University of Pittsburgh Medical Center

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• University of Pittsburgh Medical Center
• Donald D. Wolf, Jr Center for Quality Improvement
  Innovation
• Transforming Patient Care
• A Collaborative Journey of Innovation

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UPMC at a Glance

• 7.4 billion in assets
• 6.8 billion in revenue
• Leading integrated healthcare system in
  Pennsylvania one of the largest and most diverse
  in the nation
• More than 40,000 employees second largest
  employer in Pennsylvania major force in local
  economy
• Hospital 20 tertiary, community, and specialty
  hospitals
• Physician more than 4,000 physicians with
  privileges at UPMC hospitals including about
  2,300 employed
• Community Provider Services extensive network
  of rehabilitation, home care and senior services
• Insurance products covering commercial,
  Medicare and Medicaid segments, EAP, Behavior
  Health
• Strategic Business Initiatives commercial and
  international ventures that leverage UPMCs core
  competencies, intellectual capital, and
  management expertise
• On a typical day at UPMC
• 2,600 patients
• 1,000 people use emergency departments
• 8,000 are treated in outpatient facilities
• 1,200 receive services through home health
  programs

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Hopes and Aspirations for Transformation

• Our main goal is to positively impact patient
  care and the way it is delivered by making
  dramatic improvements which we can spread to our
  entire health system.
• Our mission is to teach staff to think
  differently and engage in change efforts to
  promote ongoing patient and staff satisfaction.
  We strive to be the hospital in Western PA that
  patients, visitors, staff, and physicians say is
  the best place to go for personable and
  outstanding care.

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Hospitals in TCAB
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Its the Way We Work

• TCAB design themes parallel our mission and
  vision
• Leadership perspective/support is critical
• Weekly Core team meetings
• Everyone in the same movie
• Cultural transformation executive leadership,
  department leadership, physicians, front line
  staff, ancillary teams, PATIENTS and FAMILIES are
  the Care Team.

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How Does Rapid Design Happen?

• Using rules rooted in science to solve problems
  one at a time
• Start with a single patient need
• Observe how the current work is done
• Identify the root cause of identified problem
• Identify a single potential change
• Test the potential change
• If successful, change practice

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1. Start With a Single Patient Need

• How do you determine something to redesign?
• Something patients or staff have complained about
• Call bell response
• Getting meds from the pharmacy
• A report care measure that your unit needs to
  improve
• Patient falls
• Wound care
• Observe work processes and see where breakdowns
  occur
• Staff running to supply room 6 times/hour

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How Do You Determine Something to Redesign
(contd)

• Conduct a nominal group technique brainstorming
  session
• Ask a key question at multiple staff sessions
• What gets in your way of providing the best
  patient care possible?
• How can we involve patients and families more in
  their care?
• Pick top one or two issues on the list
• Items that were voiced the most
• Staff voting
• UD selection

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How Does Rapid Redesign Happen?

• Using rules rooted in science to solve problems
  one at a time
• Start with a single patient need
• Observe how the current work is done
• Identify the root cause of identified problem
• Identify a single potential change
• Test the potential change
• If successful, change practice

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Eliminated 18 steps and 1 redundant call to
patient/family
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How Does Rapid Redesign Happen?

• Using rules rooted in science to solve problems
  one at a time
• Start with a single patient need
• Observe how the current work is done
• Identify the root cause of identified problem
• Identify a single potential change
• Test the potential change
• If successful, change practice

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Identify the Root Cause of a Problem

• Problem must be completely understood before
  trying to solve. Otherwise, the intervention may
  not correct the problem.
• Dont shift quickly from problem to solution
  avoid the quick fix
• Ask WHY 5 times to get to root cause

