LEAN Discharge and
Collaborative Nursing Practice
Editor’s Summary: In LEAN Discharge and Collaborative Nursing Practice, a team from Calgary Health Region describes an initiative to help patients move more swiftly through the cardiac sciences system. The initiative involved the application of process improvement methodologies to examine all processes in the care continuum for cardiac services. The focus of this initiative was on separating personal care tasks which the patient would do on his or her own if the illness burden requiring hospitalization was not present and which they will resume upon discharge, from those professional care tasks which had to be completed by a healthcare professional. This will facilitate optimization of provider skills and time, enabling the provider with the appropriate skill set to be providing required care. The initiative forms the baseline for evaluation and future improvements.
Contact:
Barb Stolee
Authors:
• Janice Stewart, RN MSA; Director, Cardiac Sciences, Calgary Health Region, AHS.
• Barb Stolee, RN MBA; QI Consultant, Cardiac Sciences, Calgary Health Region, AHS
Purpose:
This project was designed to create nursing capacity to implement change ideas for facilitating patient flow through cardiac sciences units. Three four-day LEAN Kaizen events resulted in creative and custom-designed change ideas. However, sustainability of the changes proved supboptimal. The Kaizen events focused, sequentially, on:• discharge from 2 medical cardiology units,
• inter-unit transfer of medical cardiology patients (CICU to ward, and patients with primary heart failure to medical cardiology units)
• “pulling” admitted cardiology patients from ED to medical cardiology units. Staff indicated the reason for lack of sustainability of changes was lack of time due to workload. This project was baseline data gathering to understand the care needs of patients on participating units. Subsequent work is being undertaken to facilitate collaborative nursing practice among licensed and non-licensed care providers.
Context:
Several contextual factors influenced this work, including:• Passage of The Alberta Health Professions Act in 1999. The enactment of this legislation resulted in an increase in scope of practice of Licensed Practical Nurses (LPN), and the return of independently licensed LPNs to acute care settings.
of ‘over compliment’ beds as a strategy to address Emergency Department length of stay for admitted patients was introduced several months prior to this project.
• The number of non-core service patients admitted to medical cardiology units. The shorter length of stay of patients admitted by cardiologists results in cardiology bed capacity not utilized by the cardiac service. Efforts have been made on all three adult acute care sites in the CHR, to focus heart failure patients, regardless of admitting physician, on cardiac units.
• Introduction of additional work for nursing staff as a result of the Kaizens, without an evaluation of what work could be stopped in order to offset the increased expectations.
• The project was chartered under the umbrella of GRIDLOCC (Getting Rid of
Inappropriate Delays that Limit our Capacity to Care), a two-year project funded by the Alberta government's Wait Times Management Initiative. GRIDLOCC focuses on system redesign to reduce waiting times and overcrowding in Calgary’s Emergency Departments. This funding supported knowledge transfer for LEAN methodologies.
Resources:
Costs will vary, depending on the number and seniority of participants, but included the sum of:• 1.5 days X # of people involved X average salary cost
• Teleform programming + Teleform data input
• data analysis (2 FTE X 10 days, for this data)
• facility rental + catering if internal facilities are not large enough
• 6 days QI consultant planning
• 4 X 2 hr planning meetings with front-line leaders and Director
Funding:
In kind contributions from organizationPatient
Populations:
The patient populations included in this project were cardiac and non-cardiac patients on 4 in-patient medical cardiology units across three facilities, and post-cardiovascular (CV) and non-CV surgery patients on one CV surgery unit.
Patient flow
entry and end
points:
For medical cardiology patients, entry points were Emergency, coronary intensive care units or direct admissions; end points were discharge from the unit. For CV surgery patients, entry points were cardiovascular intensive care unit, Emergency, or elective/direct admissions; end points were discharge.
Description/
approach:
LEAN WorkOut™ methodology was used to procure front-line staff input into understanding care provided to the differing patient populations. In order to facilitate measurement, the approach chosen was to have staff identify nursing tasks performed for the target populations. Front-line staff participants identified patient care needs and the resulting tasks, then grouped tasks into two categories, those being professional tasks and personal care tasks. Personal care tasks were defined as tasks that did not require extensive training, and that the patient would do for themselves if they were able; this category included elements such as redirecting confused patients. Professional care tasks were those that were in scope for licensed nursing staff. Care tasks in professional/personal categories were further broken down into ‘high’, ‘medium’ or ‘low’ care tasks (Appendix A), based on knowledge and skills required to perform each task, unit-specific guidelines (e.g. advanced competencies), CHR policy statements, legislation, and competencies outlined in role descriptions. A data collection tool was developed as a Teleform™1 (Appendix B), and reviewed by patient care managers and WorkOut™ participants for completeness and accuracy. Using the data collection tool, every nurse on each of the 5 participating units collected data on every patient, every shift for a period of 28 days, for a total of 5271 records.
Posters outlining the data collection form, indicator definitions, processes and timelines were available on every unit. Front-line leaders held special information sessions and
1
‘huddles’ to ensure all staff were informed of the project and expectations of them.
Tools and
tactics:
Described above, tools attached as appendices.
Measurement
approach:
Analysis included frequency counts of care tasks by category (professional vs. personal), unit, core admitting service vs. non-core admitting service, shift, diagnosis of heart failure, isolation requirements, and ‘waiting placement’ status in community care settings. System-level measures that were monitored as part of the larger GRIDLOCC project included average LOS by unit, and time to transfer from ED to unit, after a decision to admit was made.
Impact/
evaluation:
This project was baseline work to inform subsequent efforts to develop more collaborative models of working together for RN, LPN and nursing attendant roles. To date, any changes noted in system-level measures can not be directly attributed to this project.
