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University of Pittsburgh Medical Center

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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

2
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3
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

4
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.

5
Hospitals in TCAB
6
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.

7
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

8
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

9
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

10
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

11
11
12
Eliminated 18 steps and 1 redundant call to
patient/family
12
13
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

14
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

15
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

16
PCA Keys
Why, Why, Why, Why, Why?
17
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)

18
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

19
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

20
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

21
Engage those interested in testingNurse
Friendly or Curious Team Member
TWO NURSES WHO WOULD YOU RATHER HAVE
SPEARHEADING YOUR CHANGE EFFORTS?
22
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

23
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.

24
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
25
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)

26
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

27
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

28
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?

29
Condition HThe Josie King Family Call for HELP
  • A different view of patient safety at UPMC

30
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

31
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

32
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

33
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

34
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35
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36
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37
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!

38
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

39
Condition HITS THE RIGHT THING TO DO!
40
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.

41
Does Your Unit Suffer From
  • Long hallways
  • Generational differences
  • Complex patients
  • Stressful environment

42
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.

43
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.

44
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45
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.

46
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!

47
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

48
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?

49
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50
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?)

51
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
52
Outcomes Continued
All Patients with Pain Poster Felt Pain was
Adequately Controlled!
50 of Patients with No Pain Poster Felt Pain was
Adequately Controlled
53
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54
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

55
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

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_____________

57
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58
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.
59
Time to Put Your Thinking Caps On!!
60
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61
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.

62
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

63
QUESTIONS?
64
  • Kathleen Brown, Dr.NP, MHSA, BSN
  • Donald D. Wolff, Jr. Center for Quality
    Improvement and Innovation
  • brownkm_at_upmc.edu
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