Tuesday, October 7, 2008

Lean Nursing Practice Part II

In Part I of this series I discussed what we have done in our clinic to ‘lean’ nursing practices. The last 4 items are smaller but shave minutes every day and decrease the change of having to repeat a task.

Standardized Medical History
Each incoming patient has their medical history reviewed by the nurses. It is an EMR (electronic medical record) and the questions asked are developed in conjunction with the nurses. At one time I worked in a hospital where the nursing history was exhaustive and aspects of it pointless to patients who are admitted for just a day. When developing our own medical history we ask the questions; why do we need this question, is the information provided elsewhere and how many people does it apply to? Like most medical histories, ours is a combination of asking about the disorders that our important to our practice (like cardio-respiratory disease) and ‘shot-gun’ questions that cover all the bases (e.g. “Have you ever been in the hospital”).

Standing Orders for x-rays
Rather than trying to hunt down the doctors for common x-rays on consultation we have standing orders for routine x-rays with agreed upon criteria for repeating x-rays that have been sent by other practices.

Cross Coverage by ancillary services
The nurses’ skills are demanded for complex patients. Other staff will jump in to help when nurses are tied up with a difficult patient for duties that the nurses normally perform (such as organizing which patient is to be seen next, seating patients, simple medical histories).

Emergency Drills
Our clinic practices emergency drills at least once a month in each office. The drills serve two purposes. First is familiarization with infrequently used equipment and procedures. The second is to find broken or missing equipment. There has scarcely been a real ‘emergency’ I’ve been involved in a clinic/ward setting where something is not missing, the best example of which was an emergency tracheotomy where we had the tray, trach tube and local but no scalpel.

Our clinic’s lean six sigma initiatives for nursing are basic but they’ve been effective. If I had to pick one initiative as the most productive it would be decreasing time wasted trying to contact other practitioners’ (doctors) either through a) standing orders b) standardized contact agreements (e.g. phone, page) c) decreasing the need to clarifying orders. For more information a nursing unit in France has published their lean initiative here.


everdream said...

Again - thanks Dr. Furst. I am going to email links to this post, both parts 1 and 2 - to my Supervisor, the Director of Nursing, so we can have a nice dialogue about Lean concepts.

Ian Furst http://www.waittimes.blogspot.com said...

thanks everdream - i'll give some thought to failures. I write down most major initiatives when they start so I'll take a look back at which did well.

everdream said...

I look forward to it. Thanks Dr. Furst!