Observation/
Discussion:
Personal care tasks varied from ~24% (CV surgery unit) to 36% (medical cardiology) of all tasks reported by staff during data collection. These results in and of themselves led to increased openness by participants to consider alternative staffing models in order to care for patients on their units. On average, more tasks per patient were reported for non-cardiac patients on cardiology units, than for cardiology patients. Findings suggested that cardiology patients had fewer nursing care task encounters per patient per day on average, than did non-cardiology patients. This was a surprise. Given the shorter length of stay of cardiac patients and the intensity of diagnostic workups, participants had expected the average number of care task encounters per cardiac patient to be higher than the average for non-cardiac medical patients.
Reported Professional vs. Personal Tasks Cardiac Sciences May 5 to June 1 2008 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80%
U44 U56 U81 U82 U91
Unit
P
er
cen
t
Prof tasks as % of all tasks Pers tasks as % of all tasks
Critical
success
factors/
lessons:
Factors critical to the success of this work included:
• Senior leadership support and direction, to enable front-line leader participation. This project was clearly communicated as a priority to front-line leaders.
• Front-line leader support and collaboration in making staff available to participate in the WorkOut™ events, in participating in process discussions, communicating project expectations and processes to front-line staff, and overseeing data collection processes on a daily basis. Front-line leaders were champions and ‘cheerleaders’ for the work, dealing effectively with resistance, when it occurred.
• Front-line staff, through participating in content discussions (WorkOut™ event), and cooperating with data collection requirements.
• Lessons: this project has resulted in a rich database of information related to workload on these five units. Detailed unit-specific information was made available to front-line leaders. Less complex, aggregated data was more helpful and meaningful for them.
Limiting
In order to move to the next phase of this work and to enable staff to embrace alternate models for providing care, significant work to address unit-specific cultures will befactors:
necessary. Change management strategies will need to be employed that foster front-line staff involvement, facilitate dialogue and reflective practice, and enable customization of nursing models to meet the needs of each unit, if sustainable change is to be achieved.Appendix A:
Cardiac Sciences Patient Care Indicators - Activity classification tool
Risk Factor
Communication - Pt / family with communication barriers (language, cognitively impaired, sensory deficits [blind / deaf])
Professional Care Personal Care
Assessment Activities
High Med Low High Med Low1 Admission process - history, assessment, documentation, SCM (re-enter / activate orders) √
2 Assessment / monitoring - complex unstable patient, head to toe assessment with documentation √
3 Assessment / monitoring - high-frequency monitoring, (i.e. post-procedure assessments < q4h) √
4 Assessment - acute care routine i.e. head to toe assessment, vitals (once or twice per shift) √
5 Assessment - LTC routine (i.e. assessment, vitals once per week) √
6 BCLS / Code 66 - recognizing need √
7 Consult to multi-disciplinary team member(s) √
8 Labs - monitoring / interpretation of lab work including glucose / glucometer reading √
9 Observation - frequent (every few minutes to q1h) with intervention when needed (fall risk, confused / wandering, constant cueing, aggressive / combative) √
10 Observation - requires cueing / redirecting q1h(mildly confused pt) √
11 Observation - routine rounds (i.e. q1h) safety checks without intervention √
12 Restraints - management of mechanical √
Intervention Activities
1 ADL - total care (bathing, grooming, feeding, toileting, turn / reposition, transfer/lifts) √
2 ADL - assist (1-2 person transfer, set Pt up for bathing, grooming, toileting) √
3 ADL - independent, provide supplies only √
4 Advanced wound care, VAC dressing/packing √
5 Simple wound care - simple dressing changes √
6 Colostomy care - established √
7 Colostomy care - new √
8 Preparation for procedures (i.e. skin prep, obtain stretcher, wheelchair) √
9 Preparation for procedure - obtain / follow protocols √
10 Foley - insertion √
11 Foley - care √
12 Nasogastric tubes - insertion, care √
13 Tube feedings - administration, tube care √
14 Defibrillation √
15 Sheath removal √
17 Accompany patient on monitor to test √
18 Trans-radial bands - care / monitoring √
19 Pacemaker - temporary / external - care / monitoring √
20 VAD care √
21 Advanced pain management (i.e. epidural, PCA pumps, palliative including clysis lines) √
22 IV - peripheral: initiation, monitoring, maintenance √
23 IV - Central lines: flushing, blood draw √
24 IV - Central lines: dressing change √
25 IV - Blood / blood products - administration √
26 Medication - multiple IV lines, multiple meds, titrating inotropes and/or analgesics √
27 Medication - IV direct (push) √
28 Medication - mixing routine IV meds √
29 Medication - admin of routine oral and IV meds including analgesics: observation for effect √
30 Medication - supervision of self-meds √
31 Fluid balance - complex, with replacement √
32 Fluid balance - routine I/O with weight monitoring √
33 Trach care - established trach √
34 Trach care - new and/or unstable √
35 Chest tubes - maintenance √
36 Chest tubes - complex, removal √
37 Chest tubes - dressing change √
38 O2 - high flow - monitoring √
39 O2 - low flow (< 6 litres/min) monitoring √
40 Bipap / CPAP - monitoring √
41 Specimen collection by unit staff (i.e. 24 hr urine, stool for OB) √
Teaching / Support Activities
1 Discharge - coordinating complex discharge, including complex medication management, coordinating with multidisciplinary team √
2 Discharge - standard teaching (checklist) √
3 Teaching re: new disease (i.e. diabetes) √
4 Teaching - standard teaching (i.e. deep breathing & coughing, pre-op teaching, procedure preparation) √
5 Psych / social - Complex grief management / counseling & intervention, creating plan √
6 Psych / social - support for pt / family (i.e. advocacy) √
7 Social - support for pt / family - reassurance, comfort, encouragement √
