ess

Extent of Knowledge(Derived from observation and measurement)Extent of Knowledge(Derived from observation and measurement)

1. We use previous experience

2. We collect data and then look at the numbers

3. We group data so as to form charts and graphs

4. We use census data with descriptive statistics

5. We use sample data with descriptive statistics

6. We use sample data with inferential statistics

As the level of analysis increases

so does our success

Mary Hickey, AMNCH

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

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

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

How do you do it?

1. Stabilize processes

2. Standardize processes

3. Simplify processes

Mary Hickey, AMNCH

Process levels

Greet patient

Identify Patient

LogPatient

Queuepatient

Take patient details

Confirm patient’s

GP

Confirm Condition /

injury

Advise patient of

next steps

Level 1

Level 2BusinessProcesses Map / SIPOC

Core Business

Level 3

Detailed Sub-process Map

Patient Admission

Focuses on the REAL root cause(s) of problems

Mary Hickey, AMNCH

Current State

Future State

Mary Hickey, AMNCH

Stabilize – Understanding WasteWaste: anything that adds cost or time without

adding value

Mary Hickey, AMNCH

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

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

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