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.

Lean Nursing Practices Part 1

Everdream asked me to blog about Lean nursing practices.

Disclaimer
Our clinics are the equivalent of a ‘surgi-centre’ with both consultative appointments and procedures under anaesthetics. While I’ve been staff at hospitals for years, I have never supervised a floor lean initiative. I have supervised many clinic lean initiatives with our own 20+ nursing staff. For a framework of lean initiatives click here and here and here.

Semantics
Normally I consider initiatives that decrease repetition of a task Six Sigma and initiatives that decrease either the time or variation in time of a task Lean. I think most of us would agree that there is a continuum so all of the listed changes are ‘Lean Six Sigma’.

Goals
Time with the patient
Better Quality of Care

All the nursing initiatives are to increase time with the patient. In our minds, that means defining projects that are relatively small and well defined. They must not create more daily work for the staff. Nurses are not administrators but clinicians. Their time with the patient is at least as important as the doctors.

One of the reasons we never completed ISO9000 was our concern that the paperwork would overshadow the goals of quality improvement. In the same vain, we try not to let lean initiatives distract from the ultimate goal. For instance, endless meetings or daily paperwork that is burdensome are not part of initiatives.

The rest of this blog describes some of the short initiatives we’ve undertaken.

Contacting Doctors
As far as I’m concerned this is the biggest waste of time for nurses. Even in our clinics nurses could spend an hour a day trying to c contact various doctors. In 2002 installed an email server (Exchange) in-house and in 2005 a Blackberry BES Server. The network was necessary and the small additional expense in administration was more than compensated for in nursing time. Now, unless it is urgent, the nurses can simply email the question or request rather than trying to hunt down the doctors. It is not uncommon for me to get an email while talking with a patient from a nurse that is 20 feet down the hall.

When needed for patient in the clinic the nurses also had to search the office to let the doctor know the patient was ready. When we increased the size of the office this had the potential to become a major problem. Now, rather than trying to hunt us down, they will call our desk and if not there page us. Instead of waiting several minutes x 30 patients a day they can move on to the next patient and keep the system flowing.

Equipment:

Sundry Items
The quintessential nursing lean initiative is decreasing how much they walk. I can still remember a friend being asked to wear a pedometer in 1982. We set up each room identically so items are easy to find. We also ‘double stock’ each room with quickly used sundry items (gloves, masks, etc…). Each will have the item in use and a back up. When one runs out they can immediately use the next to save time having to search.

Placing Equipment
When designing our current building consideration was given to the location of the central supply (we are a 20,000 clinic). Central supply houses items used for each case and is centrally located. A supply room holds a weekly supply of materials in the basement.

Broken Equipment
Broken equipment used to go through 2 levels of management before replacement. They would give the part to a supervisor who would give it to the manger who would ok the order. Ironically the nurse was often the one ordering the part anyway. Now the nurses contact the supplier directly and have it ordered for routine repairs. Common items are ECG leads and saturation probes.

Out of Date Equipment
Certain items expire but are rarely used (e.g. defibrillator pads). The expiry date is now kept with the drug expire dates and checked weekly on a checklist

Cost Control
With increased stocking comes an increased cost. Rather than trying to control sundry item cost from the outset we stocked the rooms to maximize efficiency with the patient then re-created our stocking system for ‘just in time’ delivery of most times so that supply costs didn’t spiral out of control. I’ve found this to be a constant battle between preventing a zero-outage and minimizing stock in the basement. It is still a work in progress.


Standardized Training and References (Skills, Knowledge, Judgment)
Uncertainty on what to do in the first two years of the job was common. In 2001 we initiated a standardized training (on-the-job) program for nurses with 2 week, 1 month, 6 month and 2 year goals. Although logic predicts learning should come in the order of knowledge, skill, judgment we’ve found practically that skills, knowledge, judgment is easier to learn. The first month is focused on the basic skills, the next 6 on knowledge and the first 2 years on advanced skills and knowledge. We’ve now added standardized references to the package so nurses have less hunting to do for information. Items include written emergency procedures, common drug monographs, and written basic skills.

Tomorrow I’ll blog about emergency drills, standardized histories, standing orders and cross coverage by ancillary services.

The Effect of Nurses on Patient Flow

When it comes to health care wait times and ER wait times nurses play a major role. Our office conducted a survey several years ago and asked all staff, including doctors, to list their role in patient care. Surprisingly, every group listed patient flow near or at the top of the list. We wanted to know what effect each group really had on patient flow so we data mined 596 patient records and examined their wait times once in the office. Specifically, this was for consultation regarding a general anaesthetic for a minor procedure in the office. When the patient has their medical history completed (on an Electronic Medical Record) the nurse that records it is stamped with the date & time. This particular part of the study examined the effect nurses had on patient flow. The nurses, in our office, play a wide variety of roles. Once the patient is registered they walk them to the consultation area, take x-rays if needed, complete a medical history (and hunt down any medications from families and pharmacies) and frequently bring the patient to the front again for treatment planning.

Based on this patient pool, the nursing role used approximately 42% of the time and caused 42% of the variation in the patients’ appointment. This figure, however, will be highly dependant on the procedure being completed and adds little to our understanding of what causes wait. The more telling number is the effect of nursing seniority. There is a relationship between less experience and more waiting. In the graph below the most senior nurse is ranked as #1 (roughly 15 years experience in the office) and the least senior is ranked #11 (roughly 1 year). As the seniority increases the office wait time goes down (it is approximately flat after 3 years of experience). The R2 value roughly translates to the amount of variation that can be explained by the factor being examined. In this case, roughly 26% of the variation that is seen in then nursing wait times can be explained by the seniority of the nurse. Remember that the nurse accounts for 43% of the total time with the patient so seniority accounts for approximately12% of the variation in wait time.

In our case it is the nurse that assumes the major role in the office with patient interaction. Since experience plays such a major role, there should be a mandate in each office to train the person that fills similar roles well. Does your office train the person by osmosis or is there a thoughtful training program? I’d recommend the following strategy:

Decide which tasks make up the majority of the work for the nursing role
-Which computer skills will be needed?
-If procedures are involved (surgical/interventional) provide some training so the person has context
-Create a learning program that educates at a reasonable pace
-Provide and maintain reference materials for study
-Especially drug references and procedures
-Create training that comes in a variety of formats
-Create goals within a timeframe so that people have something to work towards

As an example our office:
-There are 2 week, 3 month and 1 year objectives
-Nurses learn the procedures during the same time that they start doing the consultations for the patients. This way they learn the “important” questions to ask
-Drugs frequently used during the procedures are specifically listed and they are asked to learn more about their pharmacology
-Drugs that can cause surgical problems (anti-coagulants, bisphosphonates, cardiac, etc…) are specifically listed as well
-There is a learning program from basic to more complex objectives

It’s beyond the scope of this particular blog to list all the objectives but health care wait times have a real and linear relationship to nursing skill and experience. Being aware of how important the nursing role is, and providing sufficient training is important. It is even more important if you’re clinic or hospital suffers from high turnover (>20%) as this means few of your nurses are likely to be highly proficient. Value their experience, assist them in learning and do not underestimate the impact of high turnover.