Title: University of Pittsburgh Medical Center
1- 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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3UPMC 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
4Hopes 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.
5Hospitals in TCAB
6Its 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.
7How 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
81. 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
9How 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
10How 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
1111
12Eliminated 18 steps and 1 redundant call to
patient/family
12
13How 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
14Identify 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
15Example 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
16PCA Keys
Why, Why, Why, Why, Why?
17PCA 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)
18How 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
194. 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
20Testing 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
21Engage those interested in testingNurse
Friendly or Curious Team Member
TWO NURSES WHO WOULD YOU RATHER HAVE
SPEARHEADING YOUR CHANGE EFFORTS?
22Testing 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
23An 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.
24Testing 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
25Aim 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)
26Rapid 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
27How 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
28Examples 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?
29Condition HThe Josie King Family Call for HELP
- A different view of patient safety at UPMC
30Lets 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
31What 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
32Why 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
33When 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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37Condition 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!
38Condition 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
39Condition HITS THE RIGHT THING TO DO!
40Vitality 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.
41Does Your Unit Suffer From
- Long hallways
- Generational differences
- Complex patients
- Stressful environment
42Staff 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.
43How 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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45Quote 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.
464 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!
47Comments 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
48Patient 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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50Pain 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?)
51Outcomes
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
52Outcomes 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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54Serious 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
55Solution
- 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
56- 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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58Therapy 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.
59Time to Put Your Thinking Caps On!!
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61Heres 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.
62Heres 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
63QUESTIONS?
64- Kathleen Brown, Dr.NP, MHSA, BSN
- Donald D. Wolff, Jr. Center for Quality
Improvement and Innovation - brownkm_at_upmc.edu