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Example of the 5 WHYs

• Why is patients 12pm medication missing from
  patients medication drawer?
• It was not delivered by the Pharmacy Tech
• Why was it not delivered by the Tech?
• Medication order was not processed and filled
  prior to techs departure from Pharmacy
• Why was it not processed and filled?
• Copy of medication order was not received for
  validation
• Why was it not sent to Pharmacy from the nursing
  unit?
• Copy of medication order sitting in a batch of
  additional orders waiting to be sent to Pharmacy.
• Why are copies of medication order forms batched?
• Worker does not realize this delays medication
  delivery.work activity of sending copies is not
  specified

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PCA Keys
Why, Why, Why, Why, Why?
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PCA Keys

• Problem
• Patient pain relief delayed
• 23 searches / day /unit for keys
• 49 minutes wasted / unit / day
• Solution
• Set of keys to for each RN
• Outcome
• Immediate pain relief--patient satisfaction
• Savings of 298 RN hours / year (40 bed unit)

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How Does Rapid Redesign Happen?

• Using rules rooted in science to solve problems
  one at a time
• Start with a single patient need
• Observe how the current work is done
• Identify the root cause of identified problem
• Identify a single potential change
• Test the potential change
• If successful, change practice

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4. Identify a Single Potential Change5. Test the
Potential Change

• Test its the only real way to learn!!
• Start small
• N 1
• One nurse, one shift, one patient, one
  change-of-shift report
• LOW TECH
• Dont wait for a committee approval, go to the
  committee after you have tested and have some
  data to support the new changes

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Testing ConsiderationsWho Will Fix It?

• Need a small group to own it
• Must have front line staff involvement in design
  and testing
• Who and what positionsRNs, PCTs, HUCs,
  therapies???
• Anyone else from other departments?
• Must have a leader to keep it going
• Staff member versus Manager
• Great people skills
• Good Organizer and Follow-up

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Engage those interested in testingNurse
Friendly or Curious Team Member
TWO NURSES WHO WOULD YOU RATHER HAVE
SPEARHEADING YOUR CHANGE EFFORTS?
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Testing ConsiderationsHow Will We Know That a
Change is an Improvement?

• Make a prediction before you test that is a
  statement of your expectation
• Compare result of test to prediction to increase
  learning
• Collect some data (quantitative and qualitative)
• Short term and long term measures
• Run multiple tests simultaneously
• Test several things at once Communication
  Multi-disciplinary Rounds Coaching Culture
• It takes many tests to build innovation
• Sequence of tests

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An AIM Statement (Goal)

• In the next 2 months, we will decrease the number
  of trips staff make to the supply room by 50.
• We wont have any patient falls for the next 60
  days.
• By the end of next week, we will improve meal
  satisfaction of dialysis patients by delivering
  meal trays to the dialysis unit. We will use a
  satisfaction survey and predict 80 will give a
  4 rating or better.

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Testing and Implementing Changes
changes that result in improvement
Act
Plan
Cycle 8
Do
Study
Cycle 7
data for learning
Cycle 6
Cycle 5
hunches, theories ideas
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Aim The Multidisciplinary Plan of Care is
Customized to Meet Patients Daily Goals

• Cycle 1 One nurse elicits daily goals using
  script
• Cycle 2 One nurse customizes the dialogue for
  each patient
• Cycle 3 All nurses on one shift elicit daily
  goals
• Cycles 4, 5, 6, 7.
• Cycle 8 One nurse put daily goals in chart
• Cycle 9 One nurse uses white boards in room to
  communicate goals
• Cycle 10 All nurses on one shift put goals on
  white boards
• Cycle 11 Standardize process for identifying
  and communicating goals
• Cycles 12, 13, 14
• (continue testing cycles until the aim is met)

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Rapid Testing Approach

• Adapt Are there ideas that can be adapted to
  fit the need. i.e. open visiting hours make
  sense, has been done so need to adapt to work in
  our environment
• Abandon get rid of what is not working.
• i.e. Call me physician sheets flopped-do not
  beat to death but move on
• Adopt worked in a the test environment move
  it out via a designed spread strategy. i.e.
  Chart Locators, monitor battery changes
• Innovate these are entirely new approaches,
  built out of need to change the business of
  health care. i.e. Liberalized diet or Condition H

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How Does Rapid Redesign Happen?

• Using rules rooted in science to solve problems
  one at a time
• Start with a single patient need
• Observe how the current work is done
• Identify the root cause of identified problem
• Identify a single potential change
• Test the potential change
• If successful, change practice

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Examples of Work Done

• Insanity is doing the same things over and over
  again and expecting different results. Albert
  Einstein
• Just a few more tasks
• Just until staffing is better
• Just a few more patients
• I can handle thisright?

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Condition HThe Josie King Family Call for HELP

• A different view of patient safety at UPMC

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Lets Set the Stage

• Sorrel King video clip says it all!
• Institute of Healthcare IHI forum December 2004
  leadership challenge
• 100,000 Lives campaign
• Small idea grows to gain local and national
  interest

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What If?

• Nurse called MD when her eyes rolled back in her
  head
• Josie was able to drink or have an IV
• Residents noticed her weight dropped 15 in a 24
  hour period
• She did not receive Methadone
• Taken my comments seriously
• Patient safety program in place

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Why Condition HWhy Not?

• Shifts power to patient and family by providing
  the ability to call a rapid response team to come
  to the bedside when we traditionally place them
  on the outside looking in
• Serves as a safety umbrella while healthcare
  fixes the multitude of broken systems that
  surround the patient

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When to Call Condition H

• Noticeable clinical change when healthcare team
  not present or not responding to concerns of
  patient or visitors
• Breakdown in how care being managed and/or
  confusion over what needs to be done

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Condition H Rapid Response Team Activated by
Patients or Their Family

• Risk Specialist Analysis-Year 1 Calls
• Retrospective analysis of Condition H calls
  revealed 69 of calls may have resulted in
  serious patient harm had Condition H not been
  activated!

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Condition H Rapid Response Team Activated by
Patients or Their Family

• Post Condition H Follow Up
• Patient Relations Coordinator (PRC) bedside
  meeting post each H call- 24 hours post call
• Administrative Nursing Coordinator (ANC) follow
  up on Sundays for calls received Saturdays in
  absence of PRC
• Phone calls to patient homes after D/C

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Condition HITS THE RIGHT THING TO DO!
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Vitality and Teamwork

• Within a joyful and supportive environment that
  nurtures professional formation and career
  development, effective care teams continually
  strive for excellence.
• 64 of clinicians, students, and staff say
  There is someone on this unit who always
  encourages my development,
• 48 of clinicians, students, and staff say I
  am part of an effective work team that
  continuously strive for excellence even when the
  conditions are less than optimal.

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Does Your Unit Suffer From

• Long hallways
• Generational differences
• Complex patients
• Stressful environment

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Staff Vitality Staff Morale

• Daily Staff Huddle-each day an impromptu huddle
  occurs led by a staff nurse initially
  orchestrated by the TCAB champion.
• Our way to bond with one another
• To create a stress breaker
• To come face-to-face with each other during the
  shift.

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How Does It Work

• Go around the room and say two truths and one
  lie-have the staff determine which is not true
• Fill a jar with MMs and have the staff to pick
  a color, based on the color a particular question
  or statement is made.blue color may have you
  state your favorite vacation, green color may ask
  you to state your favorite book, etc.

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Quote for the Week

• Posted weekly on the bulletin board in the
  hallway so that both patients and staff have a
  reminder each time they pass to pause and reflect
  on what is posted.
• Proving to be a great patient morale booster as
  well. The quote is generated by the staff and at
  times patients.

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4 Main Quotes

• Something wonderful, something hidden, a gift
  unique to you. Find it!
• Never let yesterday use up too much of today
• Just remember you dont have to be what they
  want you to be
• He who laughs, lasts!

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Comments about Huddles

• It is really nice to learn something personal
  about a co-worker.it helps me to understand the
  person a little better
• This is a nice change interjected in the shift
  to help with stress
• I find myself looking forward to this each
  shift
• This is making a difference, a positive
  difference

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Patient Control

• Have you ever heard?
• When is mom due for a pain pill?
• Nurse what pain medicine am I on?
• Can Mr. Smith have something for pain?
• Nurse when is my pain med due?

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Pain Survey

• Patient Satisfaction regarding Pain Management on
  5 West
• Date ___________ Pt Initials _____
  Room ________ ? v if pain poster in room
• Did you need pain medication to help relieve
  your pain? Yes No
• (if no, do not continue with interview)
• Did you know when your next dose of pain
  medicine was due? Yes No
  
• If yes, how did you know?
• Did you feel that your pain was adequately
  controlled? Yes No
• (If no, why?)

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Outcomes
All Patients with a Pain Poster Knew When the
Next Pain Med Dose was Available to Them
None of the Patients with No Pain Poster Could
Identify When the Next Pain Med Dose was Available
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Outcomes Continued
All Patients with Pain Poster Felt Pain was
Adequately Controlled!
50 of Patients with No Pain Poster Felt Pain was
Adequately Controlled
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Serious Events

• Problem
• Patients receiving Ativan IV require and
  assessment and documentation of sedation score,
  respiratory rate, and pulse oximetry PRIOR to
  administration and then FIFTEEN, THIRTY, and
  NINETY minutes after administration. The
  documentation of this data was not always complete

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Solution

• Tip sheet developed to remind staff to document
• Placed in Acudose drawer with Intravenous Ativan
• When removing Ativan, remove tip sheet and use
  for documentation of results
• Enter results into eRecord

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• Chart time med administered under e-MAR
• Chart the following under ad hoc Vital Signs
  form
• PRIOR TO ADMINISTRATION
• Time________ Respiratory Rate___________
• 
  Sedation Score_____________
• (type in under comment section) Pulse Oximetry
  ____________
• 15 MINUTES AFTER ADMINISTRATION
• Time________ Respiratory Rate___________
• Pulse Oximetry
  ____________
• (type in under comment section) Sedation
  Score_____________
• 30 MINUTES AFTER ADMINISTRATION
• Time________ Respiratory Rate___________
• Pulse Oximetry
  ____________
• (type in under comment section) Sedation
  Score_____________
• 90 MINUTES AFTER ADMINISTRATION
• Time________ Respiratory Rate___________
• Pulse Oximetry
  ____________
• (type in under comment section) Sedation
  Score_____________

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Therapy Minutes Tracker

• As a patient in inpatient rehabilitation, you are
  required to have a minimum of 3 hours (180
  minutes) of therapy daily at least 5 days per
  week. The therapy will be a combination of
  physical therapy, occupational therapy, and/or
  speech therapy depending on your individual
  needs, with the goal being to help you be as
  independent as possible when you are discharged.

Track your progress below you will see a STAR
for each day you complete 3 hours of therapy.
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Time to Put Your Thinking Caps On!!
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Heres What the Patients and Families Tell Us

• As a patient on this unit, I can tell the staff
  really does care and that has made all the
  difference.
• We have been treated with kind, prompt attention
  from the moment we arrived, this is what we
  needed.
• The staff is here to meet the smallest of things
  and the biggest. Kudos to everyone.
• This is the only unit for our family. Thanks to
  the leadership and the staff.
• Praise to the leaders and staff for the superb
  care my husband and I have had on this unit.

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Heres What the Nurses Tell Us

• Our input is valuable and acted upon by
  management.
• TCAB assists us in providing quality care with
  increased time with patients
• TCAB makes a difference in our daily work as well
  as the care to our patients

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QUESTIONS?
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• Kathleen Brown, Dr.NP, MHSA, BSN
• Donald D. Wolff, Jr. Center for Quality
  Improvement and Innovation
• brownkm_at_upmc.edu